Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 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.
Expired syringes were found in Medication Cart South during observation, and the MDSC and DON stated the items could have affected quality and sterility. The facility also had an outdated Water Management Plan with staff roles that no longer matched current assignments, and the MS was only monitoring resident room sinks and showers even though the plan called for weekly monitoring of specific control points. The IP stated the plan had not been updated since 2018.
Failure to Assess and Report Resident Skin Changes: A resident with dementia and chronic bullous pemphigoid had widespread skin lesions, scabbing, and open areas involving the chest, neck, hands, and face. Staff observed frequent scratching and wounds on multiple body areas, but the record lacked a clear COC assessment or documentation showing when the skin changes began or whether the condition was improving or worsening. The DON stated there was no record of wound progress monitoring and that the resident’s representative was not notified about the progression to the facial area.
Improper food labeling, storage, and damaged cutting boards were observed in the kitchen. An opened container of non-dairy creamer, chocolate-flavored syrup, corn tortillas, and several dry goods lacked open date labels, while multiple items were left open or not properly sealed. Expired salad dressing and cayenne pepper were also found, and six chopping boards had staining and knife scratches. The DS stated opened items must be dated and sealed, expired items must be discarded, and the boards were old and could no longer be adequately cleaned.
Improper Dumpster Storage and Pest Attraction: Two outside dumpsters were observed with rust, dirt, dried liquid spills, ants, gaps under the lids exposing garbage, and one dumpster overflowing with trash and left partially open when not in use. The DS stated kitchen waste was collected after meals and taken to the dumpster area, while the MS stated housekeeping placed garbage in the dumpsters throughout the day and noted the gaps could attract insects and pests. Facility policy required tight-fitting lids, daily emptying, and daily exterior cleaning.
Incomplete Privacy Curtain During G-Tube Medication Administration: A resident with no speech and severely impaired cognition was observed during g-tube medication administration with the privacy curtain only halfway closed, leaving part of the body visible. The blanket was removed and the gown lifted to access the g-tube, exposing the abdomen. The MDSC stated the curtain should have been fully closed, and the DON confirmed privacy curtains are used to protect resident privacy and dignity during care.
Failure to Inform Resident of Medication Indications: An MDSC administered aspirin and polyethylene glycol to a resident without first explaining the reason for each medication. The resident had no speech and severely impaired cognition, and the H&P stated the resident could not make own medical decisions but could make needs known. The DON stated residents must be told the name and reason for each medication before administration, and the physician orders listed aspirin for clot prevention and polyethylene glycol for bowel management.
Call Light Not Within Reach for a Resident With Severe Mobility Limits. A resident with no speech, severely impaired cognition, and dependence for ADLs and mobility was observed lying in bed with a touch pad call light placed about a foot away from the face instead of within reach. The MDSC stated the resident had contractures and needed the call light positioned by the elbow to activate it, and the DON stated call lights must remain within reach and be answered promptly. The care plan and facility policy both indicated the call light should be within reach when the resident is in bed.
Failure to Assist Resident With Advance Directive: A resident with intact cognition, DM, HF, depression, and anxiety was admitted with documentation showing an advance directive acknowledgment, but the record also showed no advance directive was available. The resident later stated she did not currently have an advance directive and wanted help creating one, while the SSD confirmed he did not follow up to verify whether she still wanted to execute one. Facility policy required the SSD or designee to provide written information about medical decision-making rights and ask about any existing advance directive at or before admission.
A resident with stroke, COPD, and schizophrenia had an incomplete belongings inventory that did not list hearing aids brought in by a family member and lacked the required responsible party signature. The DSS found only one facility representative signature on the form and no other inventory in the record, while the DON stated all resident items must be inventoried and documented.
Incomplete MDS Assessment for Resident with Dementia: A resident with acute pyelonephritis and vascular dementia was assessed as sometimes understood and sometimes able to understand others, but the MDS did not include the BIMS or Resident Mood Interview. The MDSC noted the resident’s communication abilities conflicted with the sections stating the resident was rarely or never understood, and stated the resident likely could have completed both assessments, even if not answering every question.
