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 Villa Scalabrini Special Care during CMS and state inspections, most recent first.
A resident with depression, insomnia, and psychosis was maintained on routine Temazepam for insomnia, with MARs showing 7 to 8 hours of nighttime sleep and only brief evening sleep. The CP flagged the hypnotic for re-evaluation and noted the need for a GDR unless clinically contraindicated, but the chart lacked a documented GDR attempt or clear clinical rationale for continuing the medication. The DON confirmed the resident had no documented insomnia behaviors and that the psychiatrist note did not include a Temazepam plan.
Controlled medication accountability was not maintained for three residents and for three eKITs containing CSs. An LPN stated that doses of clonazepam and tramadol had been given but were not signed on the controlled drug record, and the DON confirmed the documentation was not entered immediately. In addition, three eKITs in the med room had no shift-change reconciliation logs, and staff acknowledged the kits were not inventoried as required by policy.
Missed Scheduled Medications During Morning Pass: An LVN administered several ordered meds to three residents but failed to give additional scheduled meds, including folic acid, multivitamin with minerals, cyanocobalamin, loratadine, and Systane. The LVN acknowledged the omissions and stated the residents did not receive the meds within the facility’s 60-minute medication window. The DON confirmed the missed doses and noted the residents’ relevant diagnoses and ordered supplements/meds.
Unsafe food storage and tray transport were observed when pasta was kept in a container with the lid not fully closed, cut onion and tomato halves were stored in the refrigerator with no date, and meal trays for two residents were moved down a hallway with some food items uncovered. The residents involved had significant cognitive impairment and functional dependence, including dementia, Parkinson's disease, and Alzheimer's disease.
Failure to Maintain Mask Use in the Dining Room: A CNA was observed assisting and transporting residents in the dining room without a face mask and stated he had forgotten to put it back on. The DODS was also observed in the dining room without a mask and stated he did not need one because he was vaccinated. The IP stated staff must wear masks 100% of the time around residents, and the facility's COVID-19 Surveillance Plan required all staff to wear a surgical mask during working hours.
A resident with depression, psychotic disorder, and severely impaired cognition was prescribed trazodone for insomnia, but the care plan only directed staff to monitor and document sleep hours and medication effectiveness without setting a measurable sleep goal. The MAR showed sleep was tracked each evening and night, and the MDSC and DON stated the plan lacked an individualized target needed to evaluate whether the trazodone was effective and when to escalate concerns.
Dementia Care Plan Lacked Supervision Intervention: A resident with dementia, impaired vision, and dependence for multiple ADLs was found eating lunch alone in the dining room while facing the wall and without supervision. The dementia care plan noted confusion, disorientation, and short-term memory loss, but did not include an intervention for supervision. CNA and IP stated the resident should not have been left alone, and the DON confirmed the care plan was not individualized to address supervision needs.
The facility failed to implement comprehensive person-centered care plans for three residents, leading to significant deficiencies. A resident on anticoagulant therapy was not monitored for bleeding, another at high risk for falls lacked floormats, and a third did not have a care plan for their RNA program. These oversights resulted in inadequate care and increased risk of injury.
The facility failed to assess the risk of entrapment for residents using bed rails, as required by policy. A resident with Alzheimer's and another with major depressive disorder were observed with siderails without a Risk for Entrapment Assessment. Additionally, a cognitively impaired resident was placed in a bed with full side rails without a physician's order or assessment, posing a risk for entrapment and injury.
The facility failed to properly store and dispose of medications, including an expired insulin pen for a resident with diabetes and expired supplies in a treatment cart. Staff confirmed the oversight, acknowledging the importance of timely removal of expired items to prevent medication errors.
Two residents experienced significant weight loss without timely assessment or intervention by a Registered Dietitian (RD) due to staffing challenges and high turnover rates. The facility's RD, who worked remotely and onsite once a week, had not assessed the residents after their weight loss was noted, leading to a deficiency in nutritional oversight.
The facility failed to ensure proper food storage practices, risking foodborne illnesses for three of 53 residents. Observations revealed a jar of olives without an expiration date, a five-pound bag of buttermilk mix without an open date, and a gallon of milk without an open date. The Dietary Supervisor confirmed that all food items should be dated upon receipt to ensure timely disposal. This oversight could lead to the consumption of expired or improperly stored food.
