Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at High Valley Lodge during CMS and state inspections, most recent first.
A resident with intact cognition and multiple chronic conditions reported an incident with an LVN via email to the DON, stating the nurse’s response was unacceptable and later reporting that no one had followed up or explained any investigation. Although the DON acknowledged receiving the grievance and verbally informing the SSD, review of the grievance binder showed the complaint was never filed, the required grievance form was not completed, and no investigation was initiated within the 24-hour timeframe required by the facility’s grievance policy, which guarantees residents the right to voice grievances without discrimination or reprisal.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
Four large containers of canned fruit in the kitchen refrigerator were found with only a preparation date and no use-by date, exceeding the recommended three-day consumption period. The Dietary Supervisor confirmed the containers were not labeled or discarded according to facility policy, which requires both an open date and a use-by date for refrigerated food items.
A resident with multiple diagnoses, including dementia and diabetes, was incorrectly assessed on the MDS as having no oral or dental issues, despite lacking natural teeth and reporting difficulty chewing. The MDS nurse confirmed the assessment was inaccurate and did not reflect the resident's true oral/dental status, resulting in incorrect data being sent to CMS.
A resident with diagnoses of depression, dementia, and diabetes had an active depression diagnosis documented in their MDS and was dependent on staff for ADLs, but the facility failed to include depression in the resident's care plan. Staff interviews and record reviews confirmed that no individualized goals or interventions for depression were developed or implemented, contrary to facility policy.
The facility did not ensure that its services met professional standards of quality, as evidenced by practices that did not align with established guidelines for care delivery.
A nurse failed to flush a resident's gastrostomy tube with the physician-ordered amount of water before and after medication administration, instead using a lesser volume than prescribed. The resident, who had severe cognitive impairment and was dependent on staff for care, was at risk due to this deviation from the care plan and physician orders. The DON confirmed that the nurse should have followed the physician's order rather than the facility's default policy.
A resident did not receive food prepared in a form that met their individual needs, as the facility did not consistently modify or adapt meals to accommodate specific dietary requirements or physical limitations.
The facility did not consistently provide food that accommodated resident allergies, intolerances, and preferences, and failed to offer appealing meal options, as observed during the survey.
A resident with chronic medical conditions was found to have opened, unlabeled perishable food items at their bedside that were not refrigerated as required by facility policy. Staff interviews confirmed that the items should have been labeled and stored in the refrigerator, but this was not done, resulting in a failure to follow established procedures for food safety.
The facility's Infection Preventionist did not complete the required ten hours of annual continuing education in infection prevention and control, as confirmed by interviews and lack of documentation. The DON stated that this training is necessary for the IP to effectively educate staff and stay current with infection control practices.
A CNA assisted a resident with severe cognitive and physical impairments by feeding them while the resident was reclined in a Geri chair and not at eye-level, contrary to facility policy and best practices for dignity and aspiration prevention. Both an LVN and the DON confirmed that the resident should have been positioned more upright and that feeding should occur at eye-level to maintain dignity and safety.
A deficiency was identified when 24 resident rooms were found to be below the required 80 sq. ft. per resident, with most two-bed rooms measuring about 149.38 sq. ft. and a four-bed room at 282.87 sq. ft. Despite the space shortfall, no adverse effects on resident care, privacy, or safety were observed during the survey, and the facility acknowledged the deficiency through a waiver request.
A facility failed to follow protocols for administering medications via G-tube for two residents. One resident did not receive the required water flush between medications, risking drug interactions. Another resident's G-tube placement was not verified before medication administration, risking leakage and infection. These actions violated facility policy and posed health risks.
The facility failed to act on pharmacist recommendations for two residents, including adding vitamin B12 and discontinuing docusate sodium. Additionally, a physician disagreed with a recommendation to discontinue vitamin B without providing a rationale. These actions did not comply with the facility's policy, potentially placing residents at risk.
The facility failed to ensure proper medication management, including leaving medications unattended and not labeling an open vial of Lidocaine. A nurse left medications on a cart unattended, and another left prepared medications at a resident's bedside multiple times. The resident had severely impaired cognition and was dependent on staff for assistance. The facility's policies require medications to be attended and properly labeled.
