High Valley Lodge

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program when: 1. One of one inspected medication carts (Medication Cart South) contained a package of syringes with an expiration date of [DATE]. 2. The facility's water management plan was out of date and not implemented as written. These failures had the potential to increase the risk of transmission of infectious microorganisms and waterborne illness to all residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for one of one sampled resident (Resident 14) by failing to: 1. Conduct a change of condition (COC- a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains), assessment, and monitoring of Resident 14's generalized skin condition. 2. Notify Resident 14's resident representative for the progression of skin condition to the facial area. This failure resulted in insufficient information regarding the resident's wound progression and created the potential for worsening skin condition for Resident 14.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. In reach-in refrigerator 1, one container of non-dairy creamer and a chocolate-flavored syrup did not have an open date label. 2. In reach-in refrigerator 2, a bag of corn tortillas did not have an open date label. There was an opened bag of flour tortillas, a storage bag containing an opened bag of shredded cheese, and a container bottle of sliced dill pickles-left open and not properly sealed. There was one bottle of salad dressing found expired on 6/20/2026. 3. On the storage rack, there were no open date labels on containers of beef flavor soup base, tarragon leaves, ground cinnamon powder, poultry seasoning, cocoa powder, chicken flavor soup base, ground rosemary, and ground cumin. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly when: 1. Two dumpsters (a movable waste container designed to be brought and taken away by special collection vehicles, or to a bin that specially designed garbage truck lifts) bodies were not free of rust, dirt and dried liquid spills. 2. The black-colored dumpster had a cluster of ants. 3. Two dumpsters were not completely covered when it had a gap under the lids exposing garbage when not in use. 4. The blue-colored dumpster had overflowing with garbage and not completely closed when not in use. These failures attracted ants and have the potential to attract other pests (animals or microorganisms that have a negative effect on humans) such as rats, cockroaches, and flies, which may spread infection to 45 out of 45 residents living in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that promoted resident dignity and respect for one of five residents (Resident 6) observed during the medication administration facility task when the Minimum Data Set Coordinator (MSDC) failed to completely close Resident 6's privacy curtain during medication administration. This failure violated the resident's right to be treated with respect and dignity and had the potential to negatively affect resident's sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of five residents (Resident 6) observed during medication administration was informed of the indication (reason for the use) of the medications prior to administration of the medications. This deficient practice violated Resident 6's right to be informed in advance of the treatment being provided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a call light (a device used by a resident to signal his or her need for assistance from staff) was within reach for one of 14 sampled residents (Resident 6). This failure had the potential to result in Resident 6 not being able to call for staff assistance and delay in the provision of necessary care and services which could negatively affect the residents' comfort and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident was provided with information and assistance to formulate an advance directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for one of five sampled residents (Resident 2). reviewed under the Advance Directive care area. This failure violated Resident 2's right to be fully informed of the option to formulate their advance directive and had the potential to cause conflict with a resident's wishes regarding health care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure reasonable care for the protection of resident's property from loss or theft by failing to have a completed belongings inventory for one of one resident (Resident 45) reviewed under the Personal Property care area. This failure had the potential to result in failure to provide safe keeping of Resident 45's personal belongings.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 14 sampled residents (Resident 51) had an accurate and complete assessment reflected in the Minimum Data Set (MDS - a resident assessment tool) when the BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) screening and Resident Mood Interview (a standardized assessment to screen for potential symptoms of depression) were not completed although the resident was assessed as being sometimes understood (ability is limited to making concrete requests) and sometimes able to understand (responds adequately to simple, direct communication only). This failure resulted in Resident 51 having an inaccurate and incomplete MDS assessment.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document outlining a detailed approach to care customized to an individual resident's need) for one of fourteen sampled residents (Resident 45) by failing to address Resident 45's recurring impacted cerumen (a buildup of earwax that causes symptoms like hearing loss, earache, or a feeling of fullness). This failure placed Resident 45 at risk for pain, infection, impaired hearing and communication difficulties.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication was properly stored when one of one inspected medication carts (Medication Cart South) had unlabeled, unpackaged tablets in the bottom of two cart drawers. This failure resulted in the improper storage of medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's medical records for advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) was clarified and completed accurately for one of five sampled residents (Resident 2). This failure had the potential to result in confusion in the care and services for Resident 2 and placed the resident at risk of receiving unwanted treatment and not receiving appropriate care based on her wishes.

