Above average — CMS composite of the measures below.
The next survey window likely opens 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 The Hills Healthcare Center during CMS and state inspections, most recent first.
Open medication eKits containing antibiotics and IV meds were left unreplaced beyond the 72-hour window, and multiple eKits containing controlled drugs in medication rooms and a med cart lacked shift-by-shift accountability logs. RN staff and the DON acknowledged the kits were used, awaiting pharmacy replacement, and not reconciled as required by facility policy.
Side rail documentation for two residents did not match the rails actually in use. One resident was observed with 1/3 side rails even though the assessment and consent referenced quarter rails, and another resident was observed with four rails while the chart contained altered assessments and informed consent that did not match the original documentation. Staff interviews confirmed the discrepancies, and the DON, MRD, MDSC, RN, and ADM stated they did not know who changed the records.
Medication Administration Timing Errors: An RN administered ordered meds to two residents outside the prescribed 7:30 a.m. time, including aspirin, metoprolol, and ferrous sulfate for one resident and ferrous sulfate for another. The RN acknowledged the meds were given later than the facility’s 60-minute window and not as ordered, and the DON confirmed the timing errors. Record review showed one resident had anemia and the other had iron deficiency, HTN, and atrial fibrillation.
Missing medication room temperature logs were found in two medication rooms, and two bottles of Calcium with Vitamin D tablets in one medication room were past the manufacturer expiration date and still stored as facility stock. RN and DON interviews confirmed that temperatures should be documented daily and that the expired tablets should have been removed from use.
Meal tray contents were not fully verified against diet tickets and physician orders when an IP checked trays for five residents but initially did not lift the lids to confirm the food inside. The IP later acknowledged the trays should have been opened, and the DON stated nursing staff were expected to compare tray contents with orders as a secondary check to catch nutrition staff errors. The affected residents had ordered therapeutic diets, including no added salt, easy to chew, regular texture, and thin liquids.
Incomplete and Altered Medical Records: The facility failed to keep accurate resident records for two residents. One resident’s side rail assessment form was altered without a date, time, or author, while the resident had cognitive impairment, needed substantial ADL assistance, and had an order for bilateral side rails. Another resident’s diagnosis report omitted current diagnoses, including depression and schizoaffective disorder, despite physician orders and care plans addressing both conditions.
Improper Use of Gait Belt as a Restraint: A resident with severe cognitive impairment and diagnoses including metabolic encephalopathy, schizophrenia, and Alzheimer’s disease was observed seated in a wheelchair with a gait belt fastened around the waist and chair. The DON stated there was no order for restraints and the resident could not release the belt himself, while RN 2 stated there was no informed consent or care plan for the restraint. Facility policy required a physician’s order and consent before restraint use.
MDS Did Not Reflect All Active Diagnoses: A resident’s MDS failed to list active diagnoses of depression and schizoaffective disorder, even though the record showed diagnoses, physician orders for Prozac and Zyprexa, and care plans addressing both conditions. The DON confirmed the omissions during record review and stated the MDS should reflect the resident’s current diagnoses for a complete and accurate clinical overview.
A resident with an indwelling Foley catheter and moderately impaired cognition had catheter tubing observed looped, preventing urine from flowing freely into the drainage bag. The RN adjusted the bag so the tubing would uncoil, and staff stated that looped tubing can allow urine to back up into the bladder and cause a UTI. The resident’s care plan and facility policy both called for unobstructed urine flow and tubing kept free of kinks.
The facility failed to follow infection control practices for two residents. One resident had deteriorated porous foam padding duct taped to a bedside rail even though the resident did not require padded rails, and staff acknowledged the material could not be adequately disinfected with the wipes being used. Another resident receiving IV ertapenem had an IV in the hand that was unlabeled with an insertion date, and staff could not verify how long the IV had been in place because the date and time were not documented.
Multiple resident rooms failed to meet the required square footage per resident, with 27 of 28 rooms providing less than 80 sq. ft. per resident. The ADM submitted a waiver request and stated the rooms still allowed enough space for care, dignity, and privacy, while surveyors observed residents and staff moving freely and nursing staff able to provide care with beds, side tables, dressers, and resident care equipment in place.
Two residents were not treated with dignity during mealtime assistance as staff members stood over them while feeding. One resident, with severe cognitive impairment, was fed by an RNA standing due to space constraints, while another resident, with moderate cognitive impairment, was fed by a CNA standing to expedite the process. This was against the facility's policy, which requires staff to be seated to ensure residents' safety, comfort, and dignity.
The facility failed to ensure that call lights were within reach for two residents, both with severe cognitive impairments and requiring assistance with daily activities. Observations revealed that the call lights were improperly placed, making them inaccessible. The DON confirmed that call lights should be within reach to allow residents to summon help, as per facility policy.
The facility failed to provide non-pharmacological interventions before administering opioid medications to two residents. One resident with a pelvic fracture and severe cognitive impairment, and another with a history of falls and dementia, were both prescribed tramadol without attempts at non-pharmacological interventions, contrary to the facility's policy. The DON confirmed the oversight, highlighting the importance of such interventions to prevent unnecessary medication.
Two residents experienced medication administration discrepancies when Tramadol was removed from the CDR without corresponding entries in the MAR. One resident had a pelvic fracture and severe cognitive impairment, while the other had a history of falls and dementia. Interviews with an LVN and the DON confirmed the failure to follow facility procedures, posing a risk of medication errors and drug diversion.
The facility failed to implement the Medication Regimen Review (MRR) for two residents, resulting in missed communication of critical medication monitoring recommendations to physicians. A resident with multiple diagnoses, including hydrocephalus and dementia, did not have recommended blood tests for valproic acid and heparin levels conducted. Another resident with a subdural hematoma and dementia also missed a recommended PTT blood draw for heparin monitoring. The Director of Nursing did not follow the facility's policy to ensure MRR recommendations were communicated to physicians.