The facility failed to properly label and store food, risking foodborne illnesses. Unlabeled French toast and moldy food were found in refrigerators, lacking preparation dates and resident identifiers. The Dietary Supervisor and DON confirmed the importance of labeling to prevent spoilage, as per facility policy.
The facility failed to maintain proper infection control practices by not labeling residents' urinals and improperly storing them, as well as by allowing staff food to be stored with residents' food in the kitchen refrigerator. These actions were acknowledged by staff and administration as contrary to facility policies, posing potential infection risks.
The facility failed to ensure call lights were within reach for two residents, potentially delaying assistance. One resident with severe cognitive impairment and another with multiple health issues were found without accessible call lights, despite care plans and facility policy requiring them to be within reach for safety.
A resident with cognitive impairments verbally abused another resident in the dining room, calling them an offensive name. The incident was reported to the Social Service Director, and the Activity Director witnessed the event, attempting to redirect the behavior. Despite the facility's abuse prevention policy, the measures were insufficient to prevent this occurrence.
A facility failed to report an allegation of verbal abuse involving two residents to the State Survey Agency (SSA). A resident with cognitive impairments used offensive language towards another resident, who reported the incident to the Social Service Director (SSD). The SSD informed the Administrator, but the Administrator did not report the incident to the SSA as required by the facility's policy. This resulted in a delay of an onsite inspection and potential risk to other residents.
The facility failed to update care plans for two residents, one with hypertension, diabetes, and dementia, and another with encephalopathy and hemiplegia. The care plans were not revised quarterly as required, potentially impacting the delivery of necessary care and services.
The facility did not implement a bowel and bladder retraining program for two residents identified as candidates. One resident, with conditions like arthritis and diabetes, was not started on the program despite an assessment indicating suitability. Another resident, with hypertension and depression, was also not offered the program due to non-ambulatory status, although the assessment suggested it was needed. The facility's policy to restore normal bowel and bladder function was not followed.
A resident with severe cognitive impairment and total immobility was observed with all four bed rails up, contrary to an evaluation recommending against their use. The MDS Nurse confirmed the inappropriate use and noted it was the charge nurses' responsibility to monitor this. Despite the facility's policy on bedrail management, the resident's condition and evaluation were not adequately considered.
A facility failed to accurately document the administration of Ambien for a resident, leading to discrepancies between the Controlled Drug Record and the MAR. The LVN documented the administration time incorrectly, which was acknowledged during an interview. The facility's policy required immediate and accurate documentation of controlled substances, which was not adhered to in this case.
A resident experienced a delay in laboratory services when a urine specimen ordered for urinalysis and culture was not picked up promptly. The specimen, ordered due to a change in condition indicating a burning sensation upon urination, was still awaiting collection the following day. The Infection Preventionist noted a lack of communication with the lab, which contributed to the delay, contrary to the facility's policy on timely lab services.
An LVN at the facility was found to have willfully falsified the medication administration record for a resident by documenting incorrect administration times for Ativan. The resident, with a history of anxiety disorder, was supposed to receive the medication at a specific time, but the LVN administered it later and recorded false times in the MAR and Controlled Drug Record. The facility's policy mandates accurate documentation of medication administration, which was not followed in this case.
A facility failed to ensure hospice staff attended IDT meetings for a resident with dementia, hypertension, and diabetes, leading to potential delays in hospice care coordination. The resident's MDS indicated impaired cognitive skills and dependence on staff for daily activities. The DON cited communication breakdown as the reason for the absence, despite a contract requiring hospice nurse attendance.
The facility failed to meet the federal requirement of 80 square feet per resident in 23 out of 24 rooms, with rooms only having about 149.38 square feet for two residents. Despite this, residents could move freely, and staff provided care without issues. A waiver was submitted, indicating no adverse effects on residents' health or safety.
