Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Hills Healthcare Center during CMS and state inspections, most recent first.
Two residents were not treated with dignity during mealtime assistance as staff members stood over them while feeding. One resident, with severe cognitive impairment, was fed by an RNA standing due to space constraints, while another resident, with moderate cognitive impairment, was fed by a CNA standing to expedite the process. This was against the facility's policy, which requires staff to be seated to ensure residents' safety, comfort, and dignity.
The facility failed to ensure that call lights were within reach for two residents, both with severe cognitive impairments and requiring assistance with daily activities. Observations revealed that the call lights were improperly placed, making them inaccessible. The DON confirmed that call lights should be within reach to allow residents to summon help, as per facility policy.
The facility failed to provide non-pharmacological interventions before administering opioid medications to two residents. One resident with a pelvic fracture and severe cognitive impairment, and another with a history of falls and dementia, were both prescribed tramadol without attempts at non-pharmacological interventions, contrary to the facility's policy. The DON confirmed the oversight, highlighting the importance of such interventions to prevent unnecessary medication.
Two residents experienced medication administration discrepancies when Tramadol was removed from the CDR without corresponding entries in the MAR. One resident had a pelvic fracture and severe cognitive impairment, while the other had a history of falls and dementia. Interviews with an LVN and the DON confirmed the failure to follow facility procedures, posing a risk of medication errors and drug diversion.
The facility failed to implement the Medication Regimen Review (MRR) for two residents, resulting in missed communication of critical medication monitoring recommendations to physicians. A resident with multiple diagnoses, including hydrocephalus and dementia, did not have recommended blood tests for valproic acid and heparin levels conducted. Another resident with a subdural hematoma and dementia also missed a recommended PTT blood draw for heparin monitoring. The Director of Nursing did not follow the facility's policy to ensure MRR recommendations were communicated to physicians.
The facility failed to monitor medication levels for two residents, leading to a deficiency. One resident was prescribed valproic acid and heparin, while another was prescribed heparin. The Medication Regimen Review recommended monitoring levels, but these were not communicated to the physician, and necessary tests were not conducted. The Director of Nursing acknowledged the oversight, which put the residents at risk of adverse effects.
The facility failed to ensure residents were free from significant medication errors by not checking therapeutic levels for two residents, leading to potential health risks. A resident with multiple diagnoses was prescribed valproic acid and heparin, but the facility did not follow up on the pharmacist's recommendation to check the valproic acid level and PTT. Similarly, another resident was prescribed heparin, but the facility failed to follow up on the recommendation for a PTT blood draw. The DON acknowledged the oversight, which was considered a medication error.
The facility failed to label stored food with use-by dates, as observed during a survey. Items in the refrigerator and dry storage, including garlic, ham, apple sauce, puddings, gelatine desserts, and potatoes, lacked proper labeling. The Dietary Supervisor and DON acknowledged the oversight, which violated the facility's policy and posed a risk to residents.
The facility failed to maintain sanitary trash storage as two dumpsters were observed with open lids, positioned too close to the wall to be closed. The Dietary and Maintenance Supervisors confirmed that the dumpsters should have been closed to prevent attracting pests and potential infection control issues. The facility's policy requires dumpsters to be kept closed to prevent pest access.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices or wounds, as required by policy. Staff did not wear gowns during high-contact care activities, and EBP signs and PPE were not provided outside residents' rooms. The Infection Preventionist and Director of Nursing acknowledged the lack of implementation, despite CMS guidelines mandating EBP for such residents.
A facility failed to maintain a resident's advance directive in their active clinical record, despite the resident's severe cognitive impairment and need for assistance. The document was found in an overflow section, contrary to facility policy requiring it to be readily accessible to guide staff in honoring the resident's healthcare preferences.
A resident with severe cognitive impairment and mobility issues was found to have their Low Air Loss Mattress (LALM) incorrectly set at a higher weight than their actual weight, potentially compromising pressure injury care. The facility's failure to adhere to the physician's order for the correct LALM setting was confirmed by the Director of Nursing, who acknowledged the risk of further skin injuries.
The facility failed to store medications in a locked compartment, as observed at Nursing Station Two where the medication cabinet lacked a lock. This cabinet contained various medications, including iron supplements and acetaminophen. The Director of Staff Development confirmed the need for locked storage to prevent resident access, while the DON was unaware of the issue. Facility policy mandates locked storage for medications.