The facility failed to monitor medication levels for two residents, leading to a deficiency. One resident was prescribed valproic acid and heparin, while another was prescribed heparin. The Medication Regimen Review recommended monitoring levels, but these were not communicated to the physician, and necessary tests were not conducted. The Director of Nursing acknowledged the oversight, which put the residents at risk of adverse effects.
The facility failed to ensure residents were free from significant medication errors by not checking therapeutic levels for two residents, leading to potential health risks. A resident with multiple diagnoses was prescribed valproic acid and heparin, but the facility did not follow up on the pharmacist's recommendation to check the valproic acid level and PTT. Similarly, another resident was prescribed heparin, but the facility failed to follow up on the recommendation for a PTT blood draw. The DON acknowledged the oversight, which was considered a medication error.
The facility failed to label stored food with use-by dates, as observed during a survey. Items in the refrigerator and dry storage, including garlic, ham, apple sauce, puddings, gelatine desserts, and potatoes, lacked proper labeling. The Dietary Supervisor and DON acknowledged the oversight, which violated the facility's policy and posed a risk to residents.
The facility failed to maintain sanitary trash storage as two dumpsters were observed with open lids, positioned too close to the wall to be closed. The Dietary and Maintenance Supervisors confirmed that the dumpsters should have been closed to prevent attracting pests and potential infection control issues. The facility's policy requires dumpsters to be kept closed to prevent pest access.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices or wounds, as required by policy. Staff did not wear gowns during high-contact care activities, and EBP signs and PPE were not provided outside residents' rooms. The Infection Preventionist and Director of Nursing acknowledged the lack of implementation, despite CMS guidelines mandating EBP for such residents.
A facility failed to maintain a resident's advance directive in their active clinical record, despite the resident's severe cognitive impairment and need for assistance. The document was found in an overflow section, contrary to facility policy requiring it to be readily accessible to guide staff in honoring the resident's healthcare preferences.
A resident with severe cognitive impairment and mobility issues was found to have their Low Air Loss Mattress (LALM) incorrectly set at a higher weight than their actual weight, potentially compromising pressure injury care. The facility's failure to adhere to the physician's order for the correct LALM setting was confirmed by the Director of Nursing, who acknowledged the risk of further skin injuries.
The facility failed to store medications in a locked compartment, as observed at Nursing Station Two where the medication cabinet lacked a lock. This cabinet contained various medications, including iron supplements and acetaminophen. The Director of Staff Development confirmed the need for locked storage to prevent resident access, while the DON was unaware of the issue. Facility policy mandates locked storage for medications.
The facility did not meet the required 80 square feet per resident in multiple resident rooms, affecting 15 rooms. Despite this, observations showed adequate space for movement and care. The facility requested a waiver, claiming no adverse effects on residents.
The facility failed to schedule necessary follow-up appointments with cardiology and pulmonology for a resident as per discharge instructions and did not monitor the resident after a noted change in condition, leading to a significant lapse in care.
A facility failed to develop a comprehensive care plan for a resident with heart failure, despite multiple admissions and severe cognitive impairment. The absence of this care plan, which should have been created within 14 days, could negatively impact the resident's care.
The facility failed to ensure a resident's history and physical (H&P) was completed by the attending physician upon admission. The resident, with serious medical conditions and severely impaired cognition, had an undated and incomplete H&P, signed without a date. This could lead to inconsistent care coordination.
A facility failed to ensure an LVN documented the administration of Plavix for a resident with severe cognitive impairment and heart conditions. The RN confirmed the absence of documentation on the MAR, violating the facility's medication administration policy.
Open eKits Not Replaced and Controlled Drug Reconciliation Missing
Penalty
Summary
The facility failed to replace multiple open medication emergency kits within 72 hours of opening and failed to reconcile controlled drug eKits at each shift change. During observation in Medication Room Station 1, an open antibiotic eKIT showed documents indicating it was opened on 12/10/2025 and again on 12/11/2025, and an open IV medication eKIT labeled IV180 showed documents indicating it was opened on 12/11/2025. Both kits had pink labels stating they needed to be returned within 72 hours of opening for compliance, and RN 2 acknowledged they were used and awaiting replacement from pharmacy. RN 2 stated the kits should have been replaced within 72 hours and were not compliant. In the same medication room, an eKIT labeled AF133 containing controlled drugs was stored in the refrigerator without an accountability log showing reconciliation of controlled drug inventory at every shift change for December 2025. RN 2 stated all controlled drugs, including those in eKits, should be reconciled at every shift and acknowledged this kit was not reconciled as required. In Medication Room Station 2, an open antibiotic eKIT labeled A102 showed documents indicating it was opened on 12/8/2025 and again on 12/9/2025, and RN 1 acknowledged it was used and awaiting replacement but had not been replaced within 72 hours. Also in Medication Room Station 2, an eKIT labeled AF172 containing controlled drugs was stored in the refrigerator without an accountability log for shift-by-shift reconciliation in December 2025. In Medication Cart Station 2, three controlled drug eKits labeled NARC1 144, NARC2 131, and NARC2 093 were present without an accountability log for reconciliation at every shift change for December 2025. RN 1 and the DON both stated controlled drug eKits should be counted and reconciled at every shift change, and the DON confirmed the listed eKits were not reconciled as required. Facility policy stated eKits should be replaced within 72 hours of opening and controlled drugs should be counted each shift for accountability.