Failure to Initiate and Investigate Resident Grievance per Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and promptly investigate a resident’s complaint. Resident 1, who had intact cognition and required varying levels of staff assistance for activities of daily living, was admitted with diagnoses including diabetes mellitus with diabetic nephropathy, chronic kidney disease, and an anxiety disorder. On the morning of 3/4/2026, an incident occurred between Resident 1 and Licensed Vocational Nurse 1 (LVN 1) at approximately 6:30 a.m. Later that morning, at 8:36 a.m., Resident 1 emailed the Director of Nursing (DON) describing the incident and expressing that LVN 1’s response was not acceptable and was wrong. By 3/6/2026, Resident 1 reported that no facility staff had asked about the incident, and no one had explained whether the incident had been investigated. Record review and staff interviews confirmed that the grievance was not processed or investigated in accordance with facility policy. The DON acknowledged receiving the resident’s email on the morning of 3/4/2026 and stated that the Social Services Director (SSD), who was responsible for filing grievances, had been verbally informed. However, review of the facility’s Grievances and Complaints binder showed that the grievance had not been filed and no investigation had been initiated. The Administrator confirmed that the grievance should have been entered into the grievance filing system and that an investigation should have been started. The SSD also confirmed that the required Complaint/Grievance form had not been used to initiate the grievance process and that no investigation had begun. This was inconsistent with the facility’s written policies, which state that residents have the right to voice grievances without discrimination or reprisal and that the Grievance Officer must conduct an initial investigation within 24 hours of receiving a grievance, using prescribed forms.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Improper Labeling and Storage of Prepared Canned Fruit
Penalty
Summary
The facility failed to ensure that plastic containers of canned fruit stored in the refrigerator were properly labeled and dated. During an observation in the kitchen with the Dietary Supervisor, four large plastic containers of canned fruit were found with only a preparation date and no use-by date. The Dietary Supervisor confirmed that the fruit should be consumed within three days of preparation to maintain quality and safety, but the containers exceeded this period and were not labeled with a use-by date as required. The facility's policy and procedures indicated that all food items in the refrigerator should be labeled with both an open date and a use-by date, which was not followed in this instance.
Inaccurate MDS Assessment of Oral/Dental Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the oral and dental status of a resident. The resident, who had a history of schizophrenia, bipolar disorder, dementia, and diabetes mellitus, was assessed as not having any oral or dental issues on the MDS. However, during an observation and interview, the resident reported difficulty chewing food due to the absence of natural teeth. This discrepancy was confirmed during a review of the MDS with the MDS nurse, who acknowledged that the coding was inaccurate and did not represent the resident's actual oral and dental condition. The facility's policy required that resident assessments accurately reflect the resident's status and be certified by a registered nurse. Despite this, the MDS for the resident did not document the lack of natural teeth, resulting in incorrect data being transmitted to CMS. The MDS nurse stated that accurate coding is important for quality measures, care monitoring, outcome measurement, and care planning, and acknowledged that the inaccuracy could lead to unmet care needs and services for the resident.
Failure to Address Depression Diagnosis in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address the depression diagnosis for one resident. Review of the resident's face sheet and Minimum Data Set (MDS) confirmed an active diagnosis of depression, along with dementia and diabetes mellitus. The MDS also indicated impaired cognition and total dependence on staff for activities of daily living. Despite these findings, the care plans reviewed from March through August did not address the resident's depression diagnosis, and there were no documented goals or interventions specific to depression. Interviews with the MDS nurse and the Director of Nursing confirmed that the omission of a care plan for depression was contrary to facility policy, which requires all active diagnoses to be addressed with individualized goals and interventions. Both staff members acknowledged that the lack of a care plan for depression meant the resident was not properly monitored or provided with necessary services related to their mental health needs. Review of the facility's policy further supported the requirement for comprehensive care plans to address each resident's medical, nursing, mental, and psychological needs.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines for care delivery. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the residents involved or their medical conditions, were not provided in the report.
Failure to Follow Physician Orders for GT Flushing
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to follow physician orders for gastrostomy tube (GT) care for a resident with severe cognitive impairment, diabetes mellitus, and dementia. During a medication pass, the LVN flushed the resident's GT with only 30 milliliters (mL) of water before and after administering medications, instead of the prescribed 50 mL. The LVN acknowledged the error, stating she was nervous and did not follow the physician's order, despite being responsible for verifying the correct amount prior to administration. The resident's care plan required nurses to provide fluids via GT as ordered to maintain adequate nutritional intake and prevent dehydration. The Director of Nursing confirmed the importance of adhering to physician orders, noting that the facility policy specified 30 mL but the nurse was required to follow the current physician order of 50 mL. The facility's job description for medication nurses also required treatments to be performed according to physician orders. This failure to follow prescribed GT flushing protocols was identified through observation, interview, and record review.