A resident with cerebral infarction, COPD, and schizophrenia had recurring bilateral impacted cerumen documented by ENT, and the resident reported difficulty hearing and needing ear cleaning. Although ENT notes included cerumen removal and instructions to avoid cotton swabs and objects in the ears, the MDSC stated no care plan was developed to capture the recurring earwax buildup or the ENT guidance, and the DON confirmed care plans are used to identify resident-specific problems, goals, and interventions.
Unlabeled, unpackaged tablets were found in the bottom of two drawers on Medication Cart South during survey observation. The MDSC stated the tablets should not have been there because staff did not know what the medications were or which residents they belonged to, and the DON identified loose medications as a medication storage issue. The facility P&P stated medications are to be stored properly to maintain integrity and support safe administration.
A resident with type 2 DM, chronic systolic heart failure, depression, and generalized anxiety disorder had intact cognition and was documented as having decision-making capacity, but the advance directive acknowledgement was contradictory, showing both that the resident had executed an advance directive and wished to execute one. The form also lacked the facility representative signature, and the POLST indicated the advance directive was not available. The SSD acknowledged the error and the failure to resolve the conflicting information.
Failure to Offer Annual Flu Vaccine: A resident with COPD and DM was documented as refusing the flu vaccine once after admission, but the record did not show any further offers when the next flu season began. The IP stated he assumed the resident did not want any further vaccines, and there was no documentation or care plan addressing refusal of all further vaccinations.
Failure to offer the updated COVID-19 vaccine to a resident after an earlier refusal. A resident with COPD and DM had previously refused the vaccine, but the IP did not offer the updated dose when it became available, believing the resident did not want any further vaccines. The record also lacked documentation or a care plan addressing refusal of all further vaccinations, despite facility policy requiring education and offering of vaccine doses to residents and staff as soon as available.
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.
Expired Syringes in Medication Cart and Outdated Water Management Plan
Penalty
Summary
The facility failed to maintain its infection prevention and control program when a package of syringes with an expired date was found in one inspected medication cart, Medication Cart South. During a concurrent observation and interview, the MDSC observed the syringes in a medication cart drawer and stated she did not know why they were there. The MDSC also stated that if the syringes were used on a resident, their quality could be affected because they were marked as expired. The DON later stated the expired syringes could affect quality, could be damaged, and sterility could be affected. The facility policy for Medical Supply Storage stated supplies are to be stored in a safe, clean, organized, and secure manner, and that staff shall routinely inspect supplies for expiration dates and package integrity, with expired supplies removed immediately. The facility also had an out-of-date Water Management Plan that was not implemented as written. During record review and interview, the DSD stated the staff listed in the plan no longer held those roles, including the infection control lead, maintenance program administrator, clinical representative, and laboratory contact. The Maintenance Supervisor stated she only checked water temperatures in resident room sinks and showers weekly and did not monitor any other areas, while the Water Management Plan called for weekly monitoring of control points CWS-1, HWS-1, and HWS-2 and referenced a piping and instrumentation diagram. The IP stated the plan had not been updated since 2018 and that the people involved with water management had changed. The facility's Infection Prevention and Control Program and Water Supply policies stated the program includes measures to prevent transmission of infectious agents and maintain a sanitary water supply and control waterborne microorganisms.
Failure to Assess and Report Resident Skin Changes
Penalty
Summary
The facility failed to ensure treatment and care were provided in accordance with professional standards for one resident with dementia, hypertension, atopic dermatitis, and bullous pemphigoid. The resident’s records showed severe cognitive impairment and dependence for many activities of daily living. Dermatology documentation described chronic skin involvement with urticarial lesions, large tense vesicles, erosions, and denuded surfaces affecting the head, neck, chest, abdomen, back, pelvis, and extremities, and the care plan identified altered skin integrity related to bullous pemphigoid and recurrent bullous pemphigoid with interventions to monitor for deterioration and infection. During observation, the resident was seen with generalized scabbing of varying sizes on the upper chest, neck, and hands, with some areas dry and others open. Later, the resident was observed scratching the right leg and face, and a CNA reported frequent scratching with wounds on the right side of the body, upper arms, lower legs, neck, and lower chin. The record review and interviews showed that the nursing documentation did not specify when the skin condition began, and the LVN stated that any changes in skin should prompt a change of condition assessment. The LVN also stated she was unfamiliar with the proper documentation procedure for wound assessments. The DON reviewed the wound management and change of condition documentation and was unable to provide a nursing assessment showing whether the resident’s skin condition was improving or deteriorating. The DON stated there was no record of assessment or monitoring of wound progress and that the resident’s skin changes should have been monitored, documented weekly, and reported to the physician and resident representative. The DON further stated that the documentation could not show when the scab or open wound in the neck or chin area first developed, that a change of condition evaluation was not initiated, and that the resident’s representative was not notified of the progression of the skin condition to the facial area. The resident’s family member also stated there had been a lack of communication about the progression of the condition to the face and the resident’s current state.
