Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Post Acute during CMS and state inspections, most recent first.
Multiple residents with IV access did not receive required weekly dressing changes, and staff failed to consistently measure and document arm circumference and external catheter length during dressing changes. Physician's orders and care plans for IV maintenance were missing or delayed for several residents, and some IV sites were not properly labeled upon insertion. These deficiencies were confirmed through observation, record review, and staff interviews, and were acknowledged by facility staff.
Surveyors found that the kitchen hood was not cleaned as required, kitchen utensils were in poor repair and not properly sanitized, and cutting boards were heavily marred and difficult to clean. Additionally, a chest freezer lacked a thermometer for temperature monitoring, and milk beverages were served above the recommended temperature. These deficiencies were acknowledged by the RD and Assistant DSS during observations and interviews.
Several residents reported ongoing issues with excessive noise from slamming doors and staff speaking loudly during shift changes, which disrupted their rest. Observations confirmed that doors made loud noises and that staff gatherings contributed to the problem. Additionally, a resident's room was found to have a wall in disrepair, with scratches and chipped paint, which had not been repaired despite the resident spending significant time in the room.
Two residents did not have their care plans updated to reflect current physician orders and changes in condition. One resident's care plan listed an incorrect fluid amount compared to the physician's order, and another resident's care plan was not revised when the behavioral manifestation for antipsychotic medication use changed. These omissions were confirmed by facility staff during record reviews and interviews.
A resident who was fully dependent on staff for ADLs was repeatedly observed with long, sharp fingernails and self-inflicted facial scratches. Staff interviews confirmed that nail care was not provided as required by the care plan, which specifically called for keeping nails short to prevent skin injury. The facility's policy for individualized ADL assistance was not followed, resulting in unmet personal hygiene needs and compromised skin integrity.
A resident with end-stage renal disease and a physician-ordered fluid restriction was not provided the prescribed 360 ml of fluids with each meal, instead only receiving 240 ml. The dietary department's practice did not match the physician's order, and there was no documentation of refusal or physician notification about the discrepancy, as confirmed by the resident and the RD.
Three residents received respiratory care that did not meet facility policy, including one who received oxygen therapy without a physician's order and had unsanitary equipment, and two others whose oxygen tubing and related supplies were not properly labeled or stored. Staff confirmed the lack of labeling and improper storage, and acknowledged these practices did not follow infection control protocols.
Two residents did not receive appropriate dialysis care: one was given antihypertensive medication on dialysis days against physician orders, and another's AV shunt site was not properly monitored or reported to the physician when negative findings were documented. Nursing staff and the DON confirmed that required notifications and assessments were not consistently performed.
The facility did not consistently obtain required nurse signatures on controlled substance logs for two medication carts, resulting in incomplete accountability for narcotic medications. Additionally, a nurse failed to properly administer prescribed eye drops to a resident with cognitive impairment and glaucoma, not following protocol to ensure medication absorption.
Surveyors found that a vial of Lidocaine was removed from an IV emergency kit without documentation in the Emergency Kit Usage Log, and expired Santyl ointments were present on a treatment cart. The IP, DON, and an LVN confirmed these deficiencies, noting that required documentation and removal of expired medications did not occur.
A resident who required a sippy cup for self-feeding, as documented in medical records and physician orders, was not provided with the adaptive equipment during meals. The resident used regular cups instead, and both a CNA and an LVN confirmed that the sippy cup should have been supplied but was not.
Surveyors identified that three residents had incomplete or inaccurate medical records, including missing documentation of medication administration, required monitoring, and an incomplete POLST form. One resident's weekly fluid intake was incorrectly documented as daily totals, and staff confirmed these errors during interviews and record reviews.
Surveyors observed multiple infection control lapses, including a resident's urinal placed next to drinks on a bedside table, an LVN failing to perform hand hygiene or change gloves during GT medication administration, and a nurse not using required PPE while providing GT care to a resident on Enhanced Barrier Precautions for a respiratory MDRO. These actions were confirmed by staff and posed a risk for contamination and infection transmission.