Failure to Provide Food in Appropriate Form for Individual Needs
Penalty
Summary
The facility failed to ensure that each resident received food prepared in a form designed to meet their individual needs. This deficiency indicates that meals were not consistently modified or adapted as required to accommodate specific dietary requirements or physical limitations of residents, such as texture modifications or other individualized food preparations.
Failure to Accommodate Resident Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that each resident received food that accommodated their allergies, intolerances, and preferences, and did not consistently provide appealing food options. This deficiency was identified through observations and review of food service practices, which revealed that residents were not always provided with meals that met their individual dietary needs and preferences.
Failure to Label and Refrigerate Perishable Food Brought by Visitors
Penalty
Summary
The facility failed to follow its policy and procedure regarding the labeling and storage of food items brought in by family or visitors for a resident. Specifically, an unlabeled, opened ketchup bottle and an unlabeled, opened jar of red raspberry preserves were observed at the bedside of a resident over several days. Both items were labeled by the manufacturer to be refrigerated after opening, but were instead left at room temperature in the resident's room. The resident reported that the items had been opened for several weeks and that staff had not offered to store them in the refrigerator. Interviews with a CNA and the Infection Preventionist Nurse confirmed that the food items should have been labeled with the resident's name, room number, and date received, and stored in the refrigerator as per facility policy. The staff acknowledged that improper storage of such items could lead to foodborne illness. Review of the facility's policy indicated that perishable foods must be stored in resealable containers with tightly fitting lids in the refrigerator and labeled appropriately, with nursing staff responsible for discarding perishable foods on or before the 'use by' date.
Infection Preventionist Did Not Complete Required Annual Continuing Education
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) completed the required ten hours of continuing education in infection prevention and control for the year 2024. During an interview, the IP was unable to provide documentation of having completed the necessary education hours for that year. The IP acknowledged that while he had completed continuing education hours for his nursing license renewal, those hours were not obtained in 2024 and did not specifically pertain to infection prevention and control. The IP also stated it was his responsibility to complete the annual education to stay current with new guidelines and practices. Further interviews with the Director of Nursing (DON) confirmed that the IP was responsible for educating staff on current infection prevention and control practices and that staying up to date with training was essential for this role. The DON stated that failure to complete the required annual training could result in the IP missing critical updates, which could affect the consistency of infection prevention measures. A review of the California Department of Public Health All Facilities Letter indicated that the IP should complete ten hours of continuing education in infection prevention and control annually.
Failure to Provide Dignified, Safe Feeding Assistance at Eye-Level
Penalty
Summary
A certified nursing assistant (CNA) was observed providing feeding assistance to a resident with severe cognitive impairment, hemiplegia, epilepsy, diabetes mellitus, and dysphagia. The resident was dependent on staff for eating and required a pureed, consistent carbohydrate, no added salt diet. During the lunch observation, the CNA was seated in front of the resident, who was in a Geri chair that was not in an upright position. The CNA and the resident were not at eye-level during feeding. The CNA stated the chair was reclined to prevent the resident from falling forward. A licensed vocational nurse (LVN) confirmed that the resident was lying back while eating and should have been positioned more upright to prevent aspiration. The director of nursing (DON) stated that residents should be positioned upright as much as tolerated to prevent aspiration and that CNAs should be at eye-level with residents during feeding to maintain dignity. Facility policies and the CNA job description require feeding to be provided with attention to safety, comfort, and dignity, including not standing over residents and treating them with respect at all times. The observed actions did not align with these requirements.
Resident Rooms Below Minimum Size Requirement
Penalty
Summary
The facility failed to meet the required room size measurement of 80 square feet per resident in rooms with multiple residents. A review of the facility's Client Accommodations Analysis form showed that 24 rooms did not meet the 80 sq. ft. per resident requirement, with most two-bed rooms measuring approximately 149.38 sq. ft. and a four-bed room measuring 282.87 sq. ft., both below the minimum required space. The facility had previously submitted a Room Waiver Request Letter acknowledging that these rooms did not meet the standard and outlining that accommodations would be made to ensure residents could move freely and have necessary furniture. Observations conducted during the survey period did not reveal any adverse effects on residents' care, privacy, health, or safety related to the reduced living space. The facility's policy indicated that rooms under 80 sq. ft. per resident would only be used when allowed under grandfathering provisions and would remain safe and functional. The administrator confirmed that the facility was aware of the space deficiency and maintained that residents' needs were being met despite the lack of compliance with the current room size requirements.
