Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Totally Kids Specialty Healthcare - Sun Valley during CMS and state inspections, most recent first.
A resident with multiple congenital conditions, a tracheostomy, and moderately impaired cognition, on a regular diet with pureed texture, did not receive all items listed on the facility’s lunch menu. The posted menu called for a turkey burger on a bun with lettuce, tomato, sweet potato fries, pea and cheese salad, chilled peaches, and 1% milk, but the meal card and tray contained only pureed turkey, peas, and peaches with water. The DS reported omitting the bun based on an undocumented belief that the resident did not like bread and admitted failing to provide lettuce, tomato, sweet potato fries, cheese in the peas, and milk because the menu was not checked while rushing, contrary to facility menu guidelines.
Failure to obtain advance informed consent for COVID-19 vaccination: A resident with cerebral palsy, tracheostomy status, and persistent vegetative state received the COVID-19 vaccine without the RP being informed beforehand. The RP stated they learned of the vaccination only after it was given, and record review found no documentation that informed consent was obtained prior to administration.
Failure to Develop Comprehensive Person-Centered Care Plans: Multiple residents lacked care plans for identified needs, including a critically high Depakote level, oral care, bowel and bladder training, diabetes insipidus, and influenza/COVID-19 vaccine administration. Records showed residents with severe cognitive impairment, total or substantial dependence for ADLs, and diagnoses such as cerebral palsy, encephalopathy, congenital disorders, and diabetes insipidus, while the DSD confirmed the missing care plan elements.
Failure to Follow Seizure Precautions and Helmet Safety Orders: Three residents had documented seizure or fall-related safety interventions that were not followed. Two residents with seizure histories had bed rail padding missing from portions of their beds despite care plans and facility policy requiring padded side rails on both sides at all times. A third resident with severe cognitive impairment and fall risk was observed ambulating without a prescribed soft helmet and, when wearing it, the helmet was missing its chin strap, making it ineffective per the DSD.
A facility failed to obtain physician orders before a COVID-19 vaccine was given to three residents with significant medical conditions and severely impaired cognition. Records showed the vaccine was documented on the immunization history, but the DSD and MRD confirmed there were no active or discontinued orders for the vaccine. The IP stated a clinic pharmacist administered the vaccine and that she did not obtain orders beforehand, despite the facility policy requiring physician-ordered medications to be administered using the six rights.
A resident with spastic quadriplegic CP, trach, and epilepsy received PRN clonidine multiple times, but the EMAR did not document the reason for administration or the resident’s SBP or HR at the time. The order required clonidine for tachycardia or hypertension, and the facility policy required PRN meds to include the reason and vitals.
Failure to document influenza vaccine education for responsible parties: Three residents with severe cognitive impairment and significant care needs received the flu vaccine, but the IP, MRD, and DSD confirmed there was no documented evidence that their responsible parties were given the required vaccine information sheets before administration. The facility policy required Social Services and/or the IP to provide and document this education.
A facility failed to follow its immunization policy by not documenting that responsible parties for three residents with severely impaired cognition received COVID-19 vaccine education before the vaccine was given. Records showed each resident received the vaccine, but the MRD stated vaccine information was mailed without confirmation of receipt, and chart review found no evidence in nursing or social services notes that the education was provided.
Failure to Knock Before Entering Resident Room: An LVN entered a resident’s room through a closed door without knocking or asking permission. The resident had a trach and was vent dependent, and the MDS showed she could usually make herself understood and needed varying levels of assistance with ADLs. The LVN acknowledged the lapse, and the DSD stated staff must knock and ask permission before entering a resident’s room to protect privacy and dignity.
Failure to Notify RP of Critical Depakote Result: A resident with cerebral palsy, tracheostomy, and epilepsy had a critically high Depakote level flagged as HH, but the chart did not show a COC assessment or notification to the RP. The resident was nonverbal and fully dependent for ADLs, and the DSD confirmed the critical result should have triggered a COC and RP notification.
Meal tickets containing resident PHI were found in the trash after two residents were observed eating lunch without tickets on their trays. An AA retrieved the tickets from the trash and stated the facility had been discarding them there, while an LVN said nurses disposed of them in the trash. The DS stated the tickets included the resident's name, menu, and room number and should be shredded, not thrown away.
Failure to Provide Oral Hygiene and Nail Care: A resident with severe cognitive impairment and total dependence on staff did not receive documented oral care on multiple shifts, and a family member observed debris in the mouth. Two residents were also observed with long, untrimmed fingernails; a DSD stated the nails extended past the fingertips and should have been trimmed and filed. Facility policies required daily oral hygiene and regular nail care.
An RN did not maintain a current CPR certification that included the required hands-on component. HR reviewed the RN’s file and found the CPR course was entirely web based, and the RN stated she did not know an in-person return demonstration was required. The DSD confirmed facility policy required CPR/BLS certification with a hands-on component for all clinical staff, including RNs.
Failure to Follow B&B Training Schedule: A resident with severely impaired cognition and diagnoses including osteochondrodysplasia and hydronephrosis was ordered to be placed on the toilet every 2 hours while awake as part of a bowel and bladder training program. The care plan also directed toileting assistance every 2 hours and documentation of the method used, but the DSD found no documented evidence that staff followed the toileting schedule on multiple days and confirmed the resident was not placed on the toilet as ordered.
Missed Ordered Weights and Incomplete G-Tube Water Documentation: The facility did not obtain and document ordered weights for two residents who were totally dependent and had severe neurologic conditions, despite physician orders for weekly and monthly weights. The facility also failed to document the total amount of water infused via G-tube for a comatose resident with a gastrostomy; the water bag label was blank even though the order required 170 mL of water via GT pump six times daily.