A resident with a recent pneumonia diagnosis was observed receiving continuous oxygen therapy without a physician's order or a comprehensive care plan in place. Both an LVN and the DON confirmed that the care plan for oxygen use had not been initiated after the resident's readmission.
A resident with documented dislikes for certain foods was repeatedly served those items despite clear notations on her care plan and diet card. The resident expressed frustration and did not eat her meal, and a CNA confirmed the tray should not have included the disliked foods.
A resident with dysphagia and other medical conditions was given regular peanut butter sandwiches instead of a prescribed pureed diet, leading to a choking incident and subsequent death. The healthcare assistant was unaware of the dietary restrictions, and the facility staff confirmed the inconsistency with the diet orders.
A long-term care facility failed to safeguard controlled medications for nine residents, resulting in the diversion of significant quantities of tramadol, hydrocodone-acetaminophen, and Oxycontin. The facility's medication logs were falsified to show that medications were transferred to the DON, but signatures were forged, and the medications were missing. The facility's narcotic count process did not detect the diversion, as the logs falsely indicated the medications were in the DON's possession.
A resident experienced an unwitnessed fall resulting in a head injury, but the facility failed to document the necessary post-fall assessment details as per their policy. Despite the resident's report of significant pain and visible injury, the medical records lacked comprehensive documentation of the skin and wound condition. The DON confirmed the absence of required documentation.
The facility failed to ensure complete and accurate medical records for three residents. A resident's MAR lacked documentation of blood sugar levels and medication administration on specific dates. Another resident's MAR was missing similar documentation, and a third resident's MAR lacked nurse initials for medication administration. The DON confirmed these findings, highlighting the expectation for immediate documentation post-medication administration.
The facility failed to properly manage and document controlled substances, resulting in missing oxycodone medications for a resident. The investigation revealed inconsistencies in the Medication Administration Record (MAR) and Controlled Drug record, as well as missing signatures on shift count sheets for multiple medication carts. These lapses were acknowledged by the DON and nursing staff.
Failure to Ensure Safe and Appropriate IV Care and Documentation
Penalty
Summary
The facility failed to provide necessary care and services for the safe and appropriate administration and maintenance of IV fluids and access devices for multiple residents. For several residents with PICC lines or midline catheters, the facility did not ensure that dressing changes were completed weekly as required, nor did they consistently measure and document arm circumference and external catheter length during dressing changes. In some cases, such as with one resident, the care plan for IV use was not developed in a timely manner, and documentation was bypassed by staff entering 'N/A' instead of actual measurements. Additionally, the facility did not always obtain physician's orders for the care and maintenance of IV lines, nor did they develop care plans for residents with IV access. For example, one resident received IV hydration therapy without a corresponding physician's order for maintenance, and there was no documentation of site assessment or a care plan addressing the IV site. Another resident had a peripheral IV site that was not labeled with the date, time, or initials upon insertion, and there was no physician's order or care plan for the maintenance of the IV site as required by facility policy. Observations and interviews confirmed that these lapses in care and documentation were acknowledged by facility staff, including the MDS Coordinator, RNs, and the DON. The failures included not following facility policies for IV site labeling, not performing or documenting required assessments and measurements, and not initiating or updating care plans in a timely manner. These deficiencies were identified through direct observation, medical record review, and staff interviews, and had the potential to delay the identification of catheter-related complications for the affected residents.