A facility failed to ensure proper infection control practices, including hand hygiene and equipment labeling. An LVN did not wash hands before administering eye drops to a resident on enhanced barrier precautions and exited the room without removing an isolation gown. Additionally, a urinal was not labeled with a resident's name, risking cross contamination. These actions were against the facility's infection control policies.
A facility failed to maintain a resident's dignity during meal assistance when a CNA stood over a resident while feeding them, contrary to the facility's policy. The resident, with severe cognitive impairment and dependence on staff for eating, was not assisted in a manner that promoted dignity, as confirmed by the DON.
A resident with severe cognitive impairment was found unable to reach her call light, which was hanging on the wall behind her head. The facility's policy requires call lights to be within easy reach, but during an observation, the resident could not locate it and sometimes screamed for help. The DON confirmed the requirement for call lights to be accessible at all times.
A resident's privacy was compromised when an LVN left the electronic health record (EHR) open and unattended during a medication pass. The LVN admitted this was a HIPAA violation. The resident had intact cognition and required assistance with daily activities. The facility's data privacy policy was not followed.
A facility failed to obtain a physician order for a Low Air Loss Mattress (LALM) setting for a resident with quadriplegia, epilepsy, and Parkinson's disease, who was cognitively impaired and dependent on staff. The LALM was incorrectly set at 350 pounds instead of the required 180 pounds, based on the resident's weight. The physician order for the LALM was not renewed after the resident's hospital transfer, contrary to the facility's pressure ulcer prevention policy.
A resident with dementia and other conditions did not receive restorative nursing exercises as ordered, due to a scheduling error. The RNA ambulation program was incorrectly assigned to the night shift, resulting in no treatment being administered, contrary to the facility's policy.
The facility failed to secure a television in a resident's room, posing a risk of injury, and left medication unattended with another resident who was not capable of self-administration. The DON confirmed that televisions should be secured and medications should not be left with residents, as per facility policy.
A facility failed to update the care plan and monitor for UTI symptoms for a resident with an indwelling catheter. The resident's care plan, initiated for catheter care, was not revised after its initiation, and interventions such as monitoring for UTI symptoms were not documented. The MDS Nurse confirmed the lack of updates and documentation, which led to inadequate care and supervision.
A resident with severe cognitive impairment and dependency on staff experienced significant weight loss, but the facility failed to conduct necessary nutritional assessments. Despite physician recommendations for a fortified diet and medication, the Registered Dietician did not evaluate the resident's condition after the weight loss was noted. The facility's policy required regular assessments, but high RD turnover led to a lack of follow-up, leaving the resident's nutritional needs unaddressed.
A facility failed to ensure that a nurse checked the placement of a gastrostomy tube (G-tube) before administering medications to a resident, as required by the care plan. The resident, who was totally dependent on staff and at risk for aspiration, received medications via the G-tube without verification of its placement. The LVN admitted to not checking the G-tube placement, and the DON confirmed that this oversight could increase the risk of aspiration.
Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that one sampled resident’s medication regimen was free from unnecessary psychotropic medication use. Resident 26 was admitted with diagnoses including depression, insomnia, and psychosis, and the resident’s MDS indicated routine use of antipsychotic, antidepressant, and hypnotic medications. The resident was prescribed Temazepam 7.5 mg at bedtime for insomnia starting 8/29/2024, and the care plan identified sedative/hypnotic therapy with a goal of sleeping 6 to 8 hours per night. The resident’s MARs for November 2025 through February 2026 showed sleep monitoring each evening and night shift for Temazepam use. Those records documented that the resident slept only 0.5 to 3 hours in the evening but 7 to 8 hours at night. A consultant pharmacist’s medication regimen review note dated 1/21/2026 stated the resident had been on routine Temazepam 7.5 mg at bedtime since 8/29/2024 and recommended re-evaluation of the hypnotic order, noting that federal nursing regulations require a gradual dose reduction at least quarterly for routinely used sedative/hypnotic medications unless clinically contraindicated. The record also included an LVN note stating the MD was contacted by phone and said to continue the current dose because the benefit outweighed the risks and the medication was needed to maintain quality of life and functional level. However, the psychiatrist’s note dated 1/29/2026 stated the resident felt fine, had no complaints, no behavior/problem/issue, progress was stable, and sleep was normal, without a plan for Temazepam use. During interview, the DON stated the resident did not have documented insomnia behaviors, slept at least 7 to 8 hours every night since November 2025, and the chart did not contain a GDR attempt, clinical rationale for continuing Temazepam, or documentation of contraindications preventing a GDR.
