Sun Valley Manor Assisted Living Home

Based on record review, and interview, for one of two residents reviewed, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation which included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, which was signed by a Physician, Registered Nurse practitioner, Registered nurse, or Physician assistant. Findings include: 1. In record review, R1's medical record (received personal care services) did not include documentation signed by a Physician, Registered Nurse practitioner, Registered nurse, or Physician assistant, which included whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R1's acceptance date, this documentation was required to be in the record. 2. During an interview, E1 acknowledged the required documentation was not in R1's medical record, and was not available for review.

Based on observation, documentation review, record review, and interview, for one of two residents reviewed, who received a controlled substance, the manager failed to ensure policies and procedures were implemented for inventorying controlled substances. The deficient practice posed a risk if controlled substances were not inventoried and accounted for by the facility. Findings include: 1. In observation, R1 had Tramadol medication (a schedule IV controlled substance) on site, and available for administration. The medication container indicated 30 tablets were dispensed on December 21, 2023; however, 59 tablets were observed in the medication container. 2. In documentation review, a facility policy included a section, titled, Controlled Substances, on page 32, which documented, "Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances... are subject to special requirements in the ALH... A controlled drug administration record is prepared when the ALH is receiving or documenting receipt of a controlled substance... and is used to document medication administration to maintain a perpetual inventory. The controlled substances administration record contains... name of resident... physician/prescriber... prescription number... drug name, strength, dosage form, route of administration... quantity ordered... quantity received... date received... name of person receiving the medication supply... acknowledgement by resident or caregiver of receipt of medication if medication stored in resident's ... room..." 3. In record review, R1's medical record (received personal care and medication administration services), did not include documentation of an inventory of the controlled substance. 4. During an interview, E1 acknowledged R1's controlled substance medication was not inventoried.