Multiple Food Safety and Sanitation Failures in Kitchen Operations
Penalty
Summary
Surveyors identified multiple failures in the facility's kitchen related to food safety and sanitation. During an initial kitchen tour, the hood over the stove was found to have black, dirt residue, contrary to the facility's policy requiring biweekly cleaning and USDA Food Code standards. The kitchen staff acknowledged that the hood was only cleaned monthly, and both the Registered Dietitian (RD) and Assistant Dietary Services Supervisor (DSS) recognized this as an infection control and fire hazard issue. Additionally, several kitchen utensils, including slotted scoops, spatulas, and serving spoons, were observed to have partially melted handles, discoloration, and were in poor repair, which the RD and Assistant DSS confirmed should have been replaced according to policy and food code requirements. Further observations revealed that multiple utensils and kitchenware, such as knives, scoops, and serving spoons, were dirty, with dry, crusted residue, cloudy film, and watermarks present. The RD and Assistant DSS acknowledged these items had not been properly washed, violating both facility policy and food code standards for cleanliness. Cutting boards in the kitchen were also found to be heavily marred, fuzzy, and with deep grooves, making them difficult to clean and sanitize. The RD stated the boards had been changed the previous month, but the Assistant DSS agreed they should have been replaced due to infection control concerns. Additional deficiencies included the absence of a thermometer in the chest freezer used for ice cream storage, despite facility policy requiring two thermometers per freezer and food code guidance on proper temperature monitoring. During meal service, milk beverages were found to be above the recommended temperature, with one instance measuring 43 degrees Fahrenheit and another at 49.1 degrees Fahrenheit, exceeding the facility's policy and food code requirements for cold food holding. These findings were verified by the RD and DSS during observation and interview.
Failure to Maintain Comfortable Sound Levels and Room Condition
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for several residents, as evidenced by excessive noise levels and physical disrepair in a resident's room. Multiple residents expressed concerns about loud noises caused by staff slamming kitchen and dining room doors, as well as staff speaking loudly in the hallways, particularly during shift changes at night. These concerns were consistently reported during resident council meetings and individual interviews, with residents stating that the noise disrupted their rest and that the issue persisted despite being brought to the facility's attention. Observations confirmed that the dining room door made a loud noise when closed, and both the Administrator and Maintenance Director acknowledged the problem during on-site checks. Residents reported that the noise was especially problematic during the 2300 hours shift change, when staff would gather and socialize in the hallway, further increasing the noise level. Some residents also noted that they had not been offered alternative room placements in response to their complaints about the noise. Additionally, one resident's room was found to be in disrepair, with scratches and chipped paint on the wall adjacent to the bed. The resident indicated that while some repairs had been made to other parts of the room, the damaged wall near the bed, where the resident spent significant time, had not yet been addressed. The Administrator confirmed the condition of the room and acknowledged the outstanding repairs.
Failure to Revise Care Plans Following Physician Orders and Changes in Condition
Penalty
Summary
The facility failed to ensure that comprehensive care plans were revised in accordance with physician orders and changes in resident conditions for two residents. For one resident, the care plan indicated that 240 ml of fluid should be provided with each meal, while the physician's order specified 360 ml per meal as part of a fluid restriction protocol. This discrepancy was confirmed during a review with the Registered Dietitian, who acknowledged that the care plan did not reflect the current physician's order. For another resident, the care plan addressing psychotropic medication use was not updated when there was a change in the manifestation of the resident's behavior. The physician's order was revised to monitor episodes of psychosis manifested by seeing objects that were not there, but the care plan continued to reference only persecutory delusions. Both the MDS Coordinator and the DON confirmed that the care plan was not revised to reflect the updated behavioral symptoms as required.
Failure to Provide Adequate Nail Care Resulting in Self-Inflicted Injuries
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for activities of daily living (ADL), including personal hygiene and grooming, did not receive adequate nail care. The resident was observed multiple times with long and sharp fingernails, which resulted in self-inflicted scratches on the face. Staff interviews confirmed that the resident required total assistance with ADLs and could not perform personal hygiene independently. The care plan for the resident specifically included an intervention to keep fingernails short due to a history of self-inflicted skin impairment, but this intervention was not consistently implemented. Observations and interviews with CNAs and an LVN revealed that the resident's fingernails had not been trimmed as required, and staff could not recall the last time nail care was provided. The resident was repeatedly seen scratching his face, and staff acknowledged that the long fingernails contributed to the skin injuries. The facility's policy required staff to provide ADL assistance according to individualized care plans, but this was not followed for the resident in question, resulting in unmet personal hygiene needs and skin integrity issues.
