No assessment had been done to justify placing them on the secured memory care unit.
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The facility's own written policy described exactly what was supposed to happen.
The second resident's situation was more complicated and, in some ways, more troubling.
An inspector visited the room on the morning of March 17, 2025, with LVN 2 present at Resident 695's side.
NA #6 said she didn't know how to use the facility's tablet device to get there.
The resident, identified in inspection records as Resident 38, received both Insulin Glargine and Humulin R injections.
The citation, recorded under F0684 and covering care quality, carried the most serious harm designation available under federal inspection rules.
Federal inspectors visited the facility on March 18, 2025, and found the oxygen concentrator running adjacent to Resident 123's bed.
The list was specific: bacon, pork, mushrooms, spinach, olives, cabbage, and shredded carrots.
The administrator said he was not aware he should have included it.
Resident 169 was admitted on a Saturday morning, March 22, at 5:45 AM.
Inspectors visiting North Valley Nursing Center on May 18, 2026 found it there at 10:57 in the morning.