Side rail assessments and informed consent did not match the rails in use
Penalty
Summary
The facility failed to ensure the safe and appropriate use of side rails for two sampled residents. For one resident, the admission record showed diagnoses including muscle wasting and atrophy, and the MDS indicated moderate cognitive impairment with maximal assistance needed for bed mobility and transfers. The physician’s order, side rail assessment, informed consent, and care plan all referenced bilateral quarter side rails, but during observation the resident was found in bed with side rails that were longer than quarter rails and positioned in the middle portion of the bed. The Infection Preventionist and DON both stated the resident should not have had the middle one-third side rails on the bed and that the assessment and informed consent should reflect the type of side rails actually in place. For the second resident, the record showed a history of muscle wasting and atrophy, bipolar disorder, and unspecified psychosis, and the H&P stated the resident did not have capacity to understand and make decisions. The MDS indicated moderate cognitive impairment and dependence or substantial assistance for multiple ADLs, including rolling, sitting up, and transfers. The order summary indicated bilateral 1/2 side rails x 4 up as an enabler, while the care plan and informed consent referenced bilateral 1/4 side rails. During observation, the resident was in bed with four side rails up, including two 1/3 length rails on the upper half of the bed and two 1/4 length rails on the lower half. Record review and staff interviews showed that the resident’s Side Rails Assessments form and informed consent had been altered after the fact to add different side rail information, without any indication of the date or author of the changes. Staff reviewed original and altered copies and stated they did not know why the documents were different or who made the changes. The DON, MRD, MDSC, RN, and Administrator all acknowledged the discrepancies, and the Administrator stated it was inappropriate to add information on an informed consent without contacting the responsible party with the correct information and completing a new form. The resident’s responsible party stated no one from the facility had contacted her that week regarding any changes to the documentation.
Medication Administration Timing Errors
Penalty
Summary
The facility failed to ensure that its medication error rate remained below 5 percent. Surveyors identified 4 medication errors out of 24 total opportunities, resulting in an overall error rate of 14.28 percent and affecting two residents observed during medication administration. The errors involved medications being given at times different from those ordered by the physician. During observation, an RN administered aspirin 81 mg, metoprolol 25 mg, and ferrous sulfate 325 mg to one resident at 8:55 a.m., and administered ferrous sulfate liquid to another resident at 9:29 a.m. The RN later stated that both residents had physician orders for these medications at 7:30 a.m. with breakfast or food, and acknowledged that the medications were given later than the facility’s 60-minute administration window. The RN identified these as medication errors. The DON also confirmed that the medications were not administered according to the physician orders and stated that the residents may be at risk for stomach irritation when the medications are given later than scheduled. Record review showed one resident had a diagnosis including anemia and was ordered ferrous sulfate 220 mg/5 ml, 7.5 ml by mouth once daily with food at 7:30 a.m. Another resident had diagnoses including iron deficiency, hypertensive heart disease, and atrial fibrillation and was ordered aspirin 81 mg, metoprolol 25 mg, and ferrous sulfate 325 mg once daily with food at 7:30 a.m. Facility policy required medications to be administered in accordance with prescriber orders and within one hour of the prescribed time unless otherwise specified.
Missing Medication Room Temperature Logs and Expired Stock Medications
Penalty
Summary
Medication Room Station 1 did not have the December 2025 room temperature monitoring log available during observation and interview with RN 3. RN 3 stated the log was missing and that, as a result, the room temperature had not been monitored that morning. RN 3 also stated that room temperatures should be monitored and documented every day during all shifts to ensure medications are maintained within an acceptable temperature range and that their potency is not affected. Medication Room Station 2 also did not have the December 2025 room temperature monitoring log available during observation and interview with RN 1. In the same medication room, two bottles of Calcium with Vitamin D tablets for facility stock were found with a manufacturer expiration date of November 2025. RN 1 stated the bottles should have been removed from the medication room and placed in the expired medication bin by 11/30/2025, and that expired medications have lost potency and would not be effective if used for residents. The DON stated that medication room temperatures should be monitored and documented daily and that several licensed nurses failed to remove the expired Calcium with Vitamin D bottles from Medication Room Station 2 according to facility and manufacturer guidelines.
Meal Tray Contents Not Verified Against Diet Orders
Penalty
Summary
The facility failed to ensure the Infection Preventionist (IP) checked the contents of meal trays against the diet ticket and physician's orders during lunch for five residents. During observation, the IP reviewed diet tickets but did not lift the tray lids to verify the food on the trays. When asked why, the IP stated she should have lifted the lids, then rechecked the trays by opening them and comparing the contents with the physician's orders. The IP later stated that lifting the tray lids was necessary to ensure the resident received the diet ordered by the physician and to avoid the resident being at risk for aspiration. Resident 2 had diagnoses including DM, was moderately impaired in cognition, dependent on staff for eating, and was ordered a no added salt diet with easy to chew texture and thin liquids. Resident 14 had DM, was moderately impaired in cognition, required moderate assistance with eating, and was ordered a no added salt diet with regular texture and thin liquids. Resident 34 had heart failure, was cognitively intact, required moderate assistance with eating, and was ordered a no added salt diet with regular texture and thin liquids. Resident 43 had iron deficiency anemia, was cognitively intact, was independent with eating, and was ordered a no added salt diet with regular texture and thin liquids. Resident 45 had anemia, was severely impaired in cognition, required moderate assistance with eating, and was ordered a regular diet with easy to chew texture and thin liquids. The DON reviewed the facility policy and stated nursing staff were to check trays after leaving the kitchen and lift tray lids to compare the food with physician's orders, describing this as a secondary check to catch errors made by nutrition staff.