Controlled Medication Counts and Emergency Kit Reconciliation Not Maintained
Penalty
Summary
The facility failed to reconcile three medication emergency kits containing controlled substances in the medication room for February 2026, and failed to account for one dose each of clonazepam for Resident 21, clonazepam for Resident 45, and tramadol for Resident 39 in Medication Cart Green. During observation, the controlled drug accountability logs did not match the medication counts in the bubble packs for these residents. Resident 21 was prescribed clonazepam 1 mg daily for anxiety, Resident 39 was prescribed tramadol 50 mg twice daily for osteoarthritis pain, and Resident 45 was prescribed clonazepam 0.5 mg twice daily for anxiety. During the medication cart observation, LVN 2 stated that the three doses had been administered that morning but were not signed on the Antibiotic or Controlled Drug Record accountability logs. LVN 2 stated the facility policy required each controlled medication dose to be signed after preparation and acknowledged that failing to document the doses could lead to medication error and inaccurate accountability. The DON also stated that LVN 2 failed to document the preparation of the controlled medications immediately on the accountability record. In the medication room, one eKIT stored in the refrigerator and two eKITs stored at room temperature contained controlled substances but had no accountability logs for reconciliation at every shift change for February 2026. LVN 1 stated that all controlled substances, including emergency kits, should be reconciled at every shift, and the DON acknowledged that the three eKITs were not reconciled at every shift and did not have accountability logs. The facility policy stated that controlled medications, including the emergency supply, must be physically inventoried at each shift change by two licensed nurses and documented on the controlled medication accountability record.
Missed Scheduled Medications During Morning Pass
Penalty
Summary
The facility failed to ensure its medication error rate remained below 5 percent. Surveyors identified 6 medication errors out of 31 total opportunities, resulting in an overall medication error rate of 19.35% and affecting three residents during observed medication administration. The errors involved missed ordered medications for Resident 7, Resident 39, and Resident 47 during the morning medication pass. During observation on 2/24/2026, an LVN administered several scheduled oral medications to Resident 47 but did not prepare or administer multivitamin with minerals, cyanocobalamin, or Systane as ordered. The same LVN later administered several oral medications to Resident 7 but did not prepare or administer folic acid as ordered. The LVN also administered several oral medications to Resident 39 but did not prepare or administer multivitamin with minerals or loratadine as ordered. In interview, the LVN acknowledged the missed medications and stated the residents did not receive them within the facility’s 60-minute medication administration window. Record review showed Resident 7 had diagnoses including arthritis and osteoarthritis and had an order for folic acid 1 mg daily at 9 a.m. Resident 39 had diagnoses including osteoporosis and bone density disorder and had orders for multivitamin with minerals daily and loratadine 10 mg daily at 9 a.m. Resident 47 had diagnoses including osteoarthritis, macular degeneration, and polyneuropathy and had orders for multivitamin with minerals daily, cyanocobalamin 1000 mcg daily, and Systane to the left eye twice daily. The DON stated the missed medications increased the risk of vitamin deficiencies, worsening dry eyes, and allergies, and confirmed the LVN failed to follow the facility’s medication administration guidelines.