Failure to Provide Prescribed Fluid Amounts with Meals
Penalty
Summary
A deficiency occurred when a resident with end-stage renal disease and a physician-ordered fluid restriction of 2000 ml per 24 hours did not receive the prescribed amount of fluids with meals. The physician's order specified that the dietary department should provide 360 ml of fluids with each meal (breakfast, lunch, and dinner), totaling 1080 ml per day from dietary sources. However, the resident was only provided with 240 ml of fluid (a carton of Nepro) at each meal, which was consistent with a lower fluid restriction than ordered. There was no documentation indicating that the resident refused the additional fluids or that the physician was notified about the discrepancy. The issue was identified through observation, interviews, and medical record review. The resident confirmed only receiving 240 ml of fluid with each meal and expressed a preference for a variety of fluids, including water, juice, and hot chocolate. The registered dietitian (RD) verified that the dietary department was not following the physician's order and that the resident had not received the ordered amount of fluids since at least a specific date. The RD also confirmed that the kitchen's diet order did not match the physician's order, and there was no documentation of any refusal or physician notification regarding the missed fluids.
Failure to Provide Safe and Sanitary Respiratory Care
Penalty
Summary
The facility failed to provide safe and sanitary respiratory care for three residents who required oxygen therapy. One resident received oxygen therapy without a physician's order, and the oxygen tubing and nasal cannula for this resident were found lying on the floor, not maintained in a sanitary manner. The resident had a recent history of pneumonia and was readmitted from an acute care hospital, but there was no current physician order for oxygen therapy, as confirmed by both observation and staff review of the medical record. Another resident was observed using oxygen tubing that was not labeled with the date it was first used or changed, and the tubing was not stored in a sanitary manner, being left on the bed and not placed in a plastic bag as required by facility policy. Staff interviews confirmed that the tubing should have been labeled and stored properly to prevent contamination, and that the tubing was being changed every 72 hours, although the infection preventionist later stated the change interval was weekly. The tubing was replaced after the deficiency was identified. A third resident's oxygen tubing and humidifier bottle were also not labeled with the date they were last changed, contrary to facility policy. Staff verified that labeling was necessary to ensure timely changes and prevent infection. The Director of Nursing confirmed the importance of dating these items for infection control. These findings were based on direct observation, staff interviews, and review of facility policies and medical records.
Failure to Provide Appropriate Dialysis Care and Monitoring
Penalty
Summary
The facility failed to provide necessary care and services for two residents requiring dialysis. For one resident, who was scheduled for dialysis three times per week, physician orders specified that antihypertensive medications should be withheld on dialysis days. Despite these orders, the medication Benazepril hydrochloride was administered on several dialysis days, as confirmed by both the Medication Administration Record (MAR) and the Director of Nursing (DON). This occurred even after the physician's orders were updated to clarify when the medication should be held. For another resident with an arteriovenous (AV) shunt in the left upper arm, the facility did not consistently assess and monitor the dialysis access site as required. The facility's policy and physician orders required that the AV shunt be checked for bruit and thrill every shift, and that the site be monitored for redness, bleeding, skin breakdown, and edema. Documentation in the MAR showed multiple instances where the AV shunt was assessed as negative for thrill and bruit, and positive for signs of redness, bleeding, skin breakdown, or edema. However, there was no evidence that the physician was notified of these findings, despite facility policy and physician orders requiring immediate notification for such changes. Interviews with nursing staff confirmed that the absence of bruit and thrill, as well as the presence of redness, bleeding, skin breakdown, or edema, should have prompted physician notification. The DON and other staff acknowledged that these findings represented a change in condition and that the physician should have been informed, but this did not occur according to the documentation reviewed.