Incomplete and Altered Medical Records
Penalty
Summary
The facility failed to maintain accurate medical records for two sampled residents. For one resident, the Side Rail Assessments form in the chart was altered without any indication of the date, time, or author of the change. The resident had been admitted and later readmitted to the facility with diagnoses including muscle wasting and atrophy, bipolar disorder, and unspecified psychosis. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS showed moderate cognitive impairment with substantial assistance needed for most ADLs, including rolling, sitting up, and transferring. The resident’s order summary included an order for bilateral side rails, 1/2 x 4 up, as an enabler for turning and repositioning while in bed and for feeling safe. During observation, the resident was in bed with four side rails up. The Side Rails Assessments form initially reviewed by staff indicated bilateral 1/4 siderails in the approaches section, but later the form in the chart indicated bilateral 1/4 siderails and bilateral 1/3 siderails. The DON, MRD, and MDSC each stated they did not know why the form had been changed or who made the change, and the MRD stated changes to records must be dated to clarify what was changed and when. The facility policy required medical record documentation to be objective, complete, and accurate, and required corrections or addenda to be signed and dated. For the second resident, the Diagnosis Report in the chart was incomplete and did not list all current diagnoses. The resident’s record showed diagnoses including encephalopathy, muscle wasting and atrophy, schizoaffective disorder, dementia, and depression. The resident also had physician orders for Prozac for depression and Zyprexa for schizoaffective disorder, and care plans addressing both conditions. During review, the DON stated the Diagnosis Report should have included both depression and schizoaffective disorder, but it did not. The DON stated the report should reflect the resident’s current diagnoses to provide a complete and accurate overview of the resident’s health status.
Improper Use of Gait Belt as a Restraint
Penalty
Summary
The facility failed to ensure Resident 5 was treated with respect and dignity, including the right to be free from physical restraints, when staff used a gait belt fastened around the resident’s waist and wheelchair without a physician’s order, informed consent, or a care plan. Resident 5 was admitted and later readmitted with diagnoses including metabolic encephalopathy, schizophrenia, and Alzheimer’s disease. The MDS dated 10/7/2025 indicated severe cognitive impairment and dependence on staff for most ADLs. During observation on 12/15/2025, Resident 5 was seated in a wheelchair with a gait belt fastened around the waist and chair, with the clasp fastened behind the back of the wheelchair. The DON stated the gait belt should not have been there and that the resident did not have an order for restraints, and also stated the resident could not release the gait belt himself and there was a risk of entrapment. RN 2 stated there was no informed consent or care plan for a lap belt or restraint and that the gait belt could cause harm, create a risk of entrapment, and stop Resident 5 from moving normally. The facility policy stated restraints require a physician’s order and consent from the resident or responsible party.
MDS Did Not Reflect All Active Diagnoses
Penalty
Summary
The facility failed to conduct an accurate MDS for one resident by not ensuring Section I, Active Diagnoses, reflected all current diagnoses. Resident 13 was admitted with diagnoses including encephalopathy, muscle wasting and atrophy, schizoaffective disorder, dementia, and depression. The resident’s record also showed physician orders for Prozac for depression and Zyprexa for schizoaffective disorder, and care plans dated 8/12/2025 addressed both antidepressant and antipsychotic use based on the resident’s depression and schizoaffective disorder. During a concurrent interview and record review with the DON, the MDS dated 11/12/2025 was reviewed and did not list Resident 13’s diagnoses of schizoaffective disorder and depression in Section I - Active Diagnoses. The DON stated both diagnoses should have been listed and that the MDS should reflect the resident’s current diagnoses to provide a complete and accurate overview of the resident’s health status. The facility policy on charting and documentation stated the medical record should facilitate communication among the interdisciplinary team and that documentation should be objective, complete, and accurate.
Looped Foley Tubing Prevented Free Urine Flow
Penalty
Summary
The facility failed to ensure appropriate catheter care for a resident with an indwelling urinary catheter. Resident 62 was admitted with diagnoses including metabolic encephalopathy, congestive heart failure, and hypertensive heart disease, and the MDS indicated moderately impaired cognition and use of an indwelling urinary catheter. The care plan identified a Foley catheter for acute urinary retention and directed that urine flow be kept unobstructed by maintaining patency of the tubing and drainage by gravity. Physician orders included a Foley catheter to gravity drainage. During a concurrent observation and interview, the resident’s urinary catheter tubing was found looped, which prevented urine from flowing freely into the collection bag. The RN observed the looped tubing and adjusted the collection bag so the tubing would uncoil and urine could flow into the bag. The RN stated that if urine had backed up into the resident’s bladder, it could have caused a UTI. A CNA also stated that catheter tubing should never be looped because urine can back up into the tubing and bladder and cause an infection. The facility policy on urinary catheter care stated that tubing should be kept free of kinks and the drainage bag positioned lower than the bladder to prevent urine from flowing back into the bladder.
Infection Control Lapses With Bed Rail Padding and Unlabeled IV
Penalty
Summary
The facility failed to implement appropriate infection control practices for two residents. For one resident with diagnoses including dementia, cardiomegaly, atherosclerotic heart disease, and type 2 diabetes mellitus, the resident’s bedside rail had deteriorated black porous foam material duct taped to it. During observation, the foam was noted to be falling apart and not easily cleaned, and the RN stated it was an infection control issue and had been left on the railing from a previous resident who occupied the bed before this resident. The resident’s side rail assessment indicated the resident did not require padded side rails. The facility’s housekeeping staff stated they disinfect resident bedside rails and any black porous foam padding on the railing with Clorox Bleach Germicidal Wipes. The Infection Preventionist reviewed the wipe instructions and stated the wipes are intended for hard, nonporous surfaces, and that the foam padding was not suitable to be adequately cleaned because of its porous nature. The Infection Preventionist also stated the inability to clean the foam adequately created a risk for causing infection and illness. Facility policies identified bed rails as non-critical environmental surfaces and stated non-critical items require cleaning followed by disinfection according to manufacturer instructions. For another resident with chronic kidney disease and severe cognitive impairment, the resident received IV ertapenem for pneumonia and had an IV antibiotic therapy care plan with monitoring of the IV site every shift. During observation, the resident’s left hand IV was unlabeled with an insertion date. The DSD stated she was not sure how long the IV had been in place, and the Infection Preventionist found no documentation of the date and time the IV was started in the chart or MAR. The DON stated the practice is to label the IV site with a start date and document the location, start date, and time so staff will know how long to keep it before changing, and that this is important because the IV should be present for less than four days per policy.