Failure to Follow G-Tube Medication Administration Protocols
Penalty
Summary
The facility failed to adhere to physician's orders for a resident with a gastrostomy tube (G-tube), specifically regarding the flushing of the tube between medication administrations. Resident 6, who was admitted with severe cognitive impairment and required assistance with all activities of daily living, had specific orders to flush the G-tube with five to 10 milliliters of water between each medication. However, during an observation, a Licensed Vocational Nurse (LVN 1) was seen administering multiple medications through the G-tube without performing the required flushes. This oversight was acknowledged by the Director of Nursing (DON), who confirmed that the failure to flush could lead to medication interactions and affect the effectiveness of the medications. Additionally, the facility did not ensure proper verification of G-tube placement before administering medications to Resident 17, who had dysphagia, Type 2 Diabetes Mellitus, and dementia. During a medication administration observation, LVN 2 failed to check the placement of the G-tube by auscultating and aspirating stomach contents, as required by facility policy. This lapse was admitted by LVN 2, who recognized the risk of medication leakage into the abdominal cavity, potentially leading to infection and sepsis. The facility's policy on medication administration via enteral tubes, which mandates flushing between medications and verifying tube placement, was not followed in these instances. These deficiencies posed significant risks to the residents involved, potentially leading to drug interactions and serious health complications.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The facility failed to act upon the pharmacist's recommendations for two residents, leading to potential risks of unnecessary medication or adverse side effects. For one resident, the pharmacist recommended adding vitamin B12 to the medication regimen due to long-term use of metformin, which can decrease vitamin B12 absorption. However, there was no documentation indicating that the physician responded to or acted upon this recommendation. Additionally, the pharmacist suggested discontinuing docusate sodium for the same resident, as they were already receiving multiple other medications for constipation. Again, there was no evidence that the physician addressed this recommendation. Another deficiency involved a different resident, where the pharmacist recommended discontinuing vitamin B, as the resident was already receiving a multivitamin. The physician disagreed with this recommendation, but there was no documented rationale for the disagreement. This lack of documentation is contrary to the facility's policy, which requires that any disagreement with a pharmacist's recommendation be accompanied by an explanation. The facility's policy on Medication Regimen Review and Reporting mandates that recommendations from the pharmacist be documented and acted upon within a reasonable timeframe. The policy also requires that if a physician disagrees with a recommendation, they must provide a rationale for their decision. The failure to adhere to these policies resulted in the deficiencies noted in the report, potentially placing residents at risk of receiving unnecessary medications or experiencing adverse side effects.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure that medications were not left unattended by licensed nurses, which could lead to serious side effects if accessed by unauthorized individuals. During an observation, a nurse left two medicine cups with medications on top of a medication cart unattended for two minutes while she went into an activity room. The facility's policy clearly states that medications should not be left on top of the cart and must be visible to the personnel administering them. Additionally, the facility did not label an open multi-dose vial of Lidocaine 1% with an open date, which could compromise the medication's therapeutic effectiveness. During an observation, a nurse confirmed that all opened multi-use vials should be dated for safety. The facility's policy requires that the date opened and the initials of the first person to use the vial be recorded on multidose vials. Furthermore, a nurse left prepared medications unattended at a resident's bedside multiple times. The resident had severely impaired cognition and was dependent on staff for assistance with all activities of daily living. The nurse left the medications out of eyesight while attending to other tasks, which could result in unauthorized access. The Director of Nursing confirmed that medications should never be left unattended at the bedside, as it could lead to negative outcomes for the resident.