Improper Food Labeling, Storage, and Damaged Cutting Boards
Penalty
Summary
Safe and sanitary food storage and food preparation practices were not maintained in the kitchen. During observation with the Dietary Supervisor, reach-in refrigerator 1 contained an opened container of non-dairy creamer and a chocolate-flavored syrup without open date labels. Reach-in refrigerator 2 contained an opened bag of corn tortillas without an open date label, an opened bag of flour tortillas, a storage bag containing an opened bag of shredded cheese, and a container of sliced dill pickles left open and not properly sealed. One bottle of salad dressing was found expired on 6/20/2026. On the storage rack, containers of beef flavor soup base, tarragon leaves, ground cinnamon powder, poultry seasoning, cocoa powder, chicken flavor soup base, ground rosemary, and ground cumin had no open date labels, and a container of cayenne pepper powder was found expired on 5/20/2026. During a separate observation, six chopping boards were noted to have staining and knife scratches. The Dietary Supervisor stated that opened food items are expected to be labeled with the date they were opened, expired food items must not be kept in the kitchen and are required to be discarded promptly, and opened food items must remain properly sealed. The Dietary Supervisor also stated that the chopping boards were old and required replacement because they could no longer be adequately cleaned and presented a potential risk for bacterial growth. Facility policy required food items stored in the storeroom, refrigerator, and freezer to be appropriately labeled and dated, newly opened food items to be securely closed and labeled with the date of opening, and utensils and equipment to be kept clean, well-maintained, and free from breaks, cracks, and chipped areas.
Improper Dumpster Storage and Pest Attraction
Penalty
Summary
The facility failed to dispose of garbage and refuse properly when two outside dumpsters were observed with bodies that were not free of rust, dirt, and dried liquid spills. During observation, the black-colored dumpster had a cluster of ants crawling on it, and both dumpsters had a gap of about three inches under the lids, leaving garbage exposed when the dumpsters were not in use. The blue-colored dumpster was also observed overflowing with garbage and not completely closed when not in use. During interview, the Dietary Supervisor stated that kitchen and food item garbage was collected by housekeeping staff after each meal and disposed of in the outside dumpster area. The Maintenance Supervisor stated that housekeeping staff removed garbage as needed and placed it in the dumpsters throughout the day, but did not know who was maintaining dumpster cleanliness. The Maintenance Supervisor also stated that the gap in both dumpsters could potentially attract insects and pests, and that the garbage cover should remain closed and sealed to prevent attraction of insects and pests. Facility policy required garbage containers to have tight-fitting lids, remain covered when not in use, be emptied daily, and have exteriors cleaned at least once a day.
Incomplete Privacy Curtain During G-Tube Medication Administration
Penalty
Summary
The facility failed to provide care in a manner that promoted Resident 6's dignity and respect when the Minimum Data Set Coordinator did not completely close the resident's privacy curtain during medication administration. Resident 6 was admitted and re-admitted to the facility with diagnoses including pneumonia, COPD, and muscle contracture of both upper arms. The resident's MDS indicated no speech and severely impaired cognitive skills, and the H&P stated the resident could not make own medical decisions but could make needs known. During a medication pass observation, the MDSC drew the privacy curtain only halfway along the bed, leaving the lower portion of Resident 6 visible. The blanket covering the resident's abdomen was removed and the resident's gown was lifted to access the g-tube for medication administration, exposing the resident's abdomen. The MDSC stated the curtain should have been drawn all the way with no gaps and acknowledged that the partial curtain placement did not prevent others from seeing the resident. The DON stated privacy curtains are used during treatments to protect residents' privacy and dignity, and the facility policy required privacy curtains, doors, or screens to be closed before beginning any treatment or personal care that may expose the resident.