Multiple Resident Rooms Below Required Square Footage
Penalty
Summary
The facility failed to meet the requirement for at least 80 square feet per resident in multiple resident bedrooms, affecting 27 of 28 rooms identified in the report, including rooms 2 through 12, 14 through 19, 21, and 23 through 30, as well as room [ROOM NUMBER]. During review of the Client Accommodation Analysis Form submitted by the Administrator on 12/18/2025, the listed room sizes showed that the multiple-occupancy rooms provided less than 80 square feet per resident, with measurements ranging from 71.3 to 77.34 square feet per resident depending on the room. The Administrator also submitted a letter dated 12/22/2025 requesting a continuing waiver for the affected rooms and stating that there was still enough space for each resident's care, dignity, and privacy, and that the rooms were in accordance with the special needs of residents. During observation on 12/15/2025 at 11:30 a.m., surveyors observed room [ROOM NUMBER] and noted that both residents and staff had enough space to move about freely, and throughout the survey the team observed enough space for residents and staff to move freely and for nursing staff to safely provide care with beds, side tables, dressers, and resident care equipment present. In follow-up interview on 12/18/2025 at 10 a.m., the Administrator stated that multiple resident rooms should have at least 80 square feet per resident, with a minimum of 160 square feet for two residents and 240 square feet for three residents.
Failure to Maintain Dignity During Mealtime Assistance
Penalty
Summary
The facility failed to uphold the dignity and respect of two residents during mealtime assistance. Restorative Nursing Assistant 1 (RNA 1) was observed standing over Resident 49 while assisting with eating. Resident 49, who has severe cognitive impairment and requires supervision for daily activities, was seated in a wheelchair in the hallway. RNA 1 admitted to standing due to the lack of space for a chair in the hallway and the need to monitor other residents. This action was contrary to the facility's policy, which mandates that staff should be seated while assisting residents with meals to ensure safety, comfort, and dignity. Similarly, Certified Nursing Assistant 3 (CNA 3) was observed standing over Resident 18 while feeding them lunch. Resident 18, who has moderately impaired cognition and requires assistance with eating, was in a High Fowler's position in bed. CNA 3 acknowledged the need to be seated during feeding but chose to stand to expedite the process. This was also against the facility's policy, which emphasizes the importance of staff being seated at eye level with residents during meals to prevent aspiration and ensure residents do not feel rushed. Interviews with various staff members, including Treatment Nurse 1, Licensed Vocational Nurse 2, and the Director of Nurses, confirmed that the facility's policy requires staff to be seated while assisting residents with meals. The policy aims to maintain residents' dignity and ensure their safety and comfort during mealtimes. The failure to adhere to this policy potentially impacted the self-esteem and self-worth of the residents involved.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the resident call light was within accessible reach for two residents, Resident 23 and Resident 59. Resident 23, who was admitted with conditions such as spinal stenosis, a displaced fracture of the left femur, and aphasia, was observed to have a call light looped over the upper side of the wall light, making it inaccessible. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and a need for moderate assistance with daily activities. During an observation, a Restorative Nursing Assistant (RNA) noted that the call light should have been clipped to the pillow to facilitate ease of use, acknowledging that its inaccessibility could prevent the resident from asking for help and potentially lead to a fall. Similarly, Resident 59, who had diagnoses including senile degeneration of the brain and aphasia, was found to have an adaptive call light located behind the head of the bed, out of reach. The MDS for Resident 59 also indicated severe cognitive impairment and dependency on assistance for daily activities. The RNA confirmed that the call light should have been clipped to the pillow for accessibility. The Director of Nursing (DON) stated that the call light should always be within reach to ensure residents can summon help when needed, as outlined in the facility's policy and procedure on the call system.
Failure to Implement Non-Pharmacological Interventions Before Opioid Administration
Penalty
Summary
The facility failed to ensure that licensed nurses provided non-pharmacological interventions before administering as-needed opioid medications to two residents. Resident 36, who was admitted with a pelvic fracture and had severe cognitive impairment, was prescribed tramadol for moderate pain. The resident's care plan, however, did not include any non-pharmacological interventions, and the facility's policy required such interventions to be attempted before administering pain medication. Similarly, Resident 61, who had a history of falls and dementia, was prescribed tramadol for moderate to severe pain. Like Resident 36, the care plan for Resident 61 also lacked non-pharmacological interventions, despite the facility's policy. During a review of the residents' records and interviews with the Director of Nurses (DON), it was confirmed that non-pharmacological interventions were not attempted prior to administering pain medication. The DON acknowledged the oversight and emphasized the importance of attempting non-pharmacological interventions to reduce the risk of unnecessary medication administration. The facility's policy on pain management, which was last reviewed shortly before the survey, clearly stated the requirement for assessing pain and attempting non-pharmacological interventions before administering pain medications.