Unsafe Food Storage and Uncovered Tray Transport
Penalty
Summary
Safe and sanitary food storage was not maintained when a container of pasta in the dry storage area was observed with the lid placed on top at an angle, leaving the pasta exposed to air. During the observation, the Director of Dietary Services stated the lid should be closed so nothing touches the pasta and no pests get into the container. The facility's Food Storage policy, last reviewed 1/21/2026, required food to be properly stored, and the food storage chart indicated opened pasta should be kept in an airtight container. In the walk-in refrigerator, one half of an onion and one half of a tomato were observed wrapped in plastic with no date. The Director of Dietary Services stated the items should be labeled with the date they were cut so dietary staff would know when they were prepared and when they could safely be used. The Food Storage policy required all open food items to have an open date, and the food storage chart indicated ripe tomatoes should be refrigerated for 1-2 days. The report also described meal trays for two residents being transported down a hallway to residents eating in their rooms with some food items left uncovered; one resident had Parkinson's disease and dementia, was rarely or never understood, and was dependent on staff for all ADLs, while the other had Alzheimer's disease, severe cognitive impairment, and required assistance with toileting, bathing, dressing, hygiene, and eating.
Failure to Maintain Mask Use in the Dining Room
Penalty
Summary
Infection control measures were not maintained when a CNA was observed in the dining room assisting residents and transporting residents without wearing a face mask. During the observation, the CNA was also chewing food as he entered the dining room and stated that he knew he was supposed to wear a mask but had forgotten to put it back on. The Infection Preventionist entered the dining room during the observation and told the CNA to put on a mask, stating that staff must wear masks around residents to keep them safe from respiratory illnesses. The facility policy titled COVID-19 Surveillance Plan, last reviewed 1/21/2026, stated that all staff are to wear a surgical mask during working hours. The Director of Dietary Services was also observed in the dining room without a mask while residents were seated waiting for their lunch trays. The DODS stated that because he had been vaccinated, he did not need to wear a mask. During interview, the Infection Preventionist stated that all staff members must mask 100% of the time regardless of vaccine status and that staff need to wear masks anywhere residents live or receive care, including the dining room. The same facility policy stated that all staff are to wear a surgical mask during working hours.
Care Plan Lacked Measurable Sleep Goal for Trazodone Monitoring
Penalty
Summary
Resident 12’s care plan for depression manifested by insomnia did not include an objective, measurable goal for the number of hours of sleep expected while receiving trazodone 50 mg at bedtime. The resident’s admission record showed diagnoses including depression and psychotic disorder, and the MDS indicated severely impaired cognition. The MDS also indicated the resident did not have symptoms of trouble falling or staying asleep or sleeping too much, yet the order summary showed trazodone had been prescribed for insomnia related to depressive disorder since 4/21/2025. The care plan, dated 2/20/2026, directed staff to monitor and document hours of sleep on the evening and night shifts and to monitor side effects and effectiveness of trazodone, but it did not identify a measurable target for sleep duration. The MAR showed the resident was monitored for hours of sleep every evening and night and slept up to 3 hours in the evening and 6 to 8 hours at night daily. During interview, the MDS Coordinator and DON stated that care plans should include measurable goals for hours of sleep to evaluate trazodone’s effectiveness, and that without such a goal staff could not determine whether the resident’s sleep pattern was acceptable or when to communicate concerns to the physician.
Dementia Care Plan Lacked Supervision Intervention
Penalty
Summary
The facility failed to ensure that a resident diagnosed with dementia received appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Resident 23 was admitted with diagnoses including dementia and macular degeneration, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS indicated the resident usually understood others, usually made herself understood, had moderately impaired vision, was unable to recall three words, and was dependent on staff for toileting, bathing, hygiene, and putting on/taking off shoes. The resident’s dementia care plan identified episodes of confusion, disorientation, and short-term memory loss, but it did not include interventions addressing the need for supervision. During observation in the dining/activity room, Resident 23 was seated in a wheelchair at the far end of the dining room, facing the wall, eating lunch alone and without supervision. CNA 1 stated the resident should never be left alone and had only left for a few minutes to get something to eat, while also stating the resident takes a very long time to eat and is usually the last resident in the dining room. The IP stated Resident 23 has dementia and should not be left alone in the dining room, especially because the resident was facing the wall and his face was not visible in the event he was choking. The DON reviewed the dementia care plan and stated it was not individualized to include an intervention addressing supervision.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for three residents, leading to significant deficiencies in their care. Resident 33, who was admitted with a history of falling and dementia, was not monitored for signs and symptoms of bleeding despite being on anticoagulant therapy. The Director of Nursing (DON) acknowledged the absence of documentation indicating monitoring for bleeding, which is crucial for timely intervention. Additionally, Resident 33, assessed as high risk for falls, did not have a care plan addressing this risk, resulting in a fall that caused a laceration on the forehead. Resident 34, who was also at high risk for falls, was not provided with bilateral floormats as indicated in their care plan. The absence of floormats was confirmed during an observation, and the Minimum Data Set Nurse (MDSN) stated that without them, the resident was at risk of serious injury from falls. The facility's policy on falls requires a care plan outlining specific risk factors and interventions, which was not adequately implemented for Resident 34. Resident 45, admitted with dementia and a history of falls, did not have a comprehensive care plan for their Restorative Nursing Assistant (RNA) program. Despite a physician's order for RNA ambulation, there were no entries in the restorative treatment records, and the care plans lacked documentation of person-centered interventions. Both the MDSN and the Director of Rehabilitation confirmed the absence of a care plan, which is necessary to monitor the resident's range of motion and ambulation. The Director of Nursing stated that the lack of a care plan could result in inadequate care and monitoring of the resident's condition.