Failure to Account for Controlled Medications and Improper Eye Drop Administration
Penalty
Summary
The facility failed to ensure proper accounting and safeguarding of controlled medications by not consistently obtaining signatures from incoming and outgoing licensed nurses on the Controlled Substance Logs for two medication carts. Multiple instances were identified where nurses' signatures were missing for various shifts, as verified by facility staff and the Director of Nursing. The facility's policy requires a physical inventory and documentation of controlled medications at each shift change, but this procedure was not consistently followed, creating gaps in medication accountability. Additionally, the facility did not ensure proper administration of an eye drop medication for a resident with moderate cognitive impairment and a diagnosis of mild open-angle glaucoma. During a medication administration observation, the nurse did not compress the resident's tear duct or ensure the resident's eyes remained closed for the required time after instilling the eye drops, as outlined in facility policy. The nurse left the room before confirming the medication was properly absorbed, and the resident was observed opening and wiping his eyes shortly after administration.
Failure to Document Emergency Kit Medication Use and Remove Expired Medications
Penalty
Summary
The facility failed to ensure proper documentation and storage of medications as required by its own policies and professional standards. During an inspection of the medication room's IV emergency kit, it was observed that a vial of Lidocaine was missing from the kit, and there was no documentation in the Emergency Kit Usage Log regarding its removal, the resident it was administered to, or the date it was taken. The Infection Preventionist (IP) and Director of Nursing (DON) confirmed that the nurse who removed the medication did not document the usage as required by facility policy. Additionally, expired Santyl collagenase ointments were found on Treatment Cart 2 during an inspection. The ointments had expiration dates that had already passed, and the presence of these expired medications was verified by an LVN, who acknowledged that expired medications or medical supplies should be disposed of. The DON was informed of these findings and acknowledged the presence of expired medications on the treatment cart.
Failure to Provide Required Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide special eating equipment, specifically a sippy cup, to a resident who required it to maintain independence in self-feeding. Medical records, including a nutrition evaluation and physician order, indicated the resident should have a sippy cup for meals. The resident's diet card also specified the need for adaptive equipment at all meals. During a mealtime observation, the resident was seen using regular cups for both milk and juice, and a CNA confirmed that the sippy cup was not provided as required. The CNA stated that the kitchen should have supplied the sippy cup, and an LVN verified that the resident should have received it, confirming the deficiency.
Incomplete and Inaccurate Medical Record Documentation for Multiple Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, as evidenced by missing or incomplete documentation in medication administration records (MAR), physician orders, and required forms. For one resident, the MAR did not show administration of prescribed medications such as Protonix and Humalog insulin, nor did it document completion of a tuberculin test or required monitoring activities, including hours of sleep, non-pharmacological interventions, side effects of hypnotics, signs and symptoms of bleeding related to anticoagulant use, and pain level assessments for specific shifts. The LVN confirmed that these omissions meant the care or monitoring was not performed or not documented as required. Another resident's Physician Orders for Life-Sustaining Treatment (POLST) form was found to be incomplete, lacking the physician's name, telephone number, license number, signature, and date for a period of six months. Both the Social Services Designee and the DON acknowledged that the POLST should have been fully completed according to requirements. Additionally, the facility did not accurately calculate and document weekly fluid intake totals for a third resident who was on a physician-ordered fluid restriction and required weekly evaluation of intake and output. The documentation reflected daily, rather than weekly, fluid intake amounts, which was verified as inaccurate by the DON. These documentation failures were confirmed through interviews and concurrent record reviews with facility staff.
Infection Control Lapses in Resident Care and GT Procedures
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices as evidenced by multiple observed deficiencies. In one instance, a resident's urinal containing approximately 200 ml of urine was placed on a bedside table next to a water pitcher and two cups of juice, creating a potential for contamination of the drinks. The MDS Coordinator confirmed the placement and acknowledged the risk of contamination. Additionally, staff did not adhere to hand hygiene protocols during gastrostomy tube (GT) care. An LVN was observed administering medication via GT without performing hand hygiene or changing gloves after touching the privacy curtain, despite facility policy requiring handwashing before handling GTs. Furthermore, a nurse failed to follow Enhanced Barrier Precautions (EBP) for a resident with a respiratory MDRO and an indwelling medical device, as she did not don a gown and mask while providing GT care, even though signage and care plans indicated EBP was required. These lapses were verified by staff during interviews.