Medication Administration Discrepancies
Penalty
Summary
The facility failed to ensure that two residents were free from medication errors by not reconciling the Controlled Drug Record (CDR) with the Medication Administration Records (MAR). For Resident 36, the CDR indicated that Tramadol was removed on three occasions, but there were no corresponding entries in the MAR for those dates. Resident 36 was admitted with a pelvic fracture and was severely impaired in cognition, requiring moderate assistance with daily activities. The facility's policy required that controlled substances be reconciled upon administration, but this was not followed. Similarly, for Resident 61, the CDR showed that Tramadol was removed on two occasions without corresponding entries in the MAR. Resident 61 was admitted with a history of falls and dementia, and was moderately impaired in cognition, requiring supervision for personal hygiene and dressing. The facility's policy mandated that the administration of medications be recorded in the resident's medical record, but this was not adhered to, leading to discrepancies between the CDR and MAR. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nurses (DON) confirmed the discrepancies and the failure to follow the facility's procedures. The LVN and DON both acknowledged the importance of signing both the CDR and MAR to ensure accurate accounting of controlled medications and to prevent potential medication errors. The failure to document the administration of controlled substances as per the facility's policy posed a risk of medication errors and drug diversion.
Failure to Implement Medication Regimen Review
Penalty
Summary
The facility failed to implement the Medication Regimen Review (MRR) for two residents, Resident 49 and Resident 63, as required by their policies and procedures. The MRR is a pharmacist's thorough evaluation of a resident's medication routine and recommendations, which should be communicated to the resident's physician for review and potential action. In both cases, the Director of Nursing (DON) did not notify the physicians of the MRR recommendations, which included necessary blood tests to monitor medication levels and prevent potential adverse effects. Resident 49 was admitted with multiple diagnoses, including hydrocephalus, dysphagia, a history of falling, and dementia. The resident was prescribed valproic acid to prevent seizures and heparin to prevent deep vein thrombosis (DVT). The MRR recommended checking valproic acid levels and partial thromboplastin time (PTT) to ensure safety from bleeding, blood clots, and seizures. However, these recommendations were not communicated to the physician, and the necessary blood tests were not conducted. Similarly, Resident 63, who was admitted with a nontraumatic subdural hematoma, a history of falling, and unspecified dementia, was prescribed heparin to prevent DVT. The MRR recommended a PTT blood draw to monitor heparin levels, but this recommendation was also not communicated to the physician, and the blood test was not performed. The facility's policies clearly state that it is the responsibility of the DON to ensure that MRR recommendations are followed up with the physician, which did not occur in these instances.
Failure to Monitor Medication Levels for Two Residents
Penalty
Summary
The facility failed to ensure that the drug regimens for two residents were free from unnecessary drugs by not adequately monitoring valproic acid and heparin levels. Resident 49 was admitted with multiple diagnoses, including hydrocephalus, dysphagia, a history of falling, and dementia. The resident was prescribed valproic acid to prevent seizures and heparin to prevent deep vein thrombosis. However, the Medication Regimen Review (MRR) recommended monitoring valproic acid levels and partial thromboplastin time (PTT), but these recommendations were not communicated to the physician, and the necessary blood tests were not conducted. Similarly, Resident 63, who was admitted with a nontraumatic subdural hematoma and unspecified dementia, was prescribed heparin to prevent DVT. The MRR recommended a PTT blood draw to monitor heparin levels, but this recommendation was also not communicated to the physician, and the blood tests were not performed. The Director of Nursing (DON) acknowledged the oversight and stated that it was her responsibility to notify the physician of the MRR recommendations. The failure to monitor these medication levels put the residents at risk of bleeding, blood clots, and seizures. The facility's policies and procedures required the consultant pharmacist to review each resident's drug regimen monthly and for the facility to follow up on the pharmacist's recommendations by providing them to the primary physician. The DON was responsible for ensuring proper follow-through. The policies also required the physician to assess the effects of medications through lab work and collaborate with the pharmacist and nursing staff. However, these procedures were not followed, leading to the deficiency.
Failure to Monitor Therapeutic Levels Leads to Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors by not checking therapeutic levels for two residents, leading to potential health risks. Resident 49 was admitted with multiple diagnoses, including hydrocephalus, a cerebrospinal drainage device, dysphagia, a history of falling, and dementia. The resident was prescribed valproic acid and heparin, but the facility did not follow up on the pharmacist's recommendation to check the valproic acid level and partial thromboplastin time (PTT). The Director of Nursing (DON) acknowledged that it was her responsibility to notify the physician of these recommendations, which were missed, putting the resident at risk for bleeding, blood clotting, and seizures. Similarly, Resident 63 was admitted with a nontraumatic subdural hematoma, a history of falling, and unspecified dementia. The resident was prescribed heparin, but the facility failed to follow up on the pharmacist's recommendation for a PTT blood draw. The DON admitted that the order to check the heparin level was missed, which was necessary to ensure the resident's safety from bleeding and blood clots. This oversight was considered a medication error, as the facility did not verify the appropriate medication dosage based on lab work. The facility's policies and procedures required monthly drug regimen reviews by a consultant pharmacist, with the responsibility to follow up on recommendations resting with the facility. The policies also indicated that the attending physician should assess the relevance of recommended interventions and collaborate with the pharmacist and nursing staff. However, these procedures were not adequately followed, leading to the deficiencies identified in the report.
Failure to Label Food with Use-By Dates
Penalty
Summary
The facility failed to adhere to professional standards for food storage by not labeling stored food items with a use-by date. During an observation and interview with the Dietary Supervisor, it was noted that several food items in the refrigerator, including a zip-lock bag of garlic, a plastic container of ham, and a plastic container of apple sauce, were not labeled with a use-by date. Additionally, in the dry storage room, various pudding and pie fillings, gelatine desserts, scalloped potatoes, instant mashed potatoes, and seasoned applesauce were also found without use-by date labels. The Dietary Supervisor acknowledged that the absence of these labels could potentially affect the residents' health. The Director of Nursing confirmed that all food should be labeled with a use-by date, as per the facility's policy and procedure on Food Receiving and Storage. This policy, reviewed shortly before the survey, mandates that dry food stored in bins should be removed from original packaging, labeled, and dated, and all food stored in the refrigerator should be covered, labeled, and dated. The failure to comply with these standards posed a risk of foodborne illness to 66 of the 67 residents who receive food from the facility kitchen.