Improper Food Labeling and Storage in Facility
Penalty
Summary
The facility failed to ensure proper labeling and storage of food items, which could potentially lead to foodborne illnesses among residents. During an observation, a kitchen refrigerator was found to contain an unlabeled bag with prepared French toast, which should have been labeled with the date it was prepared. Additionally, a designated resident refrigerator in the staff break room contained a plastic bag with moldy, unidentifiable food that was labeled with a resident's name but not the date it was placed inside. Another unlabeled bag containing refried beans was also found, lacking both a resident identifier and the date it was placed inside the refrigerator. Interviews with the Dietary Supervisor and the Director of Nursing revealed that it is the responsibility of charge nurses or CNAs to label food items with the date they are stored or prepared, as well as with a resident identifier. The facility's policy requires that all food items in storage be labeled and dated, with leftovers covered, labeled, and dated. The failure to adhere to these procedures could result in residents consuming spoiled or expired food, potentially leading to foodborne illnesses.
Infection Control Deficiencies in Urinal Handling and Food Storage
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices concerning the handling and labeling of urinals for residents. In one instance, a resident's urinal was found hanging on a trash receptacle next to the resident's bed without a label. The Certified Nursing Assistant (CNA) acknowledged that the urinal belonged to the resident and admitted that it should have been stored in the restroom with the resident's name on it. The CNA also recognized the importance of labeling the urinal to prevent cross-contamination and ensure proper identification. In another case, a different resident's urinal was observed hanging on the side rail of the bed, also without a label and containing liquid. The CNA confirmed the urinal's ownership and stated that the contents should be discarded and the urinal stored properly with the resident's name. The facility's administrator reiterated that urinals should not be placed on trash receptacles and should be labeled to prevent infection risks. Additionally, the facility did not maintain proper separation of staff and residents' food in the kitchen refrigerator. A staff member's personal food was found stored alongside residents' food, which the Dietary Supervisor and Director of Nursing acknowledged was against facility practice. They emphasized the importance of keeping staff food separate to prevent potential cross-contamination and foodborne illnesses among residents. However, the facility lacked a specific policy addressing this issue.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, potentially delaying the provision of services and not meeting residents' needs. Resident 6, who was readmitted with conditions including gastrostomy, hypotension, and dysphagia, was observed with a call light not within reach. Despite having a care plan intervention to keep the call light accessible, it was found hanging off the side rail during an observation. A Certified Nursing Assistant (CNA) confirmed the call light should be within reach for safety. Similarly, Resident 25, with diagnoses including hypertension, chronic obstructive pulmonary disease, and osteoarthritis, was found without a call light within reach. The resident was heard yelling for help, and upon investigation, the call light was discovered on the floor behind the headboard. A CNA retrieved and placed it within reach, acknowledging the importance of accessibility for safety. The facility's policy, reviewed in April 2024, mandates that call lights be within easy reach when residents are in bed or confined to a chair.
Verbal Abuse Incident in Dining Room
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse when one resident verbally abused another in the main dining room. On the specified date, a resident with intact cognitive skills and independence in activities of daily living was called an offensive name by another resident who has cognitive impairments due to dementia and Alzheimer's disease. The incident was reported by the verbally abused resident to the Social Service Director, who confirmed the occurrence of verbal abuse. The Activity Director witnessed the incident, noting that the resident with cognitive impairments was cursing and looking in the direction of the other resident. Although the Activity Director attempted to redirect the behavior, the facility's policy on abuse prevention and protection was not effectively implemented to prevent this incident. The facility's policy, last revised in March 2023, outlines procedures for the prevention, identification, investigation, and reporting of abuse, but these measures were not sufficient to prevent the verbal abuse from occurring.