Failure to Assess Bed Rail Entrapment Risk
Penalty
Summary
The facility failed to properly assess residents for the risk of entrapment when using bed rails, as required by their policy. Resident 14, who was admitted with Alzheimer's disease and gastroesophageal reflux disease, was observed with half bed siderails up on both sides of the bed. Although there was a Side Rail Use Assessment and physician's orders for the use of bed rails, the Director of Nursing (DON) confirmed that a Risk for Entrapment Assessment was not conducted. This oversight placed the resident at risk for potential injury due to entrapment. Similarly, Resident 50, who was admitted with major depressive disorder and gastroesophageal reflux disease, was observed with siderails up while sleeping. The DON confirmed that although there was a Side Rail Use Assessment and physician's orders, a Risk for Entrapment Assessment was not completed. This failure to assess for entrapment risk could lead to potential injury for the resident. Resident 11, who was cognitively severely impaired and had multiple diagnoses including multiple sclerosis and chronic kidney disease, was found in a bed with full side rails without a physician's order, assessment, or consent. The Minimum Data Set Nurse (MDSN) acknowledged that the resident was likely placed in the bed with full side rails by mistake, which posed a risk for entrapment and injury. The facility's policy requires an assessment and physician order for the use of restraints, including bed rails, which was not followed in this case.
Improper Storage and Disposal of Medications
Penalty
Summary
The facility failed to ensure proper storage and disposal of drugs and biologicals, leading to potential risks for residents. An insulin pen past its discard date was found in a medication cart intended for a resident with diabetes and hypertension. The insulin pen, labeled with an open date of 12/29/2025, was observed during a medication cart inspection on 2/15/2025. Licensed Vocational Nurse 2 confirmed that insulin should be used within 28 days of opening to maintain efficacy. The Director of Nursing acknowledged that using insulin beyond this period could result in ineffective diabetes management for the resident. Additionally, during an inspection of Treatment Cart 1 on 2/16/2025, expired medications and supplies were found, including a vaginal cream belonging to a discharged resident and povidone-iodine swab sticks. Licensed Vocational Nurse 3 confirmed the expiration of these items and stated that expired medications should be removed immediately. Registered Nurse 1 emphasized the importance of inspecting medication and treatment carts every shift to prevent medication errors. The facility's policy requires the immediate removal and disposal of outdated or deteriorated medications, which was not adhered to in these instances.