Failure to Inform Resident of Medication Indications
Penalty
Summary
The facility failed to ensure that Resident 6 was informed of the indication for medications before administration. Resident 6 was originally admitted on 3/27/2022 and re-admitted with diagnoses including pneumonia, COPD, and muscle contracture of both upper arms. The MDS dated 6/11/2026 indicated the resident had no speech and severely impaired cognitive skills, and the H&P dated 7/16/2025 stated the resident could not make own medical decisions but could make needs known. During medication pass observation on 6/30/2026 at 8:56 a.m., the MDS Coordinator administered aspirin 81 mg and polyethylene glycol 3350 powder 17 gm dose to Resident 6 without informing the resident of the reason for either medication before giving them. The physician orders listed aspirin for clot prevention and polyethylene glycol for bowel management. In interview, the MDS Coordinator stated she forgot to tell the resident the indication for the medications and acknowledged it was her responsibility to inform the resident before administration. The DON stated residents must be told the name and reason for each medication before it is given and that Resident 6 should have been informed before administration.
Call Light Not Within Reach for Resident With Severe Mobility Limitations
Penalty
Summary
The facility failed to ensure that the call light was within reach for Resident 6. Resident 6 was originally admitted on 3/27/2022 and re-admitted with diagnoses including pneumonia, COPD, and muscle contracture of the left and right upper arm. The MDS dated 6/11/2026 indicated the resident had no speech, severely impaired cognitive skills, and was dependent for ADLs and all mobility functions. The H&P dated 7/16/2025 stated the resident could not make own medical decisions but could make needs known. The care plan for ADL/Self Care Deficit, initiated 3/12/2026, included the intervention to have the call light within reach and answer promptly. During a concurrent observation and interview on 6/29/2026 at 12:30 p.m., the MDSC observed Resident 6 lying in bed with the touch pad call light placed approximately a foot away from the resident's left side of the face. The MDSC stated the resident had very limited mobility due to contractures and used a touch pad call light that was supposed to be placed by the elbow so the resident could activate it with the arm. The MDSC stated the call light was not accessible where it had been placed. During an interview on 7/2/2026 at 8:41 a.m., the DON stated call lights must always remain within reach and be responded to promptly, and that not having accessibility to the call light may cause delay in providing care or unmet needs. The facility policy titled, Answering the Call Light, stated that when the resident is in bed or confined to a chair, the call light should be within reach.
Failure to Assist Resident With Advance Directive
Penalty
Summary
The facility failed to ensure that Resident 2 was provided with information and assistance to formulate an advance directive. Resident 2 was admitted with diagnoses including type 2 DM, chronic systolic HF, depression, and generalized anxiety disorder. The resident’s MDS dated 3/19/2026 indicated cognition was intact, and the initial H&P dated 3/7/2026 stated the resident had the capacity to understand and make decisions. The record review showed an Advance Directive Acknowledgement dated 3/18/2026 in which Resident 2 marked both that she had executed an advance directive and that she wished to execute an advance directive. However, the POLST dated 3/27/2025 indicated the resident’s advance directive was not available. During interview on 7/1/2026, Resident 2 was awake, alert, oriented to person, place, and time, and stated that she did not currently have an advance directive and wanted assistance in creating one because of concerns about her current health status. The SSD stated he was responsible for asking residents about advance directives and providing additional information as needed, but he did not confirm with Resident 2 whether she still intended to execute one. The DON stated the SSD was responsible for inquiring about advance directives and assisting residents in completing them. Facility policy required the SSD or designee to provide written information about the right to make medical decisions and to inquire about any written advance directives prior to or at admission.