Inspectors wroteBased on interview and record review, the facility failed to offer the updated 2025/2026 influenza (flu, a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and lungs) vaccine (medications used to prevent diseases usually given by injection or by mouth) at the start of the respiratory illness season (typically from October through April in the U.S., peaking between December and February, characterized by increased circulation of respiratory illnesses including the flu) when the vaccine became available for one of five sampled residents (Resident 1). This failure had the potential to increase Resident 1's risk of acquiring the flu virus and experiencing complications from the flu virus.

Inspectors wroteBased on interview and record review, the facility failed to offer the updated 2025 Coronavirus disease (COVID-19 a highly contagious respiratory illness) vaccine (medications used to prevent diseases usually given by injection or by mouth) when the vaccine became available for one of five sampled residents (Resident 1). This failure had the potential to increase Resident 1's risk of getting COVID-19.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's grievance was addressed and investigated per the facility's policy and procedure (P&P) for one of four sampled residents (Resident 1). This deficient practice violated the resident's right to have his grievance addressed and had the potential for further concerns to not be addressed.

Inspectors wroteBased on interview and record review, the facility failed to revise the comprehensive care plan (a detailed, resident-centered document outlining all aspects of a person's healthcare needs, including medical, social, and emotional support, and was designed to promote overall well-being) for three out of three sampled residents (Residents 2, 3, and 7) when:1. Resident 2's diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) care plan did not reflect the active insulin (a hormone that removed excess sugar from the blood, could be produced by the body or given artificially via medication) orders. 2. Resident 3's dementia (a progressive state of decline in mental abilities) care plan did not reflect the active namenda (a medication used to treat dementia) order. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure plastic containers of canned fruit stored in the refrigerator were labeled and dated. This deficient practice had the potential to result in improper food safety practices and could lead to possible food-borne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) for 45 of 47 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide feeding assistance at eye-level to one of nine residents (Resident 2) on 8/5/2025 during lunch. This deficient practice had the potential to negatively impact Resident 2's self-esteem and self-worth and increased the risk of aspiration (inhaling or drawing something into the lungs or airways that was not air), which could lead to serious complications (a medical problem that occurred during a disease) such as pneumonia (an infection/inflammation in the lungs).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set ([MDS] - a resident assessment tool), accurately reflected the oral/dental status for one of six sampled residents (Resident 35). This deficient practice resulted in incorrect data being transmitted to the Center for Medicare and Medicaid Services (CMS) regarding Resident 35's oral/dental status and had the potential to negatively affect the resident care plan and delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive, person-centered care plan was developed and implemented to address depression (a mental health disorder) diagnosis for one of six sampled residents (Resident 8). This deficient practice placed Resident 8 at risk of not receiving appropriate care and resident-centered interventions to meet the resident's needs and services related to depression.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of care for two of two sampled residents (Resident 38 and Resident 40), when Licensed Vocational Nurse (LVN) 2 administered antihypertensive medications (used to treat high blood pressure using blood pressure readings obtained two hours prior to administration. This deficient practice increased the risk for hypotension (low blood pressure), dizziness, and falls for Residents 38 and 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary gastrostomy tube (GT- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) services for one of nine residents (Resident 47) when, Licensed Vocational Nurse (LVN) 1 did not flush the GT line with the prescribed amount of water before and after medication administration. This deficient practice had the potential to result in Resident 47's GT clogging (blocked), which may lead to Residents 47 not receiving the full dose of medication or feeding as prescribed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and serve food to meet individual needs for two out of ten sampled residents (Resident 27 and 45) by failing to ensure Residents 27 and 45 received the correct food texture. This deficient practice did not meet Residents' 27 and 45 individual needs and potentially placed Residents 27 and 45 at risk for choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and serve food to meet the individualized needs for three out of ten sampled residents (Resident 20, Resident 27, and Resident 45) by failing to: 1. Honor Resident 20's food preferences. 2. Serve Residents 27 and 45 the same food items as other residents. These deficient practices did not meet Resident 20, 27, and 45's individual needs and had the potential to impact the resident's nutritional intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and properly store food brought by family/ visitors for one out of nine residents (Resident 44), in accordance with the facility's Policy and Procedure (P&P) titled, Foods brought in by family/ visitors. This deficient practice had the potential to result in food borne illnesses (any illness resulting from eating contaminated/spoiled foods) and also lead to other serious medical complications and hospitalization for Resident 44.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist (IP) completed ten hours of continuing Infection Prevention and Control education on an annual basis. This failure had the potential for the IP to be unaware and be unable to educate the facility's staff of updated information regarding Infection Prevention and Control practices.