Inadequate RD Oversight Leads to Unaddressed Weight Loss
Penalty
Summary
The facility failed to ensure adequate oversight of the Food and Nutrition Services by qualified personnel, specifically a Registered Dietitian (RD), for two residents who experienced significant weight loss. Resident 25, who was admitted with conditions including absolute glaucoma, dysphagia, and a history of falling, experienced a weight loss of 5% or more within a month and 10% or more over six months. Despite these changes, the RD did not assess or evaluate the resident after the weight loss was noted on 6/5/2024 and 7/4/2024. The facility's RD, who started in October 2024, was not aware of Resident 25's condition and had not conducted any assessments since 5/3/2024. Similarly, Resident 53, who was admitted with type 2 diabetes mellitus, legal blindness, and hypertension, lost 13 pounds, equating to 10% of their body weight in one month. The last RD assessment for Resident 53 was conducted on 4/21/2024, and no further evaluations were made after the significant weight loss was recorded on 12/26/2024. The facility's RD, who worked remotely and onsite once a week, had not assessed or visited Resident 53 and was unaware of the resident's weight loss. The Director of Nursing (DON) and the Administrator acknowledged the high turnover rate of RDs and the challenges in staffing qualified dietitians, which contributed to the lack of timely assessments and interventions for residents experiencing weight loss. The facility's policies required RDs to conduct comprehensive nutritional assessments for new admissions, quarterly reviews, and as needed for residents with significant changes in health status. However, these assessments were not conducted for Residents 25 and 53, leading to a deficiency in the facility's nutritional oversight.
Improper Food Storage Practices
Penalty
Summary
The facility failed to ensure proper food storage practices, which had the potential to place three of 53 residents at risk for foodborne illnesses. During an observation and interview in the facility's kitchen, it was noted that a jar of olives in the dry storage room lacked an expiration date, and a five-pound bag of buttermilk mix did not have an open date. Additionally, a gallon of regular milk in the refrigerator was missing an open date. The Dietary Supervisor stated that all food items should be dated upon receipt with the month, day, and year to ensure they are discarded after the expiration date. This oversight in labeling and dating food items could lead to the consumption of expired or improperly stored food, increasing the risk of foodborne illnesses among residents. The facility's policy and procedure titled 'Recommended Storage Practices,' last reviewed on January 30, 2025, indicated that scoops should not be stored in food containers. However, the report does not specify if this particular policy was violated during the observation.
Infection Control Deficiencies in Hand Hygiene and Equipment Labeling
Penalty
Summary
The facility failed to ensure proper hand hygiene and adherence to enhanced barrier precautions by Licensed Vocational Nurse 4 (LVN 4) while administering medication to Resident 4. Resident 4, who was on enhanced barrier precautions due to their medical condition, was observed receiving eye drops from LVN 4 without the nurse washing their hands after administering medication via a gastrostomy tube. Additionally, LVN 4 exited the resident's room without removing their isolation gown, which is against the facility's policy for infection control. Resident 4 had been readmitted to the facility with diagnoses including Parkinson's disease and atrial fibrillation, and was totally dependent on staff for all activities of daily living due to severely impaired cognition. The failure to follow proper infection control procedures was confirmed by the Infection Preventionist, who stated that LVN 4 should have removed the gown and gloves before leaving the room to prevent the spread of infection. In another instance, the facility did not label a urinal with the resident's name, which was observed in Resident 48's room. Resident 48, who had intact cognition but required assistance with personal care, was at risk for bladder incontinence. The Director of Nursing confirmed that the urinal should have been marked to prevent cross contamination, as per the facility's infection control policy.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain or enhance a resident's dignity and respect during meal assistance. Certified Nursing Assistant 1 (CNA 1) was observed standing over Resident 25 while assisting with a meal, which is contrary to the facility's policy that requires staff to assist residents in a sitting position to promote dignity. CNA 1 admitted to standing over residents because it was easier for her, indicating a disregard for the facility's policy and the resident's dignity. Resident 25, who was originally admitted to the facility in 2020 and readmitted later, has diagnoses including absolute glaucoma, dysphagia, and a history of falling. The resident's Minimum Data Set (MDS) indicated severely impaired cognitive skills and dependence on staff for eating and other daily activities. The facility's Director of Nursing (DON) confirmed the requirement for staff to assist residents in a sitting position during meals, emphasizing the importance of maintaining the resident's dignity.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach while the resident was in bed. This deficiency was identified during an observation where the resident was seen sitting on her bed with the call light hanging on the wall behind her head, out of reach. The resident, who has severe cognitive impairment and is dependent on staff for various activities of daily living, was unable to locate the call light and mentioned that she sometimes screams for help. The Licensed Vocational Nurse confirmed that the call light was not within the resident's reach and acknowledged that it should always be accessible to the resident. The resident's care plan, which addresses communication problems related to dementia, includes an intervention to ensure the call light is answered promptly. The facility's policy and procedure on answering call lights also mandates that the call light be within easy reach of residents when they are in bed or confined to a chair. The Director of Nursing stated that call lights are required to be accessible to residents at all times, and failing to do so could result in residents being unable to call for help when needed.