The facility did not meet the required 80 square feet per resident in multiple resident rooms, affecting 15 rooms. Despite this, observations showed adequate space for movement and care. The facility requested a waiver, claiming no adverse effects on residents.
The facility failed to schedule necessary follow-up appointments with cardiology and pulmonology for a resident as per discharge instructions and did not monitor the resident after a noted change in condition, leading to a significant lapse in care.
A facility failed to develop a comprehensive care plan for a resident with heart failure, despite multiple admissions and severe cognitive impairment. The absence of this care plan, which should have been created within 14 days, could negatively impact the resident's care.
The facility failed to ensure a resident's history and physical (H&P) was completed by the attending physician upon admission. The resident, with serious medical conditions and severely impaired cognition, had an undated and incomplete H&P, signed without a date. This could lead to inconsistent care coordination.
A facility failed to ensure an LVN documented the administration of Plavix for a resident with severe cognitive impairment and heart conditions. The RN confirmed the absence of documentation on the MAR, violating the facility's medication administration policy.
Failure to Maintain Dignity During Mealtime Assistance
Penalty
Summary
The facility failed to uphold the dignity and respect of two residents during mealtime assistance. Restorative Nursing Assistant 1 (RNA 1) was observed standing over Resident 49 while assisting with eating. Resident 49, who has severe cognitive impairment and requires supervision for daily activities, was seated in a wheelchair in the hallway. RNA 1 admitted to standing due to the lack of space for a chair in the hallway and the need to monitor other residents. This action was contrary to the facility's policy, which mandates that staff should be seated while assisting residents with meals to ensure safety, comfort, and dignity. Similarly, Certified Nursing Assistant 3 (CNA 3) was observed standing over Resident 18 while feeding them lunch. Resident 18, who has moderately impaired cognition and requires assistance with eating, was in a High Fowler's position in bed. CNA 3 acknowledged the need to be seated during feeding but chose to stand to expedite the process. This was also against the facility's policy, which emphasizes the importance of staff being seated at eye level with residents during meals to prevent aspiration and ensure residents do not feel rushed. Interviews with various staff members, including Treatment Nurse 1, Licensed Vocational Nurse 2, and the Director of Nurses, confirmed that the facility's policy requires staff to be seated while assisting residents with meals. The policy aims to maintain residents' dignity and ensure their safety and comfort during mealtimes. The failure to adhere to this policy potentially impacted the self-esteem and self-worth of the residents involved.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the resident call light was within accessible reach for two residents, Resident 23 and Resident 59. Resident 23, who was admitted with conditions such as spinal stenosis, a displaced fracture of the left femur, and aphasia, was observed to have a call light looped over the upper side of the wall light, making it inaccessible. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and a need for moderate assistance with daily activities. During an observation, a Restorative Nursing Assistant (RNA) noted that the call light should have been clipped to the pillow to facilitate ease of use, acknowledging that its inaccessibility could prevent the resident from asking for help and potentially lead to a fall. Similarly, Resident 59, who had diagnoses including senile degeneration of the brain and aphasia, was found to have an adaptive call light located behind the head of the bed, out of reach. The MDS for Resident 59 also indicated severe cognitive impairment and dependency on assistance for daily activities. The RNA confirmed that the call light should have been clipped to the pillow for accessibility. The Director of Nursing (DON) stated that the call light should always be within reach to ensure residents can summon help when needed, as outlined in the facility's policy and procedure on the call system.
Failure to Implement Non-Pharmacological Interventions Before Opioid Administration
Penalty
Summary
The facility failed to ensure that licensed nurses provided non-pharmacological interventions before administering as-needed opioid medications to two residents. Resident 36, who was admitted with a pelvic fracture and had severe cognitive impairment, was prescribed tramadol for moderate pain. The resident's care plan, however, did not include any non-pharmacological interventions, and the facility's policy required such interventions to be attempted before administering pain medication. Similarly, Resident 61, who had a history of falls and dementia, was prescribed tramadol for moderate to severe pain. Like Resident 36, the care plan for Resident 61 also lacked non-pharmacological interventions, despite the facility's policy. During a review of the residents' records and interviews with the Director of Nurses (DON), it was confirmed that non-pharmacological interventions were not attempted prior to administering pain medication. The DON acknowledged the oversight and emphasized the importance of attempting non-pharmacological interventions to reduce the risk of unnecessary medication administration. The facility's policy on pain management, which was last reviewed shortly before the survey, clearly stated the requirement for assessing pain and attempting non-pharmacological interventions before administering pain medications.