Inspectors wroteDuring an observation, interview, and record review, the facility failed to meet the required room size measurement of 80 square feet ([sq. ft.]- a unit of measurement) of room space per resident in rooms with multiple residents. This deficient practice could potentially affect the residents privacy, health, and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure that a resident's physician's orders to flush (gently pushing water through the tube to clean it) the gastrostomy tube (G-Tube, a tube inserted through the abdomen that brings nutrition and medications directly to the stomach) with five to 10 milliliters (ml-unit of measure) of water in between the administration of each medication for one of 13 sampled residents (Resident 6) was followed. 2. Ensure that facility staff verified tube placement (when a healthcare professional pushes air into the g-tube and listens to hear a gurgling sound in the stomach with a stethoscope [a medical instrument that allows a person to listen to sounds inside the body]; [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Act upon the pharmacist's recommendation, dated 6/13/2024, to add vitamin B12 (supplement) to a resident's medication regimen for one of 13 sampled residents (Resident 15). 2. Act upon the pharmacist's recommendation, dated 4/29/2024, to discontinue a resident's docusate sodium (stool softener) for one of 13 sampled residents (Resident 15). 3. Document a rationale for why the physician disagreed with the pharmacist's recommendation for one of 13 sampled residents (Resident 8). These deficient practices had the potential to place the residents at increased risk of receiving unnecessary medications or experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention).

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure licensed nurse did not leave two medicine cups with medications unattended. This deficient practice has the potential to result in unwanted serious side effects if placed in undesired hands which can lead to harm. 2. Ensure an open multi dose vial of Lidocaine 1% (local anesthetic agent [causes a loss of feeling in one small area of the body]) was labeled with an open date. This deficient practice had the potential to compromise the therapeutic effectiveness of the medication. 3. Ensure Licensed Vocational Nurse 1 (LVN 1) did not leave prepared medications unattended at a resident's bedside for one of 13 sampled residents (Resident 6). This deficient practice had the potential to result in unauthorized personnel or residents having access to the unattended medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure there was no moldy food inside the designated resident refrigerator. 2. Ensure a bag of prepared French toast found inside the refrigerator in the kitchen was labeled with the date it was prepared. 3. Ensure that food found inside the designated resident refrigerator was labeled with a resident identifier and the date it was placed inside the refrigerator. These deficient practices had the potential to place 44 out of 48 residents living in the facility at risk for foodborne illness (illness caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure a resident's urinal was not placed hanging on a trash receptacle for one of two sampled residents (Resident 7). 2. Ensure a resident's urinal had the residents' name on the urinal for two of two sampled residents (Resident 7 and Resident 33). This deficient practice had the potential to result in contamination of the residents' care equipment and place residents at risk for and place the residence at risk for infection. 3. Ensure staff did not store their personal food inside the kitchen refrigerator along with the residents' food. This deficient practice had the potential to place 44 out of 48 residents living in the facility at increased risk of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights (a device used by a resident to signal his/her need for assistance from staff) were within residents' reach while in bed for two out of three sampled residents (Resident 6 and Resident 25). This deficient practice had the potential to delay the provision of services and residents' needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse (at type of abuse that uses language) for one of two sampled residents (Resident 36), when on 8/7/24, Resident 32 called Resident 36 an asshole while pointing at Resident 36 in the main dining room. This deficient practice resulted in Resident 36 being subjected to verbal abuse while under the care of the facility. Residents whoa re subjected to verbal abuse are at increased risk for low self-esteem (when someone lacks confidence in themselves and their abilities), anxiety (a feeling of fear, dread, and uneasiness), depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities for long periods of time) and social isolation (.when someone has few or no social connections or support, and lacks relationships with others).