Failure to Verify G-Tube Placement Before Med Admin: An LVN administered Miralax via a resident’s G-tube without first verifying tube placement. The resident had epilepsy, gastrostomy status, severely impaired cognition, and total dependence for ADLs. The LVN turned off the enteral pump, flushed the tube, gave the medication, and flushed again, then stated she forgot to check placement by aspirating for gastric residual. An RN stated placement should be checked before giving meds via G-tube, and the facility policy required checking enteral tube placement before administration.
Improper food storage clearance was observed in the kitchen dry storage area when multiple boxes of drinks and food items were stacked higher than the required 18-inch ceiling clearance on wire racks. The DS stated this was against facility policy, noted the clearance was needed for sprinkler coverage, and said the boxes could fall and dent, which could lead to bacteria growth. The facility policy required food to be stored and secured safely.
Improper Dumpster Closure and Waste Area Housekeeping: Surveyors observed two black dumpsters and one blue dumpster left fully open while not in use, along with soiled gloves on the ground near the dumpster area. The DS stated dumpster lids should always be closed and the area must be kept clean and free of trash for infection control and to avoid animals and pests from getting into the trash. Facility policy required waste to be disposed of properly and dumpster lids to be closed after every use.
The facility failed to submit direct care staffing information based on payroll data for the first quarter of 2024. The CASPER PBJ Staffing Report review showed missing data for this period. The Financial Coordinator claimed to have submitted the reports quarterly but did not retain copies or provide documentation for the specified dates. The Administrator in Training confirmed the FC's responsibility for submission but could not provide proof of submission to CMS.
The facility failed to develop comprehensive person-centered care plans for six residents, leading to potential inadequate care. A resident at risk for pressure injuries, another with bladder incontinence, and two on anticonvulsant medications lacked appropriate care plans. Additionally, a resident on a toileting program and another at high fall risk did not have care plans addressing these needs. The absence of these care plans was confirmed by the DON, highlighting the importance of care plans in guiding staff interventions.
A facility failed to properly store medications, leaving two medication carts unlocked and unattended, risking unauthorized access. Opened olopatadine hydrochloride vials were not discarded after 30 days for a resident with severe disabilities, and an expired antibiotic was not removed from a cart for a resident with epilepsy. Staff acknowledged these oversights, which compromised medication safety.
A resident with cerebral palsy and contractures did not receive prescribed PROM exercises, as indicated by missing documentation in the Restorative Treatment Record. Interviews with staff confirmed the lack of documentation, which is considered as the treatment not being performed. Additionally, the facility failed to develop a person-centered care plan for the resident's contracture management, contrary to its policies.
A resident with severe cognitive impairment and a physician's order to wear a soft helmet when out of the crib was observed without the helmet, placing them at risk for injury. The facility's policy required all physician orders to be followed, but staff failed to ensure the resident's safety by not adhering to this order.
A facility failed to follow physician orders for a resident with bladder incontinence by not applying warm compresses and performing bladder massages before catheterization. The resident, in a vegetative state, required specific interventions when bladder scans showed over 300 ml of urine. Records showed multiple instances where these interventions were not documented, confirmed by interviews with staff, indicating a failure to adhere to care protocols.
The facility failed to document the output of two residents, both dependent on enteral feeding, as required by policy. This lack of documentation, confirmed by the DON, is crucial for monitoring hydration and preventing dehydration or fluid overload.
A facility failed to follow its enteral tube feeding policy for a resident with a GT by not labeling the y-connector with the date it was last changed. This was observed during medication administration, where the LVN confirmed the oversight. The resident, with severe medical conditions and total dependence on staff, was at risk due to this non-compliance. The DON also acknowledged the requirement for weekly changes and labeling to prevent infection.
A facility failed to change and label the ventilator humidifier water bottle for a resident requiring mechanical ventilation, as per policy. The resident, with a history of cerebral palsy and anoxic brain damage, was dependent on staff for all ADLs. The oversight was confirmed by a Respiratory Care Practitioner and the Respiratory Department Supervisor, who noted the increased risk of infection due to this deficiency.
A facility failed to ensure a specific indication was written for an antibiotic order for a resident, as required by their medication administration policy. The order for Augmentin lacked a specific diagnosis, which was confirmed by the Infection Preventionist and DON as incomplete. This deficiency placed the resident at risk of receiving inappropriate care due to inaccurate medical records.
The facility's Arbitration Agreement failed to include a venue selection suitable for both the resident and the facility, compromising the fairness of the arbitration process. This omission was confirmed by the Social Service Director, and the Administrator in Training was unaware of this requirement.
A facility failed to follow its Sterile Tracheal Suction policy when a Respiratory Care Practitioner did not remove non-sterile gloves before donning sterile gloves during a procedure on a resident with a tracheostomy. This oversight, confirmed by the Respiratory Department Supervisor, had the potential to increase the risk of healthcare-acquired infections for the resident, who was dependent on staff for all activities of daily living.
Failure to Follow Menu and Provide All Planned Food Items for a Pureed Diet
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to follow the planned menu and provide all menu items to a resident receiving a regular diet with pureed texture. The resident had diagnoses including septo-optic dysplasia of the brain, multiple congenital malformations, and a tracheostomy, and an MDS showing moderately impaired cognition with a need for staff assistance with eating and oral hygiene. The facility’s weekly menu for the relevant lunch meal listed a turkey burger on a hamburger bun with lettuce leaf, tomato slices, sweet potato fries, pea and cheese salad, chilled peaches, and 1% milk. However, the resident’s meal card for that lunch only listed turkey burger, peas, peaches, and water. During kitchen observations, the Dietary Supervisor (DS) prepared and pureed a turkey patty, peas, and peaches, and then assembled the resident’s tray with only those three pureed items. When the tray was later observed in the resident’s room, it did not include a hamburger bun, lettuce leaf, tomato slices, sweet potato fries, pea and cheese salad (including cheese), or 1% milk as specified on the menu. In interview, the DS stated she did not serve the bun because she believed the resident did not like bread, but acknowledged there was no documentation of this preference in the resident’s nutritional assessment and that the bun should have been served because it was on the menu. The DS further stated she did not serve the lettuce, tomato slices, sweet potato fries, or cheese with the peas because she had not checked the menu and was in a rush, despite facility policy requiring foods to be prepared according to the menu and the DFNS to supervise meal preparation and service to assure the menu is followed and diet orders are implemented.