Medication Administration Discrepancies
Penalty
Summary
The facility failed to ensure that two residents were free from medication errors by not reconciling the Controlled Drug Record (CDR) with the Medication Administration Records (MAR). For Resident 36, the CDR indicated that Tramadol was removed on three occasions, but there were no corresponding entries in the MAR for those dates. Resident 36 was admitted with a pelvic fracture and was severely impaired in cognition, requiring moderate assistance with daily activities. The facility's policy required that controlled substances be reconciled upon administration, but this was not followed. Similarly, for Resident 61, the CDR showed that Tramadol was removed on two occasions without corresponding entries in the MAR. Resident 61 was admitted with a history of falls and dementia, and was moderately impaired in cognition, requiring supervision for personal hygiene and dressing. The facility's policy mandated that the administration of medications be recorded in the resident's medical record, but this was not adhered to, leading to discrepancies between the CDR and MAR. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nurses (DON) confirmed the discrepancies and the failure to follow the facility's procedures. The LVN and DON both acknowledged the importance of signing both the CDR and MAR to ensure accurate accounting of controlled medications and to prevent potential medication errors. The failure to document the administration of controlled substances as per the facility's policy posed a risk of medication errors and drug diversion.
Failure to Implement Medication Regimen Review
Penalty
Summary
The facility failed to implement the Medication Regimen Review (MRR) for two residents, Resident 49 and Resident 63, as required by their policies and procedures. The MRR is a pharmacist's thorough evaluation of a resident's medication routine and recommendations, which should be communicated to the resident's physician for review and potential action. In both cases, the Director of Nursing (DON) did not notify the physicians of the MRR recommendations, which included necessary blood tests to monitor medication levels and prevent potential adverse effects. Resident 49 was admitted with multiple diagnoses, including hydrocephalus, dysphagia, a history of falling, and dementia. The resident was prescribed valproic acid to prevent seizures and heparin to prevent deep vein thrombosis (DVT). The MRR recommended checking valproic acid levels and partial thromboplastin time (PTT) to ensure safety from bleeding, blood clots, and seizures. However, these recommendations were not communicated to the physician, and the necessary blood tests were not conducted. Similarly, Resident 63, who was admitted with a nontraumatic subdural hematoma, a history of falling, and unspecified dementia, was prescribed heparin to prevent DVT. The MRR recommended a PTT blood draw to monitor heparin levels, but this recommendation was also not communicated to the physician, and the blood test was not performed. The facility's policies clearly state that it is the responsibility of the DON to ensure that MRR recommendations are followed up with the physician, which did not occur in these instances.
Failure to Monitor Medication Levels for Two Residents
Penalty
Summary
The facility failed to ensure that the drug regimens for two residents were free from unnecessary drugs by not adequately monitoring valproic acid and heparin levels. Resident 49 was admitted with multiple diagnoses, including hydrocephalus, dysphagia, a history of falling, and dementia. The resident was prescribed valproic acid to prevent seizures and heparin to prevent deep vein thrombosis. However, the Medication Regimen Review (MRR) recommended monitoring valproic acid levels and partial thromboplastin time (PTT), but these recommendations were not communicated to the physician, and the necessary blood tests were not conducted. Similarly, Resident 63, who was admitted with a nontraumatic subdural hematoma and unspecified dementia, was prescribed heparin to prevent DVT. The MRR recommended a PTT blood draw to monitor heparin levels, but this recommendation was also not communicated to the physician, and the blood tests were not performed. The Director of Nursing (DON) acknowledged the oversight and stated that it was her responsibility to notify the physician of the MRR recommendations. The failure to monitor these medication levels put the residents at risk of bleeding, blood clots, and seizures. The facility's policies and procedures required the consultant pharmacist to review each resident's drug regimen monthly and for the facility to follow up on the pharmacist's recommendations by providing them to the primary physician. The DON was responsible for ensuring proper follow-through. The policies also required the physician to assess the effects of medications through lab work and collaborate with the pharmacist and nursing staff. However, these procedures were not followed, leading to the deficiency.