Failure to Develop Care Plan for Oxygen Therapy
Penalty
Summary
A deficiency was identified when the facility failed to develop a comprehensive care plan for a resident who was receiving oxygen therapy. The resident, who had been diagnosed with pneumonia and was recently readmitted from an acute care hospital, was observed lying in bed with an oxygen concentrator set to deliver continuous oxygen at 2 liters per minute. The oxygen tubing and nasal cannula were attached, and the resident had been receiving this therapy since readmission. During interviews and medical record reviews with both an LVN and the DON, it was confirmed that there was no physician's order for the oxygen therapy and no care plan had been initiated to address the resident's use of oxygen. The DON acknowledged that a care plan should have been started at the time the resident began receiving oxygen therapy after readmission, but this was not done.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor a resident's documented food preferences, resulting in the resident being served items she had specifically identified as dislikes. The resident's care plan and nutrition evaluation clearly listed several foods she did not want, including bacon, pork, mushrooms, spinach, olives, cabbage, and shredded carrots. Despite these documented preferences, the resident was observed being served cabbage and carrots for lunch, which were noted as dislikes on her diet card. During interviews and observations, the resident expressed frustration about receiving unwanted food items, and a CNA confirmed that the lunch tray should not have included cabbage and chopped carrots. The resident did not eat her lunch and requested an alternative meal, further verifying that her preferences were not being honored as required by her care plan and dietary documentation.
Failure to Provide Appropriate Dietary Texture Leads to Resident's Choking Incident
Penalty
Summary
The facility failed to provide a resident with the appropriate dietary texture as ordered by the physician, which put the resident at risk for choking. The resident, who had diagnoses including dysphagia, acute respiratory failure, epilepsy, and autism, was on a fortified, pureed diet with nectar thick liquids. Despite this, the resident was given regular peanut butter and jelly sandwiches, which were not consistent with the prescribed pureed diet. The facility's documents clearly indicated that peanut butter sandwiches were not allowed for residents on a pureed diet. The incident occurred when a healthcare assistant (HA) provided the resident with regular texture sandwiches, unaware of the resident's dietary restrictions. The HA stated that the resident frequently requested and consumed these sandwiches, and there was no communication regarding the resident's specific diet orders. The resident experienced a choking episode, followed by seizure-like activity, and was found unresponsive with food in their mouth. Despite efforts to perform the Heimlich maneuver and initiate CPR, the resident expired. Interviews with facility staff, including the Administrator and Director of Nursing (DON), confirmed the inconsistency with the resident's diet orders.
Controlled Medication Diversion in LTC Facility
Penalty
Summary
The facility failed to provide necessary pharmacy services to safeguard controlled medications for nine of 11 sampled residents. This deficiency was identified through interviews, medical record reviews, and facility document reviews. The missing medications included significant quantities of tramadol, hydrocodone-acetaminophen, and Oxycontin, which were not accounted for in the medication cart's locked narcotic drawer. The facility's policies and procedures required controlled substances to be handled, stored, and documented according to federal and state laws, but these protocols were not followed, leading to the diversion of medications. The investigation revealed that the controlled medication logs for the affected residents showed discrepancies. For instance, the logs indicated that medications were transferred to the Director of Nursing (DON) for destruction, but the signatures on these logs were forged. The missing medications were from residents who either had large amounts of controlled medications on hand, took pain medication infrequently, or were transferred out of the facility. The facility's narcotic count, conducted at each shift change, failed to detect the diversion because the logs falsely indicated that the medications were in the possession of the DON. Interviews with the DON and Administrator confirmed that the controlled medications were supposed to be transferred to the DON's locked cabinets when discontinued or when residents were transferred. However, the perpetrator forged the signatures of the DON and a witnessing nurse on the controlled medication logs, making it appear as though the medications were properly transferred. This failure in the facility's medication management system resulted in the unaccounted loss of controlled substances, highlighting a significant breach in the facility's responsibility to safeguard medications.
