Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
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 Halcyon House during CMS and state inspections, most recent first.
A resident with type 1 diabetes was admitted after hospitalization and did not receive required insulin due to failures in order verification, staff communication, and assessment. Despite elevated blood glucose readings and symptoms of hyperglycemia, nursing staff did not administer insulin or notify the provider, resulting in the resident developing diabetic ketoacidosis and acute kidney injury before being transferred to the hospital.
A resident with a history of chronic pain and multiple comorbidities was admitted and reported severe pain, but did not receive prescribed pain medications due to staff confusion, lack of access to medications, and inadequate communication. Despite clear orders and repeated pain assessments indicating high pain levels, no pain medication was administered, and the facility's pain management policy was not followed.
A resident with diabetes did not receive two doses of insulin, and another resident had a Fentanyl patch applied without removing the old one, leading to medication errors. The facility failed to notify the physician or responsible parties and did not document the incidents as required.
A resident with severe cognitive impairment and a g-tube received combined medications without an order, contrary to facility policy. An LPN mixed carbidopa/levodopa and quetiapine with water and administered them through the g-tube, despite the MAR lacking an order to do so.
Failure to Assess and Administer Insulin for Diabetic Resident on Admission
Penalty
Summary
A deficiency occurred when facility staff failed to assess, implement interventions, and communicate with the provider in response to a resident's rising blood sugar levels following admission. The resident, with a known history of type 1 diabetes requiring multiple daily insulin doses, was admitted after a hospitalization for heart failure. Upon admission, staff did not perform a comprehensive assessment, including checking the resident's heart, lungs, or swelling, nor did they provide a meal or check her blood sugar until later in the day. When blood glucose checks were eventually performed, results were elevated (245 mg/dL and 324 mg/dL), and the resident requested insulin, but staff reported there was no order for insulin and did not administer it. Throughout the evening and overnight, the resident continued to experience symptoms of hyperglycemia, including cotton mouth, fruity breath, dizziness, and unsteadiness. Despite these symptoms and repeated elevated blood sugar readings, nursing staff did not contact the provider or take further action to obtain or administer insulin. The following morning, critical lab values were reported, and the resident was transferred to the emergency room, where her blood glucose was found to be 701 mg/dL, and she was diagnosed with diabetic ketoacidosis (DKA) and acute kidney injury. Interviews and record reviews revealed that the hospital had provided discharge orders for long-acting and sliding scale insulin, but these were not entered into the facility's system or administered. Multiple staff members, including RNs and LPNs, were aware of the resident's diabetes diagnosis but did not verify or ensure insulin orders were in place, nor did they utilize the emergency medication kit or escalate the issue to the provider in a timely manner. Further investigation showed breakdowns in the admission process, including lack of communication between staff, incomplete review and confirmation of hospital discharge orders, and failure to follow the facility's admission checklist. Staff interviews indicated confusion over responsibilities, lack of training on emergency medication access, and failure to recognize the urgency of the resident's condition. The pharmacy also did not enter the insulin orders, and staff did not follow up to resolve the discrepancy. As a result, the resident did not receive necessary insulin, leading to a critical medical emergency.
Failure to Provide Timely Pain Management for Newly Admitted Resident
Penalty
Summary
A newly admitted resident with a complex medical history, including chronic pain, fibromyalgia, polymyalgia rheumatica, and other conditions, reported severe pain rated at 8 out of 10 upon arrival at the facility. The resident's hospital discharge summary included orders for multiple pain medications, including acetaminophen, cyclobenzaprine, and oxycodone-acetaminophen, all to be administered as needed. Despite these orders and the resident's clear communication of pain to nursing staff, no pain medication was administered on the day of admission or the following day, as documented in the Medication Administration Record (MAR). Multiple staff interviews revealed confusion and lack of preparedness during the admission process. Nurses reported not having access to the resident's pain medications due to delays in processing orders and lack of access to the Emergency Kit (E-Kit). One nurse, new to the facility, stated she could not administer any medications until they appeared in the electronic health record, while another contract nurse did not know the location of the E-Kit and did not seek assistance or notify the physician. The resident was instead provided with non-pharmacological interventions such as an ice pack and a fan, but these did not address her reported pain. The facility's pain management policy required prompt assessment and management of pain, including notifying the primary care provider if pain was indicated and following prescribed orders for pain management. However, the policy was not followed, as the resident's pain was not treated according to physician orders, and there was no documentation of pain medication administration or effective communication among staff to resolve the issue. The Director of Nursing acknowledged that expectations for pain management were not met for this resident on the day of admission.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer two doses of insulin to a resident with Type 2 diabetes mellitus, leading to a significant medication error. The resident was admitted with hospital discharge orders for insulin glargine and blood sugar checks, but the facility's care plan did not adequately address the resident's diabetes management. On a specific day, the resident's morning and noon doses of insulin lispro were omitted, and blood sugar checks were not performed. The omission was noted in the clinical records, but no incident report was filed, and the resident's primary care provider and responsible party were not notified as per facility protocol. Another resident, who required opioid medication for chronic pain, experienced a medication error involving the application of a transdermal Fentanyl patch. The resident's care plan included instructions to remove the old patch before applying a new one. However, on one occasion, a nurse applied a new patch without removing the old one, resulting in the resident having two patches on simultaneously. Although the error was documented, there was no record of notification to the physician or responsible party, and the facility's electronic health record lacked documentation of the incident. Interviews with facility staff, including a registered nurse and the Director of Nursing, revealed that the expected protocol for medication errors was not followed. Staff were instructed to notify the Director of Nursing, the resident's primary care provider, and the responsible party in the event of a medication error, and to complete an incident report. However, these steps were not taken in the cases of the missed insulin doses and the Fentanyl patch error, indicating a lapse in adherence to the facility's medication administration procedures.
Improper Medication Administration via G-Tube
Penalty
Summary
Staff combined medications without an order during the administration of g-tube medications for a resident with non-Alzheimer's dementia, Parkinson's disease, and depression. The facility's policy directed staff to administer each medication separately, but during an observation, an LPN crushed and mixed carbidopa/levodopa and quetiapine with water before administering them through the g-tube. The resident's Medication Administration Record (MAR) did not contain an order to combine these medications. The resident had a severely impaired cognition with a BIMS score of 1 out of 15 and had a g-tube for supplemental feedings. Despite the facility's policy and the care plan entry directing staff to provide medications per the order, the LPN combined the medications without the necessary order. Upon being questioned, the LPN acknowledged the need for an order to combine medications and later stated that she obtained the order after the fact.
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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 Washington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aspire Of Washington | 0.3 mi | — | 0 | 0 |
| United Presbyterian Home | 0.9 mi | — | 0 | 0 |
| Parkview Home | 9.9 mi | — | 0 | 0 |
| Pleasantview Home | 13.9 mi | — | 6 | 0 |
| Harvest Acres Nursing And Rehab | 14.2 mi | — | 10 | 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 August 2026) and official state health department websites.