Incomplete belongings inventory for resident property
Penalty
Summary
The facility failed to ensure reasonable care for the protection of a resident’s personal property by not having a completed belongings inventory for one resident reviewed under the Personal Property care area. The resident was originally admitted on 12/29/2021 and later re-admitted with diagnoses including cerebral infarction, COPD, and schizophrenia. The face sheet identified a family member as the responsible party and resident representative. The resident’s MDS dated 6/9/2026 indicated adequate hearing, no hearing aid use, usually makes self-understood and usually understands, and was cognitively intact, while the H&P dated 7/18/2025 stated the resident did not have the capacity to understand and make decisions. During interview on 6/29/2026, the resident stated she could not hear well, did not know where the hearing aids brought in by the family member were, and said she was hard of hearing in both ears and needed her ears cleaned. The inventory dated 12/30/2021 did not include the hearing aids, and the signature section for the resident or responsible party was blank. The DSS stated the inventory should have been signed by the responsible party, but only one facility representative signature was present, and no other belongings inventory was found in the record. The DSS stated the inventory was invalid because it lacked the required signatures, and the DON stated all items must be inventoried and documented on the belongings list.
Incomplete MDS Assessment for Resident with Dementia
Penalty
Summary
Ensure each resident receives an accurate assessment. The facility failed to complete the BIMS screening and the Resident Mood Interview for Resident 51 even though the resident was assessed as sometimes understood and sometimes able to understand others. Resident 51’s face sheet showed admission with diagnoses including acute pyelonephritis and vascular dementia. During interview and record review with the MDS Coordinator, the resident’s MDS was reviewed and showed that in the sections for Makes Self Understood and Ability to Understand Others, the resident was documented as sometimes understood and sometimes understands, meaning the resident could respond to simple, direct communication and make concrete requests. The same MDS indicated in the Cognitive Patterns section that the BIMS should not be completed because the resident was rarely or never understood, and in the Mood section that the Resident Mood Interview should not be completed for the same reason. The MDSC stated this conflicted with the assessment information showing the resident could sometimes be understood and sometimes understand others, and stated she believed it would be possible for Resident 51 to complete the BIMS and the Resident Mood Interview, although the resident might not answer all questions. The facility’s policy for Resident Assessment Instrument stated a comprehensive assessment of a resident’s needs shall be made within 14 days of admission and is intended to describe the resident’s capability to perform daily life functions and identify significant impairments in functional capacity.
Failure to Develop Care Plan for Recurring Impacted Cerumen
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one resident with recurring impacted cerumen. The resident was originally admitted on 12/29/2021 and later re-admitted with diagnoses including cerebral infarction, COPD, and schizophrenia. The resident’s MDS dated 6/9/2026 indicated adequate hearing, no hearing aid use, and that the resident usually made self understood and usually understood others. The resident’s H&P dated 7/18/2025 stated the resident did not have the capacity to understand and make decisions, and the face sheet identified Family Member 2 as the responsible party and resident representative. During an interview on 6/29/2026, the resident stated she could not hear well, was hard of hearing in both ears, and needed her ears cleaned. ENT progress notes dated 12/4/2025 and 6/11/2026 documented bilateral impacted cerumen on both occasions. Both notes included a plan for cerumen removal and instructions for the resident to avoid cotton swabs, avoid placing objects in her ears, and notify the nurse if she experienced discomfort in her ears. During a concurrent interview and record review, the MDSC stated the recurring wax buildup required a care plan and that the ENT physician’s instructions should have been documented as care plan interventions. The MDSC stated that a care plan had not been developed for the resident’s recurring wax buildup and that it should have been developed after the ENT visit on 12/4/2025. The MDSC stated the missed care plan development occurred during review of progress notes and other records when MDSs are completed, and that care plans are developed or updated as needed at that time. The DON stated that care plans are developed from MDS triggers, new diagnoses, medication changes, changes in condition, or specialist orders or instructions, and that care plans identify the problem, goals, and interventions specific to the resident. The facility policy stated that the facility is required to develop and execute a person-centered care plan for every resident with measurable objectives and timelines to address identified needs.
