Halcyon House

In the surveyor’s words

From the most serious findings on record at Halcyon House, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Oct 14, 2025

  Based on clinical record review, facility policy review, observation, resident and staff interviews, the facility failed to assess and implement interventions and communication with the provider in response to Resident #1's rising blood sugar levels. Resident #1 admitted to the facility on [DATE] at approximately 12:00 PM. Resident #1 list of diagnoses included type 1 diabetes, which required insulin several times a day. At 5:16 PM, facility staff completed a bedside glucose check with a result of 245 mg/dL (milligrams/deciliter). Resident #1 requested insulin be administered. The nursing staff reported to the resident the facility did not have an order for insulin. At 8:02 PM, a second bedside glucose check completed with a result of 324 mg/dL. […]

• No harm, potential for more than minimal, isolatedF698Mar 19, 2026

  Based on clinical record review, facility policy review, resident and staff interviews, the facility failed to conduct post assessment after resident received dialysis for 1 of 1 residents reviewed for dialysis (Resident #42). The facility reported a census of 50 residents. Findings include: Review of the MDS assessment, dated 2/9/26 revealed Resident #42 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS indicated medical diagnosis for end stage renal disease (ESRD). The MDS indicated Resident #42 did not receive dialysis. […]

• No harm, potential for more than minimal, isolatedF697Oct 14, 2025

  Based on clinical record review, facility policy review, resident and staff interviews, the facility failed to provide pain medication after a newly admitted resident reported a pain at 8 out of 10 for 1 of 3 residents (Resident #1) reviewed for pain. The facility reported a census of 52 residents.Findings include:Review of the electronic health record (EHR) revealed a hospital Discharge summary, dated [DATE], which indicated: admission Date: 9/22/2025. discharge: [DATE]. Disposition (discharge arrangements): SNF (Skilled Nursing facility) at HH (abbreviation for facility) .Discharge Diagnoses, in part: Chronic pain, PMR (polymyalgia rheumatica - an inflammatory condition that causes joint and muscle pain in multiple locations), Anxiety, Insomnia, Stage 3b chronic kidney disease,… […]

• No harm, potential for more than minimal, isolatedF760Oct 28, 2024

  Based on clinical record review, facility incident reports, and facility staff interview, the facility failed to administer two doses of insulin for 1 of 3 residents (Resident #1), and remove a transdermal pain patch prior to application of a new patch and notify physician and responsible party of the error for 1 of 3 residents (Resident #2) reviewed for medication administration. The facility reported a census of 51 residents. Findings include: 1. A review of [name redacted] hospital discharge orders, dated 3/6/24, Medication List revealed the following orders, in part: a. Insulin glargine 100 unit/ml (milliliters) (3 ml) injection pen. Dosage: Inject 18 units subcutaneously daily. Last time this was given: 18 units on March 5, 2024 8:50 PM. […]

• No harm, potential for more than minimal, isolatedF658Apr 4, 2024

  Based on observation, clinical record review, policy review, and staff interview, staff combined medications without an order to do so during the administration of g-tube (gastrostomy tube-a tube inserted through the abdomen which brought nutrition and medications directly to the stomach) medications for 1 of 1 residents reviewed with a g-tube(Resident #10). The facility reported a census of 50 residents. Findings: The Minimum Data Set (MDS) assessment tool, dated 1/19/24, listed diagnoses for Resident #10 which included non-Alzheimer's dementia, Parkinson's disease (progressive disorder that affected the nervous system and the parts of the body controlled by the nerves), and depression. […]