Failure to Monitor Therapeutic Levels Leads to Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors by not checking therapeutic levels for two residents, leading to potential health risks. Resident 49 was admitted with multiple diagnoses, including hydrocephalus, a cerebrospinal drainage device, dysphagia, a history of falling, and dementia. The resident was prescribed valproic acid and heparin, but the facility did not follow up on the pharmacist's recommendation to check the valproic acid level and partial thromboplastin time (PTT). The Director of Nursing (DON) acknowledged that it was her responsibility to notify the physician of these recommendations, which were missed, putting the resident at risk for bleeding, blood clotting, and seizures. Similarly, Resident 63 was admitted with a nontraumatic subdural hematoma, a history of falling, and unspecified dementia. The resident was prescribed heparin, but the facility failed to follow up on the pharmacist's recommendation for a PTT blood draw. The DON admitted that the order to check the heparin level was missed, which was necessary to ensure the resident's safety from bleeding and blood clots. This oversight was considered a medication error, as the facility did not verify the appropriate medication dosage based on lab work. The facility's policies and procedures required monthly drug regimen reviews by a consultant pharmacist, with the responsibility to follow up on recommendations resting with the facility. The policies also indicated that the attending physician should assess the relevance of recommended interventions and collaborate with the pharmacist and nursing staff. However, these procedures were not adequately followed, leading to the deficiencies identified in the report.
Failure to Label Food with Use-By Dates
Penalty
Summary
The facility failed to adhere to professional standards for food storage by not labeling stored food items with a use-by date. During an observation and interview with the Dietary Supervisor, it was noted that several food items in the refrigerator, including a zip-lock bag of garlic, a plastic container of ham, and a plastic container of apple sauce, were not labeled with a use-by date. Additionally, in the dry storage room, various pudding and pie fillings, gelatine desserts, scalloped potatoes, instant mashed potatoes, and seasoned applesauce were also found without use-by date labels. The Dietary Supervisor acknowledged that the absence of these labels could potentially affect the residents' health. The Director of Nursing confirmed that all food should be labeled with a use-by date, as per the facility's policy and procedure on Food Receiving and Storage. This policy, reviewed shortly before the survey, mandates that dry food stored in bins should be removed from original packaging, labeled, and dated, and all food stored in the refrigerator should be covered, labeled, and dated. The failure to comply with these standards posed a risk of foodborne illness to 66 of the 67 residents who receive food from the facility kitchen.
Improper Garbage Disposal Practices
Penalty
Summary
The facility failed to maintain their trash storage in a sanitary manner, as observed during a survey. Two dumpsters located outside the facility were found with their lids open and positioned too close to the wall, preventing them from being closed. This was confirmed during an interview with the Dietary Supervisor, who acknowledged that the dumpsters should have been closed to prevent attracting flies and potential infection control issues. The Maintenance Supervisor also confirmed that the open dumpster lids could attract insects or rodents, posing an infection control risk if these pests entered the facility. The facility's policy on garbage and refuse disposal, dated January 2024, requires that garbage containing food waste be stored in a manner inaccessible to pests, with outside dumpsters kept closed.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy, which is designed to prevent the spread of multidrug-resistant organisms (MDROs) by using gowns and gloves during high-contact resident care activities. This deficiency was observed in several instances involving residents with indwelling medical devices or wounds. For example, a Licensed Vocational Nurse (LVN) did not wear a gown while administering medication via a gastrostomy tube to a resident with severe cognitive impairment and multiple diagnoses, including Huntington's disease and hypertension. The facility's Infection Preventionist (IP) and Director of Nursing (DON) acknowledged that the EBP policy was not implemented, despite being mandatory for residents with indwelling devices. Another instance involved a resident with multiple sclerosis, quadriplegia, and a methicillin-resistant Staphylococcus aureus (MRSA) infection. An LVN and a Certified Nursing Assistant (CNA) failed to don gowns while administering medication via the rectum, even though the resident had an indwelling catheter. The IP admitted to being unaware of the mandatory nature of the EBP policy and confirmed that it was not implemented for this resident. The facility's policy and procedure documents clearly indicated the need for gowns and gloves during high-contact care activities, yet these were not followed. Additionally, the facility did not post EBP signs or provide personal protective equipment (PPE) outside the rooms of residents with wounds or indwelling medical devices, such as gastrostomy tubes and nephrostomy tubes. This oversight was confirmed during observations and interviews with the IP, who stated that the facility was waiting for trash bins to be delivered before posting signs. The Centers for Medicare and Medicaid Services (CMS) guidelines, which the facility claimed to follow, require EBP for residents with wounds or indwelling devices, even if they are not known to be infected with MDROs.