Unlabeled Loose Tablets Found in Medication Cart Drawers
Penalty
Summary
Medication was not properly stored on Medication Cart South when surveyors observed unlabeled, unpackaged tablets in the bottom of two cart drawers. During a concurrent observation and interview, a whole white round tablet, two halves of a white round tablet, and debris were found in one drawer, and two white round tablets, two pieces of a white round tablet, and debris were found in another drawer. The MDSC stated the tablets should not have been there because staff did not know who they belonged to or what the medications were. The DON later stated loose medications are a medication storage issue because staff do not know what the medications are or which residents they belong to. The facility policy on storage of medication stated medications are to be stored properly to maintain integrity and support safe administration, and that outdated, contaminated, or deteriorated medications are to be removed from stock and disposed of according to procedure.
Advance Directive Documentation Incomplete and Contradictory
Penalty
Summary
The facility failed to ensure that Resident 2’s medical record for advance directives was clarified and completed accurately. Resident 2 was admitted with diagnoses including type 2 DM, chronic systolic heart failure, depression, and generalized anxiety disorder. The resident’s MDS dated 3/19/2026 indicated cognition was intact, and the initial H&P dated 3/7/2026 stated the resident had the capacity to understand and make decisions. A review of the advance directive acknowledgement dated 3/18/2026 showed that Resident 2 marked both, “I have executed an Advance Directive” and “I wish to execute an Advance Directive,” and the facility representative signature was missing. The POLST dated 3/27/2025 indicated the resident’s advance directive was not available. During interview, the SSD stated the form contained an error and was contradictory, and acknowledged the failure to resolve the conflicting information. The DON stated the SSD was responsible for inquiring about advance directives and assisting residents in completing them, and emphasized the expectation that staff document accurately, completely, and timely.
Failure to Offer Annual Flu Vaccine
Penalty
Summary
The facility failed to offer the updated 2025/2026 influenza vaccine at the start of the respiratory illness season for one resident. Resident 1 was admitted with diagnoses including COPD and DM, had fluctuating capacity to understand and make decisions per the history and physical, and was documented as cognitively intact on the MDS. The MDS also showed the resident needed assistance with toileting, showering, lower body dressing, footwear, upper body dressing, and oral hygiene. The Preventative Health Care Report showed the resident refused the flu vaccine on 3/27/2025, but it did not show any other dates the vaccine was offered. The Infection Preventionist stated he usually starts offering the flu vaccine in September and believed the resident did not want any further vaccines because she had refused when admitted. He also stated there was no documentation or care plan addressing the resident's refusal of all further vaccinations. During interview, he stated flu vaccines should be offered every year around September when the vaccine becomes available and said he should have offered the resident the flu vaccine in September 2025.
Failure to Offer Updated COVID-19 Vaccine
Penalty
Summary
The facility failed to offer the updated 2025 COVID-19 vaccine to one sampled resident after the resident had previously refused the COVID-19 vaccine on 3/27/2025. Resident 1 was admitted with diagnoses including COPD and diabetes mellitus, and a later History and Physical Examination noted fluctuating capacity to understand and make decisions. The resident’s MDS dated 4/9/2026 indicated the resident was cognitively intact and required varying levels of assistance with activities of daily living, including toileting, showering, dressing, footwear, and oral hygiene. During interview and record review, the Infection Preventionist reviewed the resident’s Preventative Health Care Report and confirmed it documented only the March 2025 refusal, with no other dates showing the resident was offered the updated COVID-19 vaccine when it became available in fall 2025. The IP stated he did not offer the updated vaccine because he understood the resident did not want any further vaccines, and there was no documentation or care plan addressing refusal of all further vaccinations. The facility’s policy stated that as soon as a vaccine is available, the facility will offer vaccination to each resident and staff member, and the COVID-19 Mitigation Plan stated the facility must educate and offer recommended vaccine doses as soon as CDC recommendations are released and doses are made available.
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
We read the 6,043 citations issued within 25 miles in the last 12 months — including the 16 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
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 | ★★★★★ | 28 | 0 |
| North Valley Nursing Center | 1.2 mi | ★★★★★ | 15 | 0 |
| The Hills Healthcare Center | 1.2 mi | ★★★★★ | 17 | 0 |
| Totally Kids Specialty Healthcare - Sun Valley | 2.7 mi | ★★★★★ | 25 | 0 |
| Villa Scalabrini Special Care | 2.9 mi | ★★★★★ | 10 | 0 |
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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 October 2026) and official state health department websites.