Failure to Obtain Advance Informed Consent for COVID-19 Vaccination
Penalty
Summary
The facility failed to inform the resident and/or the responsible party in advance about the risks and benefits of administering the COVID-19 vaccine to one sampled resident. Resident 3 was admitted with diagnoses including cerebral palsy, tracheostomy status, and persistent vegetative state. The resident's MDS indicated severely impaired cognition and dependence on staff for oral hygiene, toileting hygiene, and personal hygiene. Record review showed that Resident 3 received the COVID-19 vaccine, but the resident's responsible party, FM 1, stated that they were not aware of the vaccination until after it had already been given. The DSD reviewed the resident's progress notes and stated there was no documented evidence that FM 1 was informed in advance or that informed consent was obtained before the vaccine was administered. The facility's Resident's Rights policy stated residents have the right to be fully informed, and the Informed Consent policy stated the resident's record must contain documentation of informed consent prior to implementation of the proposed treatment procedure.
Failure to Develop Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for multiple residents with identified needs. For Resident 1, the record showed admission with spastic quadriplegic cerebral palsy, tracheostomy, and epilepsy, and the MDS indicated the resident was nonverbal, rarely or never understood others, rarely or never made themself understood, and was completely dependent on staff for all ADLs. A lab report dated 10/10/2025 showed a Depakote level greater than 150 mcg/ml, flagged as a critical high result, but the DSD stated there was no care plan created to address the out-of-range Depakote value. For Resident 10, the admission record showed encephalopathy and a G-tube, and the MDS indicated severely impaired cognition and total dependence on staff for self-care. The resident had an ADL self-care performance deficit care plan, but it did not include interventions for oral care. During interview, RN 2 stated the care plan should have been resident-centered and specific and should have included oral care interventions to prevent oral infections and tooth decay. The facility also did not develop care plans for Resident 35’s bowel and bladder training program and Resident 2’s diabetes insipidus diagnosis. Resident 35’s record showed congenital malformation syndrome, paralysis of the vocal cords and larynx, and laryngeal stenosis; the MDS indicated severely impaired cognition, need for assistance with eating, oral hygiene, and toileting hygiene, and participation in a toileting program. The DSD stated there was no care plan for bowel and bladder training. Resident 2’s record showed diabetes insipidus as an active diagnosis, severely impaired cognition, and dependence on staff for oral hygiene, toileting hygiene, and personal hygiene; the DSD stated there was no care plan addressing diabetes insipidus. The facility also did not have care plans specific to influenza and COVID-19 vaccine administration for Resident 5, Resident 35, and Resident 3. Each of these residents had diagnoses and functional impairments documented in the record, and each had immunization history showing influenza and COVID-19 vaccines administered on 10/16/2025. During interview, the DSD stated that none of the three residents had care plans specific to the vaccine administration and stated that such care plans guide nursing staff on how to appropriately care for residents who were administered vaccines.
Failure to Follow Seizure Precautions and Helmet Safety Orders
Penalty
Summary
The facility failed to provide an environment free from accident hazards for three residents by not following seizure precautions and resident safety interventions documented in their care plans. One resident was admitted with spastic quadriplegic cerebral palsy, epilepsy, was nonverbal, rarely or never understood others, and was completely dependent on staff for all ADLs. That resident’s care plan called for safety at all times and padded side rails, but observation showed the bed had metal rails with padding only on the left side. An LVN stated the right rail lacked the padding needed to keep the resident safe during a seizure, and the DSD stated the facility did not follow its policy to apply padding to both sides. A second resident was admitted with anoxic brain damage, tracheostomy, and unspecified convulsions, and was in a persistent vegetative state and completely dependent on staff for all ADLs. The resident’s seizure-related care plan called for protection from injury at all times. Observation showed the bed had two upper and two lower metal side rails, but only the bottom left rail had padding. An LVN stated the resident needed the upper side rails padded to protect the head from injury, and the DSD stated the facility did not follow its seizure management policy requiring padded side rails on both the right and left sides at all times. A third resident was admitted with osteochondrodysplasia, congenital deformities of the skull, face, and jaw, and hydronephrosis. The resident had severely impaired cognition, required assistance with several ADLs, and had a history of falls. The order summary and care plans directed the resident to wear a soft helmet intermittently and as tolerated while out of bed to prevent injury related to fall risk. Observations showed the resident ambulating independently without the helmet at times and, when wearing it, the helmet lacked a chin strap. CNA 1 stated the chin strap was missing because the resident chewed on it and that a replacement helmet had not been provided despite multiple requests. The DSD observed the helmet without a chin strap and stated the helmet needed the chin strap to help prevent injuries and that direct care staff were responsible for ensuring the helmet was in good condition.
COVID-19 Vaccine Given Without Physician Orders
Penalty
Summary
The facility failed to ensure physician orders were obtained before administering the COVID-19 vaccine to three residents. Resident 5 was admitted with diagnoses including osteochondrodysplasia, congenital deformities of the skull, face, and jaw, and hydronephrosis. Resident 35 was admitted with diagnoses including congenital malformation syndrome, paralysis of the vocal cords and larynx, and stenosis of the larynx. Resident 3 was admitted with diagnoses including cerebral palsy, tracheostomy status, persistent vegetative state, and dependence on a respirator. Record review showed each of the three residents had the COVID-19 vaccine documented on their immunization history records, but there were no physician orders in the active or discontinued order records for the vaccine. The Director of Staff Development reviewed the records and confirmed that Resident 5, Resident 35, and Resident 3 received the COVID-19 vaccine without physician orders. The Medical Records Director also confirmed there were no orders for the vaccine for any of the three residents. The Infection Preventionist stated that a COVID-19 clinic came to the facility and the clinic pharmacist administered the COVID-19 vaccine to residents, and that licensed nurses did not administer the vaccine in the facility. The Infection Preventionist also stated she was not aware there were no orders for these residents and that she did not obtain physician orders before the vaccine was administered by the clinic pharmacist. The facility policy titled Medication Administration stated that physician-ordered medication is to be administered using the six rights of medication administration and that orders are to be checked against the medication record.