Improper Garbage Disposal Practices
Penalty
Summary
The facility failed to maintain their trash storage in a sanitary manner, as observed during a survey. Two dumpsters located outside the facility were found with their lids open and positioned too close to the wall, preventing them from being closed. This was confirmed during an interview with the Dietary Supervisor, who acknowledged that the dumpsters should have been closed to prevent attracting flies and potential infection control issues. The Maintenance Supervisor also confirmed that the open dumpster lids could attract insects or rodents, posing an infection control risk if these pests entered the facility. The facility's policy on garbage and refuse disposal, dated January 2024, requires that garbage containing food waste be stored in a manner inaccessible to pests, with outside dumpsters kept closed.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy, which is designed to prevent the spread of multidrug-resistant organisms (MDROs) by using gowns and gloves during high-contact resident care activities. This deficiency was observed in several instances involving residents with indwelling medical devices or wounds. For example, a Licensed Vocational Nurse (LVN) did not wear a gown while administering medication via a gastrostomy tube to a resident with severe cognitive impairment and multiple diagnoses, including Huntington's disease and hypertension. The facility's Infection Preventionist (IP) and Director of Nursing (DON) acknowledged that the EBP policy was not implemented, despite being mandatory for residents with indwelling devices. Another instance involved a resident with multiple sclerosis, quadriplegia, and a methicillin-resistant Staphylococcus aureus (MRSA) infection. An LVN and a Certified Nursing Assistant (CNA) failed to don gowns while administering medication via the rectum, even though the resident had an indwelling catheter. The IP admitted to being unaware of the mandatory nature of the EBP policy and confirmed that it was not implemented for this resident. The facility's policy and procedure documents clearly indicated the need for gowns and gloves during high-contact care activities, yet these were not followed. Additionally, the facility did not post EBP signs or provide personal protective equipment (PPE) outside the rooms of residents with wounds or indwelling medical devices, such as gastrostomy tubes and nephrostomy tubes. This oversight was confirmed during observations and interviews with the IP, who stated that the facility was waiting for trash bins to be delivered before posting signs. The Centers for Medicare and Medicaid Services (CMS) guidelines, which the facility claimed to follow, require EBP for residents with wounds or indwelling devices, even if they are not known to be infected with MDROs.
Failure to Maintain Resident's Advance Directive in Active Record
Penalty
Summary
The facility failed to ensure that a resident's clinical records were updated with their advance directives, which are crucial documents outlining a person's medical treatment preferences in situations where they cannot communicate their wishes. This deficiency was identified for one resident, who had been admitted with conditions including senile degeneration of the brain, aphasia, and a history of transient ischemic attack. The resident's Minimum Data Set indicated severe cognitive impairment, necessitating assistance for basic activities. Despite the resident having an advance directive, it was not maintained in their active clinical record, which could lead to conflicts with their healthcare wishes. During the investigation, the Director of Social Services acknowledged that the advance directive was missing from the active chart and was instead found in an overflow section of the medical record. Both the Director of Social Services and the Director of Nursing confirmed that the advance directive should have been readily accessible in the active chart to guide staff in honoring the resident's healthcare preferences. The facility's policy on advance directives, reviewed shortly before the survey, stipulated that such documents should be kept in the resident's medical record and be easily retrievable by staff, highlighting a clear deviation from established procedures.
Incorrect LALM Setting for Resident with Pressure Injury Risk
Penalty
Summary
The facility failed to ensure the correct setting of a Low Air Loss Mattress (LALM) for a resident who required it for pressure injury care. The resident, who was admitted with conditions including senile degeneration of the brain, aphasia, and a history of transient ischemic attack, was found to have the LALM set between 150 to 180 pounds, while the resident's weight was approximately 106 pounds. This discrepancy was observed during an inspection by Treatment Nurse 1, who acknowledged that the incorrect setting could render the mattress ineffective in promoting wound healing and preventing further pressure injuries. The resident's care plan, dated several months prior, indicated the use of a LALM as a pressure-relieving device due to the resident's impaired mobility and risk for pressure injuries. The physician's order also specified the need for the Charge Nurse to check the proper placement and function of the LALM. However, during an interview, the Director of Nursing confirmed the importance of following the physician's order for the correct setting, emphasizing that failure to do so could lead to further skin injuries. The manual for the air mattress also highlighted the necessity of adjusting the pressure based on the resident's weight to ensure effective wound care therapy.