Failure to Maintain Resident's Advance Directive in Active Record
Penalty
Summary
The facility failed to ensure that a resident's clinical records were updated with their advance directives, which are crucial documents outlining a person's medical treatment preferences in situations where they cannot communicate their wishes. This deficiency was identified for one resident, who had been admitted with conditions including senile degeneration of the brain, aphasia, and a history of transient ischemic attack. The resident's Minimum Data Set indicated severe cognitive impairment, necessitating assistance for basic activities. Despite the resident having an advance directive, it was not maintained in their active clinical record, which could lead to conflicts with their healthcare wishes. During the investigation, the Director of Social Services acknowledged that the advance directive was missing from the active chart and was instead found in an overflow section of the medical record. Both the Director of Social Services and the Director of Nursing confirmed that the advance directive should have been readily accessible in the active chart to guide staff in honoring the resident's healthcare preferences. The facility's policy on advance directives, reviewed shortly before the survey, stipulated that such documents should be kept in the resident's medical record and be easily retrievable by staff, highlighting a clear deviation from established procedures.
Incorrect LALM Setting for Resident with Pressure Injury Risk
Penalty
Summary
The facility failed to ensure the correct setting of a Low Air Loss Mattress (LALM) for a resident who required it for pressure injury care. The resident, who was admitted with conditions including senile degeneration of the brain, aphasia, and a history of transient ischemic attack, was found to have the LALM set between 150 to 180 pounds, while the resident's weight was approximately 106 pounds. This discrepancy was observed during an inspection by Treatment Nurse 1, who acknowledged that the incorrect setting could render the mattress ineffective in promoting wound healing and preventing further pressure injuries. The resident's care plan, dated several months prior, indicated the use of a LALM as a pressure-relieving device due to the resident's impaired mobility and risk for pressure injuries. The physician's order also specified the need for the Charge Nurse to check the proper placement and function of the LALM. However, during an interview, the Director of Nursing confirmed the importance of following the physician's order for the correct setting, emphasizing that failure to do so could lead to further skin injuries. The manual for the air mattress also highlighted the necessity of adjusting the pressure based on the resident's weight to ensure effective wound care therapy.
Medication Storage Deficiency Due to Unlocked Cabinet
Penalty
Summary
The facility failed to ensure that medications were stored in a locked compartment, as required by professional principles. During an observation and interview with the Director of Staff Development, it was noted that the medication cabinet at Nursing Station Two did not have a lock, unlike the left-side cabinet. This unlocked cabinet contained various medications, including iron supplements, bismuth subsalicylate, liquid multi-vitamins, acetaminophen, vitamin C supplements, constulose, and milk of magnesia. The Director of Staff Development acknowledged that the medication storage should not be left unlocked to prevent residents from accessing the medications. The Director of Nurses was interviewed and stated that she was unaware of the broken lock on the Station Two medication cabinet. She emphasized the importance of keeping medications in a locked cabinet to prevent resident access. A review of the facility's policy and procedure on medication storage, last reviewed on 10/16/2024, indicated that drugs and biologicals should be stored in locked compartments with proper controls for temperature, light, and humidity, and that only authorized personnel should have access to these medications.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to meet the regulatory requirement of providing at least 80 square feet per resident in multiple resident bedrooms. This deficiency was identified in 15 out of 28 resident rooms, where the space per resident was below the required standard. Specifically, rooms designed to accommodate two residents were only 156 square feet, providing 78 square feet per resident, and rooms designed for three residents were 228 square feet, providing only 76 square feet per resident. This shortfall in space allocation had the potential to result in inadequate space for safe nursing care and privacy for the residents. Despite the deficiency, observations during the survey indicated that both residents and staff had enough space to move about freely inside the rooms. The nursing staff was able to safely provide care, and there was sufficient space for beds, side tables, dressers, and resident care equipment. The facility had submitted a request for a continuation of its room size waiver, asserting that the current room sizes did not adversely affect the residents' health and safety or impede their ability to attain their highest practicable well-being.