PRN clonidine given without required indication and vital sign documentation
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when clonidine was administered as needed without documentation of the reason for administration or the resident’s blood pressure and heart rate at the time it was given. The resident was admitted with spastic quadriplegic cerebral palsy, tracheostomy, and epilepsy, and the MDS described the resident as nonverbal, rarely or never understanding others, rarely or never making themselves understood, and completely dependent on staff for all ADLs. The resident’s order was for clonidine 0.1 mg, 0.5 tablet via G-tube every 12 hours as needed for tachycardia greater than 160 bpm or systolic blood pressure greater than 150 mmHg. Review of the EMAR for February 2026 showed clonidine was administered multiple times, but there was no documentation indicating why it was given or what the resident’s SBP or heart rate was at those times. During interview and record review, the DSD stated the nurse likely forgot to add supplemental documentation and noted that without it, the oncoming nurse would not know why the medication was given and there would be no quantifiable log for the physician or pharmacist to review. The facility policy required PRN medications to include the reason for administration and vitals.
Failure to Document Influenza Vaccine Education for Responsible Parties
Penalty
Summary
The facility failed to implement its immunization policy by not ensuring that the responsible parties for three residents were provided education regarding the influenza vaccine before the vaccine was administered. Resident 5 was admitted with osteochondrodysplasia, congenital deformities of the skull, face, and jaw, and hydronephrosis; the MDS showed severely impaired cognition and the need for assistance with eating, oral hygiene, toileting hygiene, and personal hygiene. Resident 35 was admitted with congenital malformation syndrome, paralysis of the vocal cords and larynx, and laryngeal stenosis; the MDS showed severely impaired cognition and the need for assistance with eating, oral hygiene, toileting hygiene, and personal hygiene. Resident 3 was admitted with cerebral palsy, tracheostomy status, persistent vegetative state, and dependence on a respirator; the MDS showed severely impaired cognition and dependence on staff for oral hygiene, toileting hygiene, and personal hygiene. Each of the three residents had documentation showing receipt of the influenza vaccine on 10/16/2025. During interviews, the IP stated that responsible parties are informed about the influenza vaccine and that medical records is responsible for providing influenza vaccine information. The MRD stated that influenza vaccine information was sent to all responsible parties through regular mail, but there was no mail confirmation and no documentation that the responsible parties actually received the information. The DSD reviewed nursing and social services progress notes for each resident and stated there was no documented evidence that the responsible parties received influenza vaccine information prior to the vaccine being administered. The facility policy titled Immunization, reviewed 12/5/2025, stated that Social Service staff and/or the IP are to provide the parent/legal representative with Vaccine Information Sheet(s) when indicated and document when the sheets were provided. The policy also stated that vaccine information sheets can be given at any time prior to administration of the vaccine. The record review and staff interviews showed that, for these three residents, there was no documentation that the required vaccine information had been provided to their responsible parties before influenza vaccination.
Failure to Document COVID-19 Vaccine Education for Responsible Parties
Penalty
Summary
The facility failed to implement its immunization policy by not ensuring that residents’ responsible parties were provided education regarding the COVID-19 vaccine before the vaccine was administered to three sampled residents. Resident 5 was admitted with diagnoses including osteochondrodysplasia, congenital deformities of the skull, face, and jaw, and hydronephrosis, and the MDS indicated severely impaired cognition with assistance needed for eating, oral hygiene, toileting hygiene, and personal hygiene. Resident 35 was admitted with diagnoses including congenital malformation syndrome, paralysis of the vocal cords and larynx, and laryngeal stenosis, and the MDS indicated severely impaired cognition with assistance needed for eating, oral hygiene, toileting hygiene, and personal hygiene. Resident 3 was admitted with diagnoses including cerebral palsy, tracheostomy status, persistent vegetative state, and dependence on respirator status, and the MDS indicated severely impaired cognition with dependence on staff for oral hygiene, toileting hygiene, and personal hygiene. Each of the three residents had documentation in the Immunization History Record showing administration of the COVID-19 vaccine on 10/16/2025. During interviews, the Infection Preventionist stated that education is provided to residents’ responsible parties about the COVID-19 vaccine, and the Medical Records Director stated that vaccine information is sent to all responsible parties through regular mail. The Medical Records Director also stated there was no mail confirmation that the information was received and no documentation that residents’ responsible parties received the COVID-19 vaccine information. During concurrent record review, the Director of Staff Development reviewed nursing progress notes and social services progress notes for each of the three residents and stated there was no documented evidence that the responsible parties received COVID-19 vaccine information prior to vaccine administration. The facility policy titled Immunization stated that Social Service staff and/or the Infection Preventionist are to provide the parent/legal representative with Vaccine Information Sheet(s) when indicated and document when the sheets were provided, and that the information sheet can be given at any time prior to vaccine administration.