Medication Storage Deficiency Due to Unlocked Cabinet
Penalty
Summary
The facility failed to ensure that medications were stored in a locked compartment, as required by professional principles. During an observation and interview with the Director of Staff Development, it was noted that the medication cabinet at Nursing Station Two did not have a lock, unlike the left-side cabinet. This unlocked cabinet contained various medications, including iron supplements, bismuth subsalicylate, liquid multi-vitamins, acetaminophen, vitamin C supplements, constulose, and milk of magnesia. The Director of Staff Development acknowledged that the medication storage should not be left unlocked to prevent residents from accessing the medications. The Director of Nurses was interviewed and stated that she was unaware of the broken lock on the Station Two medication cabinet. She emphasized the importance of keeping medications in a locked cabinet to prevent resident access. A review of the facility's policy and procedure on medication storage, last reviewed on 10/16/2024, indicated that drugs and biologicals should be stored in locked compartments with proper controls for temperature, light, and humidity, and that only authorized personnel should have access to these medications.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to meet the regulatory requirement of providing at least 80 square feet per resident in multiple resident bedrooms. This deficiency was identified in 15 out of 28 resident rooms, where the space per resident was below the required standard. Specifically, rooms designed to accommodate two residents were only 156 square feet, providing 78 square feet per resident, and rooms designed for three residents were 228 square feet, providing only 76 square feet per resident. This shortfall in space allocation had the potential to result in inadequate space for safe nursing care and privacy for the residents. Despite the deficiency, observations during the survey indicated that both residents and staff had enough space to move about freely inside the rooms. The nursing staff was able to safely provide care, and there was sufficient space for beds, side tables, dressers, and resident care equipment. The facility had submitted a request for a continuation of its room size waiver, asserting that the current room sizes did not adversely affect the residents' health and safety or impede their ability to attain their highest practicable well-being.
Failure to Schedule Follow-Up Appointments and Monitor Change in Condition
Penalty
Summary
The facility failed to provide necessary care and services for a resident as per the discharge instructions from the General Acute Care Hospital (GACH). The resident, who had diagnoses including Non-ST-Elevation Myocardial Infarction (NSTEMI), heart failure, and unstable angina, was readmitted to the facility on multiple occasions. Despite clear instructions from the GACH to schedule follow-up appointments with cardiology and pulmonology within specified timeframes, the facility did not arrange these appointments. Interviews with the MDS Nurse and Registered Nurse 2 revealed that there was no documented evidence of these appointments being made, and there was confusion about who was responsible for scheduling them. The Social Services Director and nursing department both indicated that the other was responsible for making the appointments, leading to a lapse in care coordination. Additionally, the facility failed to monitor the resident after a noted change in condition on 10/30/2023. The resident exhibited delusional beliefs and refused medication, which should have triggered close monitoring every shift for 72 hours according to the facility's policy. However, there was no documented evidence that such monitoring occurred. This lack of monitoring was confirmed during an interview with Registered Nurse 2, who acknowledged the importance of close monitoring to detect any worsening of symptoms and to ensure timely intervention. The facility's policies and procedures, including those for admission assessment and follow-up care, as well as for changes in a resident's condition, were not adhered to. The failure to schedule necessary follow-up appointments and to monitor the resident after a change in condition represents a significant lapse in the standard of care, potentially jeopardizing the resident's health and well-being.
Failure to Develop Comprehensive Care Plan for Heart Failure
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan to address a diagnosis of heart failure for one of the sampled residents. The resident, who had been admitted and readmitted multiple times, had diagnoses including Non-ST-Elevation Myocardial Infarction (NSTEMI), heart failure, and unstable angina. The Minimum Data Set (MDS) indicated that the resident had severely impaired cognition and required maximum assistance from staff for various daily activities. Despite these needs, there was no documented evidence of a care plan specific to heart failure being developed within the required timeframe. During an interview and record review, the MDS Nurse confirmed that a comprehensive care plan for heart failure was not created for the resident. The facility's policy required such a care plan to be developed within 14 days of admission, but this was not done. The absence of this care plan had the potential to negatively affect the delivery of care and services to the resident, as it would guide staff on specific interventions needed for managing heart failure.
Incomplete History and Physical Documentation
Penalty
Summary
The facility failed to ensure the history and physical (H&P) for a resident was completed by the attending physician upon the resident's first admission. The resident was admitted with serious medical conditions including Non-ST-Elevation Myocardial Infarction (NSTEMI), heart failure, and unstable angina. The Minimum Data Set (MDS) indicated that the resident had severely impaired cognition and required maximum assistance from staff for daily activities. However, the H&P document was undated and incomplete, lacking pertinent medical information, and was signed by the attending physician without a date. This incomplete documentation could lead to inconsistent care coordination for the resident. During an interview and record review, a registered nurse confirmed that the H&P was undated and incomplete, and emphasized the importance of having a completed and dated H&P to ensure proper assessment of the resident's condition upon admission or readmission. The facility's policy and procedure require that the medical care of each resident be supervised by a licensed physician, including participating in the resident's assessment and care planning. The failure to complete and date the H&P document is a violation of this policy and could result in inadequate care for the resident.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to implement its medication administration policy by not ensuring that a Licensed Vocational Nurse (LVN) documented the administration of Plavix for a resident. The resident, who had been readmitted to the facility with diagnoses including Non-ST-Elevation Myocardial Infarction (NSTEMI), heart failure, and unstable angina, did not have documented evidence of receiving Plavix on a specified date. The resident's Minimum Data Set (MDS) indicated severely impaired cognition and a need for maximum assistance with daily activities, highlighting the importance of accurate medication administration and documentation. During an interview and record review, a Registered Nurse (RN) confirmed that there was no documentation on the Medication Administration Record (MAR) indicating that Plavix was administered or refused by the resident. The facility's policy required that medications be administered safely and timely, with the individual administering the medication initialing the MAR after each administration. The lack of documentation by the LVN on the specified date was identified as a failure to adhere to this policy, potentially leading to medication errors and confusion in care delivery.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 4,745 citations issued within 25 miles in the last 12 months — including the 26 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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 | 1.1 mi | ★★★★★ | 35 | 0 |
| High Valley Lodge | 1.2 mi | ★★★★★ | 5 | 0 |
| Totally Kids Specialty Healthcare - Sun Valley | 2.1 mi | ★★★★★ | 23 | 0 |
| North Valley Nursing Center | 2.3 mi | ★★★★★ | 13 | 0 |
| Villa Scalabrini Special Care | 2.5 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.