Privacy Breach of Resident's EHR by LVN
Penalty
Summary
The facility failed to maintain the privacy of confidential information for a resident when a Licensed Vocational Nurse (LVN) left the resident's electronic health record (EHR) open and unattended. This incident occurred during a medication pass observation in the main dining room, where the LVN left the computer screen displaying the resident's medication list while stepping away from the medication cart to administer medications. The LVN acknowledged that leaving the EHR open was a violation of the Health Insurance Portability and Accountability Act (HIPAA), which mandates the protection of residents' health information from unauthorized access. The resident involved in this incident was initially admitted to the facility with diagnoses including body myositis, generalized anxiety disorder, and essential hypertension. The resident's Minimum Data Set (MDS) indicated intact cognition and required moderate-to-maximal assistance for various activities of daily living. The facility's policy on data privacy and security, last reviewed in January 2025, outlines the requirements for ensuring the privacy and security of sensitive data within the healthcare organization's IT systems, which was not adhered to in this instance.
Failure to Obtain Physician Order for LALM Setting
Penalty
Summary
The facility failed to obtain a physician order for a Low Air Loss Mattress (LALM) setting for a resident, which is crucial for preventing and treating pressure injuries. The resident, who was admitted with conditions such as quadriplegia, epilepsy, and Parkinson's disease, was cognitively severely impaired and totally dependent on staff for all activities of daily living. The care plan for the resident indicated the use of a LALM to prevent skin integrity impairment due to decreased mobility. However, during an observation, it was found that the LALM was set incorrectly at 350 pounds instead of the required 180 pounds, which was based on the resident's weight. The Director of Nursing acknowledged that the incorrect setting would render the LALM ineffective in preventing pressure injuries. A review of the resident's records revealed that the physician order for the LALM was discontinued when the resident was transferred to the hospital and was not renewed upon readmission. The facility's policy on pressure ulcer prevention emphasizes the importance of using therapeutic mattresses and adjusting settings according to the resident's weight. The failure to renew the physician order and correctly set the LALM placed the resident at risk for discomfort and the development of pressure ulcers.
Failure to Provide Restorative Nursing Exercises
Penalty
Summary
The facility failed to provide necessary restorative nursing exercises to a resident, identified as Resident 45, to prevent a decline in range of motion. The resident, who was admitted with diagnoses including unspecified dementia, major depressive disorder, lack of coordination, and repeated falls, had a physician's order for a Restorative Nursing Assistant (RNA) program for ambulation with hand-held assistance every day, five times a week. However, a review of the resident's restorative treatment records from 1/3/2025 to 2/14/2025 showed no entries indicating that the treatment was provided. Interviews with facility staff, including the MDS Nurse and the Director of Rehabilitation (DOR), revealed that due to an error in scheduling, the RNA ambulation task was incorrectly assigned to the night shift, resulting in the treatment not being administered. The Director of Nursing confirmed that the resident had not received the RNA ambulation treatment as ordered since 1/3/2025. The facility's policy indicated that RNA services should be provided per physician orders, but this was not adhered to, leading to the potential for further decline in the resident's range of motion and activities of daily living.
Failure to Secure Environment and Medication Administration
Penalty
Summary
The facility failed to ensure a safe environment for Resident 20 by not securing the television in their room. The television was observed on top of a drawer cabinet without any strap or anchor to prevent it from falling, which was against the facility's policy that requires all televisions to be securely mounted or placed on stable surfaces. Resident 20, who was admitted with diagnoses including gastroesophageal reflux disease and Alzheimer's disease, had severely impaired cognitive skills and required substantial assistance for daily activities. The Director of Nursing (DON) confirmed that televisions should be secured to prevent potential injury. Additionally, the facility did not adhere to its medication administration policy for Resident 49, who was not capable of self-administering medications. A white pill was found left unattended in a medication cup on Resident 49's meal tray. The resident, who had moderately impaired cognitive skills and required substantial assistance for daily activities, stated that the pill was left by a nurse. The DON confirmed that medications should not be left with residents and should be administered by nurses to ensure proper observation. The facility's policy requires that residents can only self-administer medications if deemed safe by the interdisciplinary team, which was not the case for Resident 49.