Failure to Knock Before Entering Resident Room
Penalty
Summary
The facility failed to provide care in a manner that maintained a resident’s dignity and promoted respect when an LVN entered Resident 37’s room without knocking or asking permission. Resident 37 was admitted on 10/18/2018 and readmitted on 11/7/2023 with diagnoses including tracheostomy and dependence on a ventilator. The resident’s MDS dated 1/12/2026 indicated she usually made herself understood and usually understood others, and that she required supervision with eating, upper body dressing, and putting on shoes, and partial assistance with toileting, bathing, lower body dressing, and personal hygiene. During an observation and interview on 2/20/26 at 7:57 p.m., the LVN was observed entering Resident 37’s room through a closed door without knocking or requesting permission. Resident 37 was standing on the right side of her bed nearest the door at the time. After leaving the room, the LVN stated she should have knocked and asked permission before entering to ensure the resident’s privacy and dignity. The DSD later stated that anyone entering a resident’s room must knock and ask permission prior to entering and that residents’ privacy and dignity should be respected and promoted at all times. Facility policies titled Resident Rights and Privacy stated that residents are to be treated with consideration, respect, dignity, individuality, and privacy.
Failure to Notify Responsible Party of Critical Depakote Result
Penalty
Summary
The facility failed to notify a resident’s responsible party of a critical Depakote lab value greater than 150 mcg/ml, with the therapeutic reference range listed as 50-100 mcg/ml. The resident was admitted with diagnoses including spastic quadriplegic cerebral palsy, tracheostomy, and epilepsy. The Minimum Data Set indicated the resident was nonverbal, rarely or never understood others, rarely or never made themselves understood, and was completely dependent on facility staff for all activities of daily living. The lab report dated 10/10/2025 showed the Depakote result was flagged in red as HH, indicating a dangerously and critically high level. Facility records reviewed did not show a documented Change of Condition assessment after the lab result, and progress notes from 10/10/2025 through 2/21/2026 did not show that the resident’s responsible party was notified of the critical result. During interview, the Director of Staff Development stated the result was critically high, a COC should have been completed, and the responsible party should have been notified because that person is responsible for overseeing the resident’s care.
Meal tickets with resident PHI were discarded in trash
Penalty
Summary
The facility failed to ensure confidential personal information was protected when meal tickets containing resident information were discarded in the trash instead of being shredded. During observation, Resident 5 and Resident 35 were seen eating lunch in the dining/activity room, and neither lunch tray had a meal ticket visible. When the Activities Assistant was asked where the meal tickets were, she retrieved two meal tickets from the trash receptacle and stated that the facility had been throwing the meal tickets in the trash and that she was not aware they should not be disposed of there. The Licensed Vocational Nurse stated that licensed nurses dispose of the meal tickets in the trash receptacle. Record review showed Resident 5 was admitted with diagnoses including osteochondrodysplasia, congenital deformities of the skull, face, and jaw, and hydronephrosis, and had severely impaired cognition with assistance needs for eating, oral hygiene, toileting hygiene, and personal hygiene. Resident 35 was admitted with diagnoses including congenital malformation syndrome, paralysis of the vocal cords and larynx, and stenosis of the larynx, and also had severely impaired cognition with assistance needs for eating, oral hygiene, and toileting hygiene. The Dietary Supervisor stated the meal tickets contained resident information including the resident's name, menu, and room number, and that the tickets should not be thrown in the trash because they should be shredded. Facility policy stated copies of resident PHI retained temporarily are to be properly destroyed to maintain information privacy, and the HIPAA Privacy Compliance Statement required workforce training on privacy policies and procedures related to PHI.
Failure to Provide Oral Hygiene and Nail Care
Penalty
Summary
Resident 10 did not receive oral care in accordance with the facility’s Oral Hygiene policy. The resident was admitted with encephalopathy and a gastrostomy tube, and the MDS dated 12/15/2025 indicated severely impaired cognitive skills for daily decision making and total dependence on staff for self-care. During an interview, the resident’s family member stated she had concerns about oral care after observing debris accumulated in the resident’s mouth, which she believed may have resulted from the resident’s teeth not being brushed. A concurrent interview and record review with an RN showed the Documentation Survey Report on oral care did not indicate oral care was provided on 2/2/2026, 2/4/2026, 2/5/2026, and 2/6/2026 during the 7 a.m. to 7 p.m. shift. The RN stated that if residents do not receive oral care, they are at risk for developing oral infections and tooth decay. The facility’s Oral Hygiene policy, last reviewed 12/3/2025, stated each resident will be provided proper oral hygiene daily, beginning in the morning, after every meal, before bedtime, and as needed. Resident 5 and Resident 35 were observed with long, untrimmed fingernails. Resident 5’s admission record listed diagnoses including osteochondrodysplasia, congenital deformities of the skull, face, and jaw, and hydronephrosis. During observation, Resident 5’s fingernails were long and untrimmed, and the DSD later observed that the nails were long past the fingertips with sharp and uneven edges and should be trimmed and filed. Resident 35’s record listed diagnoses including congenital malformation syndrome, paralysis of the vocal cords and larynx, and stenosis of the larynx; the MDS indicated severely impaired cognition and need for supervision or touching assistance with eating, oral hygiene, and toileting hygiene, and independence with personal hygiene. Resident 35 was also observed with long, untrimmed fingernails, and the DSD stated the nails extended past the fingertips and should be trimmed and filed for resident safety. The facility’s Nail Care policy stated nail care should be performed weekly and/or as needed, with fingernails not extending past the fingertips.
CPR Certification Lacked Required Hands-On Component
Penalty
Summary
The facility failed to ensure RN 1 maintained current CPR certification for healthcare providers through a CPR provider whose training included a hands-on session in accordance with accepted national standards. During an employee file review, Human Resources staff 1 reviewed RN 1’s file and stated that RN 1’s CPR certification was entirely web based and did not include the required in-person hands-on component. RN 1 later stated she did not know a hands-on component was required for return demonstration and compliance, and confirmed the CPR course was completely web-based. During an interview, the Director of Staff Development stated that, according to facility policy, all CPR certifications must include a hands-on component to test what staff learned and ensure CPR is performed correctly. The facility policy on verification of licenses and/or credentials required certifications stated that only staff with proper certifications would be employed and that current BLS cards were required for all clinical personnel, including RNs, and must be renewed every two years. The policy also stated that BLS classes were offered in person at the facility.