Inspectors wroteBased on interview and record review, the facility failed to develop and or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act by failing to report to the State Survey Agency (SSA) an allegation of verbal abuse ( at type of abuse that uses language) for one of two sampled residents (Resident 36). This deficient practice resulted in a delay of an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse.

Inspectors wroteBased on interview and record review, the facility failed to revise and renew a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for two of three sampled residents (Resident 18 and 4). This deficient practice had the potential to result in failure to deliver the necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed that to ensure that two of three sampled residents (Resident 47 and Resident 45), who were assessed and identified to be a candidate for the facility's bowl (a tube-shaped organ in the abdomen that helps the body digest food and absorb nutrients) and bladder (a sac-shaped muscular organ that stores the urine secreted by the kidneys) retraining program (when facility staff assist a resident to the restroom at specific timed intervals) , were placed on the bowel and bladder retraining program per facility policy. This deficient practice has the potential for Resident 47 and Resident 45 to not to achieve or restore normal bowel and bladder function.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that one of two sampled residents (Resident 6), was observed to have bed side rails in place despite being evaluated that bed side rails were not recommended for use. This deficient practice had the potential for inappropriate use of bed rails that could lead to entrapment (when a person is trapped by the bed rail in a position they cannot move from) and result to injury.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's policy on medication administration by failing to ensure one of three sampled resident's (Resident 19) administration of Ambien (medication used to treat insomnia [persistent problems falling and staying asleep]) was accurately reflected on the Controlled Drug Record (accountability record of medications that are considered to have a strong potential for abuse). This deficient practice had the potential to result in medication errors and had the potential to result in confusion on when the medication was administered.

Inspectors wroteBased on interview and record review, the facility failed to provide laboratory services timely for one of three sampled residents (Resident 45). This deficient practice placed Resident 45's well-being at risk and had the potential for the resident not to receive appropriate care and treatment in a timely manner.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Licensed Vocational Nurse 3 (LVN 3) did not willfully falsify (knowingly make a false entry into a resident's medical record) the medication administration of Ativan (brand name for lorazepam, a medication used for anxiety [a feeling of fear, dread, and uneasiness]) on 8/9/2024 for one of two sampled residents (Resident 19). This willful material falsification (WMF - when staff purposefully documents false information in a medical record) resulted in Resident 19's clinical record falsely reflecting the care provided.

Inspectors wroteBased on interview and record review, the facility failed to ensure that hospice care (specialized care that provides physical comfort and emotional, social, and spiritual support for people nearing the end of life) staff was present for two Interdisciplinary Team (IDT-a group of healthcare professionals from different disciplines who work together to treat a resident) meeting for one of one sampled resident (Resident 18). This deficient practice had the potential to result in a delay or lack of coordination in delivery of hospice care and services to one of one sampled resident (Resident 18).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 23 of 24 resident rooms (room [ROOM NUMBER], 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, 21, 22, 23, 24) met the square footage requirement of 80 square feet (sq ft. - unit of measurement) per resident in multiple resident rooms. The room size for these rooms had the potential to have inadequate space for resident care and mobility.

Inspectors wroteBased on interview and record review, the facility failed to develop and or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act by failing to report to the State Survey Agency (SSA) two incidents of injuries of unknown origin (injuries resulting without knowing how it happened) that occurred on 4/15/2023 and 12/12/2023 for one of four sampled residents (Resident 1). This deficient practice resulted in a delay of an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for one of four sampled residents (Resident 1). This deficient practice had the potential to result in a delay in or lack of delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool) for Significant Change in Status Assessment (SCSA - a comprehensive assessment that must be completed after a determination has been made that a significant change such as a decline in the resident's current status from baseline occurred) was completed within the required time frame of 14 days for one of four sampled residents (Resident 1). This deficient practice had the potential to negatively affect the provision of necessary care and services.