Failure to Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting a reasonable suspicion of a crime, specifically verbal abuse, in accordance with section 1150B of the Act. This deficiency was identified when the facility did not report an allegation of verbal abuse involving two residents to the State Survey Agency (SSA). Resident 36, who was cognitively intact and independent in activities of daily living, reported to the Social Service Director (SSD) that Resident 32, who had cognitive impairments and required assistance with daily activities, used offensive language towards them in the main dining room. The SSD acknowledged the incident as verbal abuse and informed the Administrator, who is the designated abuse coordinator. Despite being informed of the incident, the Administrator did not report the allegation to the SSA, as required by the facility's policy and procedures. The facility's policy, last revised in March 2023, mandates that all alleged violations involving abuse must be reported immediately, but not later than two hours after the allegation is made. The failure to report the incident resulted in a delay of an onsite inspection by the SSA, potentially compromising the safety of other residents and leading to unidentified abuse.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to revise and renew comprehensive person-centered care plans for two residents, Resident 18 and Resident 4, as required. Resident 18 was originally admitted with diagnoses including hypertension, type 2 diabetes mellitus, and dementia. The Minimum Data Set (MDS) for Resident 18 indicated impaired cognitive skills and dependence on staff for daily activities, with a care area assessment triggering a fall risk care plan. However, the care plan was last evaluated in February 2021 and not updated in May 2024, despite the Director of Nursing (DON) acknowledging the necessity of quarterly evaluations to ensure appropriate care and services. Similarly, Resident 4, who was readmitted with conditions such as encephalopathy and hemiplegia following a cerebral infarction, had a care plan for wandering that was not updated since December 2023. The DON confirmed that the care plan should have been updated in March 2024 and quarterly thereafter. The facility's policy mandates care plan updates at least quarterly or when there is a significant change in the resident's condition, a readmission, or unmet desired outcomes. The failure to update these care plans as per policy could result in inadequate care and services for the residents.
Failure to Implement Bowel and Bladder Retraining Program
Penalty
Summary
The facility failed to implement a bowel and bladder retraining program for two residents, Resident 47 and Resident 45, who were identified as candidates for such a program. Resident 47 was admitted with conditions including arthritis, hyperlipidemia, muscle wasting, and diabetes mellitus. Despite an assessment indicating that Resident 47 was suitable for bowel and bladder training, the facility did not initiate the program. The MDS Nurse confirmed that the training should have been started to prevent further loss of bowel and bladder function. Similarly, Resident 45, who was admitted with hypertension, depression, and constipation, was also identified as a candidate for bowel and bladder training. Although Resident 45 was not ambulatory, the MDS Nurse acknowledged that the training should have been offered based on the assessment results. The facility's policy emphasizes restoring normal bowel and bladder function, yet the training was not initiated or documented for Resident 45, contrary to the facility's procedures.
Inappropriate Use of Bed Rails for Immobile Resident
Penalty
Summary
The facility failed to ensure the appropriate use of bed rails for a resident, identified as Resident 6, who was observed with all four side rails up despite an evaluation indicating that side rails were not recommended. Resident 6 was readmitted to the facility with several diagnoses, including a degenerative disease of the nervous system, hypotension, and dysphagia, and was noted to have severely impaired cognition. The Minimum Data Set (MDS) assessment dated 6/26/2024 indicated that Resident 6 was dependent on staff for various activities of daily living and was totally immobile, leading to the recommendation against the use of side rails. On 8/11/2024, during an observation and interview, the MDS Nurse confirmed that Resident 6 should not have any side rails in place based on the evaluation. The MDS Nurse acknowledged that it was the responsibility of the charge nurses to monitor residents and ensure side rails were not used inappropriately. Despite this, the MDS Nurse expressed a belief that there would be no negative outcomes from having the side rails up, as Resident 6 was unable to be entrapped. The facility's policy on bedrails, reviewed on 4/17/2024, emphasized the need for adequate management to ensure residents' well-being, which was not adhered to in this instance.
Medication Administration Documentation Error
Penalty
Summary
The facility failed to implement its policy on medication administration by not ensuring that the administration of Ambien for one resident was accurately documented on the Controlled Drug Record. The resident, who was originally admitted in 2017 and readmitted in 2019, had diagnoses including anxiety disorder, unspecified mood disorder, and hypertension. The resident's cognition was intact, and they were independent with toileting but required assistance with other personal care tasks. A physician's order indicated that Ambien was to be administered at bedtime for insomnia. On the date in question, the Licensed Vocational Nurse (LVN) documented administering Ambien at 8:58 p.m. on the Medication Administration Record (MAR), but the Controlled Drug Record indicated it was administered at 6:45 p.m. During an interview, the LVN acknowledged the discrepancy and stated that the administration time should match on both records. The Director of Nursing confirmed that controlled drug administration should be accurately reflected on both the Controlled Drug Record and the MAR. The facility's policy required immediate documentation of the administration details on the accountability record, which was not followed in this instance.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to provide timely laboratory services for a resident, identified as Resident 45, which placed the resident's well-being at risk. Resident 45 was admitted with diagnoses including encephalopathy, essential hypertension, and type 2 diabetes mellitus. On June 21, 2024, a change of condition was noted for Resident 45, indicating a burning sensation upon urination. Consequently, a physician ordered a urinalysis and culture with sensitivity testing. However, the urine specimen was not picked up promptly, as it was still awaiting collection on June 22, 2024, despite being ordered on June 21, 2024. During an interview and record review, the Infection Preventionist confirmed that the lab specimen should have been obtained and picked up on the same day the labs were ordered. The delay was attributed to a lack of communication with the laboratory regarding the readiness of the urine specimen for pick-up. The facility's policy on laboratory services, which emphasizes the timeliness and quality of lab services, was not adhered to, as there was no documented evidence of communication with the lab to ensure timely specimen collection.