Failure to Update Care Plan and Monitor UTI Symptoms for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to provide adequate care for a resident with an indwelling catheter, leading to a deficiency in care. The resident, who was admitted with conditions including unspecified dementia, benign prostatic hypertension, and uninhibited neuropathic bladder, had a care plan initiated for catheter care. However, the care plan was not updated or revised after its initiation, and interventions such as monitoring for signs and symptoms of urinary tract infections (UTIs) were not documented as being implemented. The resident's care plan included interventions to monitor fluid intake and urine output for 30 days, and to observe for signs of discomfort and symptoms of UTIs. Despite these interventions being part of the care plan, there was no documentation of monitoring for UTI symptoms, which included pain, burning, blood-tinged urine, and foul-smelling urine. This lack of documentation and failure to update the care plan after the completion of interventions or changes in the resident's condition contributed to the deficiency. During an interview, the MDS Nurse confirmed that the care plan had not been revised or updated since its initiation, and that there was no documentation of monitoring for UTI symptoms. The facility's policy required care plans to be reviewed and updated quarterly or after a change in the resident's condition, but this was not done. The failure to revise the care plan and implement the necessary interventions resulted in inadequate care and supervision for the resident.
Failure to Monitor and Assess Resident's Nutritional Status
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, identified as Resident 25, who experienced significant weight loss. The resident, who was admitted with conditions including absolute glaucoma, dysphagia, and a history of falling, was dependent on staff for daily activities and had severely impaired cognitive skills. Despite the resident's weight loss of 5% or more within a month or 10% or more in six months, the facility did not adequately assess and monitor the resident's nutritional status. The resident's physician had recommended a fortified diet and prescribed medication to manage the weight loss, but there was no documentation of the facility's Registered Dietician (RD) evaluating the resident's condition after the weight loss was noted. The last nutritional assessment by an RD was conducted several months prior to the weight loss, and no follow-up assessments or progress notes were recorded after the resident's condition changed. Interviews with facility staff, including the MDS Nurse and the Director of Nursing, confirmed the lack of RD involvement in managing the resident's nutritional needs during this period. The facility's policy required nutritional assessments upon admission, quarterly, and when significant weight changes occurred. However, due to a high turnover rate of RDs, these assessments were not conducted as required, leaving the resident's weight loss unaddressed. The Director of Nursing acknowledged that the absence of RD assessments could lead to an inability to manage the resident's weight loss effectively.
Failure to Verify G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure that licensed nurses checked the placement of a gastrostomy tube (G-tube) before administering medications to a resident, as required by the resident's care plan. This deficiency was observed during a medication administration for a resident who was totally dependent on staff for all activities of daily living and had severely impaired cognition. The resident had a G-tube due to an inability to take food or fluids orally and was at risk for aspiration. The care plan specifically required checking the placement and patency of the feeding tube prior to administering formula, water, and medication. During an observation, a Licensed Vocational Nurse (LVN) administered medications via the G-tube without verifying its placement, contrary to the facility's policy and the resident's care plan. The LVN admitted to not checking the G-tube placement with a stethoscope before administering the medications. The Director of Nursing confirmed that the LVN should have followed the nursing procedure to check the G-tube placement before medication administration, acknowledging that this oversight had the potential to increase the risk of aspiration for the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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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) |
|---|---|---|---|---|
| Totally Kids Specialty Healthcare - Sun Valley | 0.4 mi | ★★★★★ | 23 | 0 |
| All Saints Healthcare Subacute | 2.2 mi | ★★★★★ | 36 | 1 |
| Pacifica Hospital Of The Valley Dp Snf | 2.4 mi | ★★★★★ | 22 | 0 |
| The Hills Healthcare Center | 2.5 mi | ★★★★★ | 17 | 0 |
| High Valley Lodge | 2.9 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.