Failure to Schedule Follow-Up Appointments and Monitor Change in Condition
Penalty
Summary
The facility failed to provide necessary care and services for a resident as per the discharge instructions from the General Acute Care Hospital (GACH). The resident, who had diagnoses including Non-ST-Elevation Myocardial Infarction (NSTEMI), heart failure, and unstable angina, was readmitted to the facility on multiple occasions. Despite clear instructions from the GACH to schedule follow-up appointments with cardiology and pulmonology within specified timeframes, the facility did not arrange these appointments. Interviews with the MDS Nurse and Registered Nurse 2 revealed that there was no documented evidence of these appointments being made, and there was confusion about who was responsible for scheduling them. The Social Services Director and nursing department both indicated that the other was responsible for making the appointments, leading to a lapse in care coordination. Additionally, the facility failed to monitor the resident after a noted change in condition on 10/30/2023. The resident exhibited delusional beliefs and refused medication, which should have triggered close monitoring every shift for 72 hours according to the facility's policy. However, there was no documented evidence that such monitoring occurred. This lack of monitoring was confirmed during an interview with Registered Nurse 2, who acknowledged the importance of close monitoring to detect any worsening of symptoms and to ensure timely intervention. The facility's policies and procedures, including those for admission assessment and follow-up care, as well as for changes in a resident's condition, were not adhered to. The failure to schedule necessary follow-up appointments and to monitor the resident after a change in condition represents a significant lapse in the standard of care, potentially jeopardizing the resident's health and well-being.
Failure to Develop Comprehensive Care Plan for Heart Failure
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan to address a diagnosis of heart failure for one of the sampled residents. The resident, who had been admitted and readmitted multiple times, had diagnoses including Non-ST-Elevation Myocardial Infarction (NSTEMI), heart failure, and unstable angina. The Minimum Data Set (MDS) indicated that the resident had severely impaired cognition and required maximum assistance from staff for various daily activities. Despite these needs, there was no documented evidence of a care plan specific to heart failure being developed within the required timeframe. During an interview and record review, the MDS Nurse confirmed that a comprehensive care plan for heart failure was not created for the resident. The facility's policy required such a care plan to be developed within 14 days of admission, but this was not done. The absence of this care plan had the potential to negatively affect the delivery of care and services to the resident, as it would guide staff on specific interventions needed for managing heart failure.
Incomplete History and Physical Documentation
Penalty
Summary
The facility failed to ensure the history and physical (H&P) for a resident was completed by the attending physician upon the resident's first admission. The resident was admitted with serious medical conditions including Non-ST-Elevation Myocardial Infarction (NSTEMI), heart failure, and unstable angina. The Minimum Data Set (MDS) indicated that the resident had severely impaired cognition and required maximum assistance from staff for daily activities. However, the H&P document was undated and incomplete, lacking pertinent medical information, and was signed by the attending physician without a date. This incomplete documentation could lead to inconsistent care coordination for the resident. During an interview and record review, a registered nurse confirmed that the H&P was undated and incomplete, and emphasized the importance of having a completed and dated H&P to ensure proper assessment of the resident's condition upon admission or readmission. The facility's policy and procedure require that the medical care of each resident be supervised by a licensed physician, including participating in the resident's assessment and care planning. The failure to complete and date the H&P document is a violation of this policy and could result in inadequate care for the resident.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to implement its medication administration policy by not ensuring that a Licensed Vocational Nurse (LVN) documented the administration of Plavix for a resident. The resident, who had been readmitted to the facility with diagnoses including Non-ST-Elevation Myocardial Infarction (NSTEMI), heart failure, and unstable angina, did not have documented evidence of receiving Plavix on a specified date. The resident's Minimum Data Set (MDS) indicated severely impaired cognition and a need for maximum assistance with daily activities, highlighting the importance of accurate medication administration and documentation. During an interview and record review, a Registered Nurse (RN) confirmed that there was no documentation on the Medication Administration Record (MAR) indicating that Plavix was administered or refused by the resident. The facility's policy required that medications be administered safely and timely, with the individual administering the medication initialing the MAR after each administration. The lack of documentation by the LVN on the specified date was identified as a failure to adhere to this policy, potentially leading to medication errors and confusion in care delivery.
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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 Sunland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunland Post Acute | 1.1 mi | — | 33 | 0 |
| High Valley Lodge | 1.2 mi | — | 1 | 0 |
| Totally Kids Specialty Healthcare - Sun Valley | 2.1 mi | — | 23 | 0 |
| North Valley Nursing Center | 2.3 mi | — | 0 | 0 |
| Villa Scalabrini Special Care | 2.5 mi | — | 10 | 0 |
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