Failure to Document Post-Fall Assessment
Penalty
Summary
The facility failed to ensure that a resident received the necessary care and services to maintain their highest practicable well-being following an unwitnessed fall. The resident, who had the capacity to understand and make decisions, experienced a fall resulting in a head injury. Despite the facility's policy requiring a physical assessment and documentation in the Nursing Progress Notes after a fall, there was a lack of detailed documentation regarding the resident's skin condition and the description of the hematoma on the right frontal temporal region. The resident reported a pain level of 8 out of 10 and had a visible bump with a scab on the head. Although the resident was transferred to an acute care hospital and later returned to the facility, the medical records lacked comprehensive documentation of the skin and wound condition. The Director of Nursing confirmed the absence of necessary documentation, acknowledging that the staff should have documented the description of the hematoma as per the facility's policy.
Incomplete Medical Record Documentation for Residents
Penalty
Summary
The facility failed to ensure the completeness and accuracy of medical records for three of eight sampled residents. For Resident 2, the licensed nurse did not document blood sugar levels, levothyroxine administration, and the amount of regular insulin administered in the Medication Administration Record (MAR) on two specific dates. This lack of documentation was confirmed during an interview with the Director of Nursing (DON), who stated that the expectation was for nurses to document medication administration immediately after it occurred. Similarly, for Resident 3, the MAR lacked documentation of blood sugar levels, the amount of insulin administered, and the nurse's initials on the same two dates. The DON verified these findings during a review and interview, reiterating the expectation for immediate documentation post-medication administration. For Resident 8, the MAR was missing the nurse's initials for medication administration on two separate dates. The medications involved were for the treatment of Parkinson's disease. The DON confirmed these omissions during a review and interview, acknowledging the expectation for timely documentation. These documentation failures had the potential to impact the residents' care needs due to incomplete and inaccurate medical information.
Failure to Properly Manage and Document Controlled Substances
Penalty
Summary
The facility failed to provide the necessary pharmacy services for a resident, specifically in the management and documentation of controlled substances. The facility did not ensure that the resident's oxycodone medications were stored properly, resulting in missing medications. Additionally, the facility did not ensure that the Controlled Drug record and the Medication Administration Record (MAR) documentation for the resident's oxycodone matched. This discrepancy was confirmed through interviews with the Director of Nursing (DON), Registered Nurse (RN), and Licensed Vocational Nurses (LVNs), who acknowledged the missing medications and documentation inconsistencies. The facility's policies and procedures (P&P) required that controlled substances be received, stored, and documented by licensed personnel. However, the investigation revealed that the resident's oxycodone medications were not properly stored or accounted for. RN 1 admitted to receiving the medications but failed to inform anyone or properly store them, leading to the medications being unaccounted for. Further review showed that the MARs did not reflect the administration of the medications on specific dates, despite being signed out in the Controlled Drug record. Additionally, the facility failed to conduct proper inventory checks of all narcotics during shift changes. The investigation found multiple instances of missing signatures on the shift count sheets for Medication Carts 1, 2, 3, and 5, indicating that the required physical inventory of controlled substances was not consistently performed. This lapse in procedure was verified by the DON and Clinical Resource nurse, who acknowledged the missing documentation and the potential for medication diversion due to these failures.
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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 Santa Ana
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Advanced Rehab Center Of Tustin | 1.2 mi | — | 2 | 0 |
| French Park Care Center | 1.3 mi | — | 10 | 0 |
| Healthbridge Children's Hospital - Orange D/p Snf | 1.3 mi | — | 0 | 0 |
| Town & Country | 1.3 mi | — | 27 | 0 |
| Orange Healthcare & Wellness Centre, Llc | 1.6 mi | — | 24 | 0 |
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