Failure to Follow Bowel and Bladder Training Schedule
Penalty
Summary
The facility failed to implement a bowel and bladder training program for one resident by not ensuring the resident was placed on the toilet every two hours while awake as ordered. The resident was admitted with diagnoses including osteochondrodysplasia, congenital deformities of the skull, face, and jaw, and hydronephrosis. The MDS dated 12/18/2025 indicated the resident had severely impaired cognition, required assistance with eating, oral hygiene, toileting hygiene, and personal hygiene, and was currently in a toileting program. The physician’s order dated 7/7/2025 directed staff to place the resident on the toilet every two hours for two minutes and document the method used and result. The resident’s care plan, initiated on 9/3/2025, also directed staff to assist the resident to the toilet/commode/toddler potty chair every two hours while awake and as needed and to document the method used. During interview and record review, the DSD stated the resident was in a bowel and bladder training program and should be placed on the toilet every two hours to help train the resident to use the toilet. The DSD reviewed the resident’s records and stated there was no documented evidence that the resident was placed on the toilet on multiple dates in January and February 2026, and confirmed that staff did not place the resident on the toilet as ordered and did not document their efforts.
Missed Ordered Weights and Incomplete G-Tube Water Documentation
Penalty
Summary
The facility failed to obtain and document ordered weights for two residents. One resident had diagnoses including tracheostomy dependence, ventilator dependence, and seizures, and was assessed as being in a persistent vegetative state and completely dependent on staff for all ADLs. The physician’s order required weekly weights on admission/readmission and monthly weights thereafter, as well as a weekly Monday weight before the noon tube feeding for weight management. The record did not show a weight for the Monday weight or for the week of that date in January 2026, and the Director of Staff Development confirmed the weekly weight was not taken. A second resident, who had diagnoses including tracheostomy, ventilator dependence, and epilepsy, was also assessed as being in a persistent vegetative state and completely dependent on staff for all ADLs. The physician’s order required weekly weights on admission/readmission and monthly weights thereafter. The record did not show a weight for June 2025, and the Director of Staff Development confirmed that the ordered weekly weight was not obtained for that month. The facility policy stated that ordered weights must be maintained and that weight changes may be significant. The facility also failed to document the total amount of water infused via G-tube for a resident with anoxic brain damage and a gastrostomy. The resident was comatose and totally dependent on staff for self-care. The physician ordered 170 mL of water via GT pump six times daily for hydration. During observation, an empty water bag was hanging by the resident’s bedside and the label where the date, time, nurse’s initials, and amount infused were to be recorded was blank. The LVN stated the day shift should have documented the amount infused and that the label was important to show how much water had already been given.
Failure to Verify G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to follow its Medication Administration policy for one resident with a gastrostomy tube when an LVN administered Miralax via the G-tube without first verifying tube placement. The resident was admitted with diagnoses including epilepsy and gastrostomy status, and the MDS indicated severely impaired cognition and total dependence on staff for ADLs. The physician order directed Miralax 8.5 grams via G-tube twice daily for constipation, mixed with 60 mL of water. During a concurrent medication administration observation, the LVN prepared the Miralax, donned PPE, turned off the enteral feeding pump, flushed the G-tube with 5 mL of water, administered the medication, and flushed again with 5 mL of water without checking placement. When asked, the LVN stated she forgot to check G-tube placement by aspirating for gastric residual to ensure the tube was in the stomach. An RN stated that prior to medication administration via G-tube, placement should be checked by aspirating for gastric contents, and the facility policy stated enteral tube placement should be checked using a syringe to administer an air bolus while auscultating, then aspirating stomach contents and noting residual.
Improper Food Storage Clearance in Kitchen Dry Storage
Penalty
Summary
The facility failed to ensure seven medium-sized and six large-sized boxes of drinks and food items in the kitchen dry storage area were not stacked higher than 18 inches from the ceiling. During observation, the boxes were seen on two wire racks stacked above the 18-inch clearance limit. During interview, the Dietary Supervisor stated it was against facility policy to stack items higher than 18 inches from the ceiling, explained that there must be at least 18 inches for the ceiling sprinkler to reach and put out a fire, and stated the boxes could also fall and dent, which could lead to bacteria growth. The Dietary Supervisor also stated the boxes should be stored correctly as soon as they are delivered. Review of the facility's Food Storage/Preparation policy, last reviewed on 12/3/2025, indicated the facility must store and secure food safely.
Improper Dumpster Closure and Waste Area Housekeeping
Penalty
Summary
Dispose of garbage and refuse properly was cited after surveyors observed the facility dumpster area with two black dumpsters and one blue dumpster fully open while not actively being used, and a pair of soiled gloves on the ground near the dumpsters. During interview, the Dietary Supervisor stated that all trash must be inside the dumpster, the lids should always be closed, and the area around the dumpsters must be kept clean and free of trash for infection control and to avoid animals and pests from getting into the trash. The Dietary Supervisor also stated the dietary department is responsible for keeping the dumpster lid closed. Review of the facility policy titled Disposal of Infectious and Ordinary Waste Products showed that waste products are to be disposed of properly and dumpster lids are to be closed after every use.