Falsification of Medication Administration Record by LVN
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN 3) did not willfully falsify the medication administration record for a resident. On the specified date, LVN 3 was observed administering Ativan to Resident 19 at 6:45 p.m., which was later than the scheduled time of 5:00 p.m. However, LVN 3 documented in the Medication Administration Record (MAR) and the Controlled Drug Record that the medication was administered at 5:46 p.m. and 5:45 p.m., respectively. During an interview, LVN 3 admitted to falsely documenting the administration times, acknowledging that the medication was actually given at 6:45 p.m. Resident 19, who had been admitted to the facility with diagnoses including anxiety disorder and unspecified mood disorder, was supposed to receive Ativan twice daily as per the physician's order. The facility's policy requires that medication administration be documented immediately after the medication is given, reflecting the actual time of administration. The Administrator confirmed that LVN 3's actions were against the facility's policy, which prohibits willful material falsification of medical records. This incident resulted in the resident's clinical record inaccurately reflecting the care provided.
Absence of Hospice Staff at IDT Meetings
Penalty
Summary
The facility failed to ensure that hospice care staff was present for two Interdisciplinary Team (IDT) meetings for a resident receiving hospice care. The resident, who was originally admitted to the facility in March 2022 and readmitted in August 2023, had diagnoses including hypertension, Type 2 Diabetes Mellitus, and dementia. The resident's Minimum Data Set (MDS) assessment indicated impaired cognitive skills for daily decision-making and dependence on staff for various activities of daily living. Despite these needs, the hospice care provider representative was absent from IDT meetings held in February and May 2024. During an interview and record review, the Director of Nursing (DON) acknowledged the absence of the hospice nurse at the IDT meetings, attributing it to a breakdown in communication between the facility and the hospice care staff. The facility's contract with the hospice provider, dated February 2017, stipulated that a hospice nurse or RN Supervisor should attend care plan meetings. The lack of hospice staff presence at these meetings potentially resulted in a delay or lack of coordination in the delivery of hospice care and services to the resident.
Room Size Deficiency in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure that 23 out of 24 resident rooms met the federal regulation requirement of 80 square feet per resident in multiple resident rooms. During the recertification survey conducted from August 9, 2024, to August 11, 2024, it was observed that the rooms did not meet the minimum square footage requirement. Specifically, rooms intended for two residents were required to have at least 160 square feet, but the rooms in question only had approximately 149.38 square feet each, with one room having 148.29 square feet. Despite this, observations and interviews indicated that residents were able to move freely within their rooms, and there was adequate space for the use of mobility aids such as wheelchairs and walkers. The facility had submitted an application for a Room Variance Waiver for these 23 rooms, acknowledging that they did not meet the required square footage. The waiver request indicated that the lack of space did not adversely affect the health, safety, or well-being of the residents. Residents interviewed during the survey did not express any concerns regarding the room sizes, and staff were able to provide care without issues related to space constraints. The facility maintained that the rooms were comfortable and that resident needs were being met despite the variance from the building code requirements.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sunland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunland Post Acute | 0.4 mi | ★★★★★ | 35 | 0 |
| North Valley Nursing Center | 1.2 mi | ★★★★★ | 13 | 0 |
| The Hills Healthcare Center | 1.2 mi | ★★★★★ | 17 | 0 |
| Totally Kids Specialty Healthcare - Sun Valley | 2.7 mi | ★★★★★ | 23 | 0 |
| Villa Scalabrini Special Care | 2.9 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.