Failure to Submit Staffing Data for Q1 2024
Penalty
Summary
The facility failed to electronically submit direct care staffing information daily, based on payroll data, for the first quarter of 2024. This deficiency was identified during a review of the Certification and Survey Provider Enhanced Report (CASPER) payroll-based Journal (PBJ) Staffing Report, which indicated that the facility did not submit the required data for the period from January 1, 2024, through March 31, 2024. During an interview, the Financial Coordinator (FC) stated that she submitted the Staffing Data report every quarter for 2024 but did not keep copies of the PBJ Reports. Although she received electronic confirmation of data submission, she could not provide documentation for the staffing report submission for the specified dates. The Administrator in Training (AIT) confirmed that the FC was responsible for submitting the CASPER PBJ Staffing Report to CMS but was also unable to provide proof of submission for 2024.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for six residents, leading to potential inadequate care. Resident 16, who was at risk for developing pressure injuries, did not have a care plan addressing this risk despite being immobile and having a stage one pressure injury. The MDS nurse acknowledged the absence of a long-term care plan for pressure injury prevention, which is crucial for addressing the resident's needs and preventing further skin injuries. The Director of Nursing (DON) confirmed the lack of a care plan and highlighted the potential outcome of inadequate care and monitoring. Resident 27, diagnosed with quadriplegia and bladder incontinence, also lacked a comprehensive care plan addressing bladder incontinence. The resident required intermittent catheterization, as ordered by the physician, but no care plan was developed to guide staff in providing the necessary care. The DON confirmed the absence of a person-centered care plan for bladder incontinence, which could lead to a lack of care and inability to implement specific services required by the resident. Additionally, Residents 22 and 24, who were on anticonvulsant medications, did not have care plans addressing their medication use. The MDS nurse and DON acknowledged the oversight, noting the importance of care plans in providing specific interventions for residents on high-risk medications. Resident 13, on a bowel and bladder toileting program, and Resident 39, at high risk for falls, also lacked care plans addressing these needs. The absence of these care plans was confirmed by the DON, who emphasized the importance of care plans in guiding staff interventions and preventing adverse outcomes.
Medication Storage Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with accepted professional principles. Two medication carts were left unlocked and unattended, posing a risk of unauthorized access and contamination. On one occasion, a Respiratory Therapist left a medication cart unlocked while stepping into another room, and on another occasion, a Licensed Vocational Nurse left a cart with prepared medications in syringes unattended while using the restroom. Both staff members acknowledged that the carts should not have been left unattended, as it compromised the safety of the medications. The facility also failed to discard opened olopatadine hydrochloride solution vials after 30 days of opening for a resident with severe intellectual disabilities and cervical spinal cord injury. The resident was dependent on staff for all activities of daily living and received the eye drops twice daily. During an inspection, two opened vials of the solution were found in the medication cart without a beyond-use date, and the Licensed Vocational Nurse confirmed that they should have been discarded after 30 days. Additionally, the facility did not remove an expired antibiotic, nitrofurantoin, from the medication cart for a resident with epilepsy and spastic quadriplegic cerebral palsy. The resident was dependent on staff for personal care and had been receiving the antibiotic for a urinary tract infection. The medication was found in the cart three days past its expiration date, and the Licensed Vocational Nurse acknowledged that it should have been removed to prevent accidental administration of an expired medication.
Failure to Provide PROM Exercises and Develop Care Plan for Resident with Contractures
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited range of motion (ROM) by not administering Passive Range of Motion (PROM) exercises as ordered by the physician. The resident, who was admitted with diagnoses including cerebral palsy and contractures of the elbow and wrist, had physician orders for PROM exercises to be performed on both upper and lower extremities twice daily. However, the Restorative Treatment Record showed multiple instances where these exercises were not documented, indicating they may not have been performed. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed the lack of documentation for the PROM exercises on several dates. The LVN acknowledged that if the treatment was not documented, it was considered not done, and the DON emphasized the importance of these exercises in preventing the worsening of the resident's contractures. Additionally, it was revealed that the facility did not develop a person-centered care plan for the resident's contracture management, which is crucial for monitoring the resident's condition and ensuring adequate care. The facility's policies and procedures require that ROM exercises be documented immediately after being performed, and any gaps in documentation are not acceptable. The lack of documentation and the absence of a care plan for the resident's contracture management highlight deficiencies in the facility's adherence to its own policies, potentially leading to inadequate care for the resident.
Failure to Ensure Resident Wore Required Safety Helmet
Penalty
Summary
The facility failed to ensure that a resident with a physician's order to wear a soft helmet when out of the crib was wearing the helmet, placing the resident at risk for injury. The resident, admitted on February 1, 2018, had diagnoses including congenital malformations and required attention to a tracheostomy. The Minimum Data Set (MDS) dated February 1, 2024, indicated the resident had severely impaired cognitive skills and required varying levels of assistance with daily activities. On December 28, 2024, the resident was observed ambulating independently in the activities room without wearing the required helmet. A registered nurse confirmed that the resident should have been wearing the helmet for safety reasons and stated that it was the responsibility of all staff to ensure compliance with the physician's order. The facility's policy, dated February 5, 2023, indicated that all physician orders should be carried out completely and in a timely manner, which was not adhered to in this instance.
Failure to Follow Physician Orders for Bladder Incontinence Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with bladder incontinence, specifically by not adhering to physician orders for warm compress application and bladder massage prior to in and out catheterization. The resident, who was in a persistently vegetative state and dependent on staff for all care, had a history of anoxic brain damage, epilepsy, and urinary infections. Physician orders required a bladder scan four times a day, and if 300 ml or more of urine was detected, a warm compress and bladder massage were to be performed before catheterization. The Treatment Administration Records (TAR) for the resident indicated multiple instances where the bladder scan showed more than 300 ml of urine, yet there was no documentation of the warm compress and bladder massage being performed, nor the subsequent catheterization as ordered. Specifically, on several dates, the records showed significant urine retention, but the required interventions were not documented, indicating a failure to follow the physician's orders. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the staff did not document the necessary interventions or catheterizations in the resident's records. The facility's policies required documentation of all treatments and adherence to physician orders, which was not followed in this case, potentially increasing the resident's risk for urinary tract infections.
Failure to Document Resident Output
Penalty
Summary
The facility failed to implement its policy on intake and output documentation, which led to a deficiency in monitoring the hydration status of two residents, Resident 18 and Resident 8. Resident 18, who was admitted with conditions including spastic diplegic cerebral palsy, tracheostomy, and gastrostomy, was found to have no documented evidence of total output every shift as required by the facility's policy. The Director of Nursing (DON) confirmed the absence of documentation in Resident 18's Treatment Administration Record (TAR) for December 2024, which is crucial for monitoring hydration and preventing dehydration, especially given the resident's dependence on enteral feeding and issues with constipation. Similarly, Resident 8, diagnosed with spastic quadriplegic cerebral palsy and also dependent on enteral feeding, had no documented output records in their TAR for the same period. The DON acknowledged the lack of documentation, which is essential for assessing the resident's hydration status and preventing fluid overload. The facility's policy, reviewed in August 2023, mandates that the charge nurse evaluate and document each resident's intake and output every shift to ensure adequate hydration, which was not adhered to in these cases.
Failure to Label GT Y-Connector as per Policy
Penalty
Summary
The facility failed to adhere to its enteral tube feeding policy and procedure for a resident with a gastrostomy tube (GT). The deficiency was identified during an observation of medication administration, where it was noted that the y-connector of the resident's GT was not labeled with the date it was last changed. This oversight was confirmed by the Licensed Vocational Nurse (LVN) who administered the medication and acknowledged that the y-connector should be changed every Sunday and labeled accordingly. The absence of a date on the y-connector label indicated non-compliance with the facility's policy, which requires labeling to ensure timely changes and prevent microbial growth. The resident involved had a history of severe medical conditions, including encephalopathy, respiratory failure, and cerebral palsy, and was totally dependent on staff for all activities of daily living. The facility's Director of Nursing (DON) also confirmed the requirement for the y-connector to be changed weekly and labeled to prevent infection risks. The facility's policy on medication administration via enteral feeding tubes emphasizes the importance of maintaining cleanliness and safety, further underscoring the deficiency in this instance.
Failure to Change and Label Ventilator Humidifier Water Bottle
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident 22, who required mechanical ventilation. The deficiency was identified when it was observed that the aerosol/ventilator humidifier water bottle connected to the resident was not labeled with the date it was last changed. According to the facility's policy, the humidifier water bottle should be changed every three days and labeled with the date of change. This oversight was confirmed during an observation and interview with a Respiratory Care Practitioner, who acknowledged that the lack of labeling and timely change could lead to a respiratory infection. Resident 22 had a history of cerebral palsy, anoxic brain damage, and convulsions, and was totally dependent on staff for all activities of daily living. The resident's care plan emphasized the importance of remaining free from complications related to ventilator dependence, including upper respiratory infections. The facility's policy, last reviewed in 2018, required that all respiratory equipment be dedicated to individual residents and maintained according to specific guidelines, including the regular changing and labeling of humidifier water bottles. The failure to adhere to these guidelines was further corroborated by the Respiratory Department Supervisor, who noted the increased risk of healthcare-acquired infections due to this oversight.
Incomplete Antibiotic Order Lacks Specific Diagnosis
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one of the sampled residents by not ensuring a specific indication was written for an order of Augmentin, an antibiotic. This oversight was identified during a review of the resident's medical records, which showed an order for Augmentin ES-600 oral suspension to be administered via gastrostomy tube twice a day for seven days. However, the order lacked a specific diagnosis or infection that the medication was intended to treat, which is a requirement for antibiotic orders. Interviews with the Infection Preventionist and the Director of Nursing confirmed that the physician's order was incomplete, as it did not specify the infection being targeted by the antibiotic. The facility's policy on medication administration requires that physician-ordered medications include the proper resident name, medication, dosage, time, route, and rationale. The absence of a specific diagnosis in the antibiotic order placed the resident at risk of not receiving appropriate care due to inaccurate medical information.
Arbitration Agreement Lacks Venue Selection
Penalty
Summary
The facility failed to provide an Arbitration Agreement that included the selection of a venue suitable for both the resident or their representative and the facility, which is necessary to ensure a fair arbitration process. During a review of the facility's Arbitration Agreement, it was found that the agreement did not specify a neutral venue that would meet the needs of both parties involved. This was confirmed during an interview with the Social Service Director, who acknowledged the omission. Additionally, the Administrator in Training was unaware of the requirement for the Arbitration Agreement to include a suitable venue for both parties.
Failure to Follow Sterile Tracheal Suction Protocol
Penalty
Summary
The facility failed to implement its policy on Sterile Tracheal Suction, which led to a deficiency in infection prevention and control. During an observation, Respiratory Care Practitioner 2 (RCP 2) did not remove non-sterile gloves before donning sterile gloves while performing a sterile tracheal suction on Resident 4. This action was contrary to the facility's policy, which requires the removal of non-sterile gloves before applying sterile gloves to maintain a sterile field. RCP 2 was unaware of this requirement, as confirmed during an interview. Resident 4, who was admitted with diagnoses including encephalopathy and chronic respiratory failure, had a tracheostomy in place and was totally dependent on staff for all activities of daily living. The resident's care plan required regular assessment and suctioning for excessive secretions. The failure to follow proper glove protocol during the suction procedure had the potential to increase the risk of healthcare-acquired infections for Resident 4, as noted by the Respiratory Department Supervisor.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 4,933 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
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sun Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Villa Scalabrini Special Care | 0.4 mi | ★★★★★ | 10 | 0 |
| The Hills Healthcare Center | 2.1 mi | ★★★★★ | 17 | 0 |
| Pacifica Hospital Of The Valley Dp Snf | 2.3 mi | ★★★★★ | 22 | 0 |
| All Saints Healthcare Subacute | 2.5 mi | ★★★★★ | 36 | 1 |
| High Valley Lodge | 2.7 mi | ★★★★★ | 5 | 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.