Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sandstone Spring Valley during CMS and state inspections, most recent first.
A resident with quadriplegia, immunodeficiencies, protein-calorie malnutrition, and difficulty walking, who was cognitively intact and had a history of behavioral issues and frequent use of profanity toward staff, became frustrated and yelled at a CNA using foul language. Multiple staff, including a PTA and another CNA, reported witnessing a verbal altercation in which both the resident and the CNA exchanged profane language, including repeated use of the F word. An LPN also recalled a separate episode where the same resident yelled at staff and threatened their employment. The CNA later admitted responding to the resident with profanity out of frustration, and the incident was verified as staff-to-resident verbal abuse, demonstrating a failure to maintain professional boundaries and protect the resident from verbal abuse.
Air conditioning in 1300 Hall and 2300 Hall was not maintained in working condition after a power surge, and residents reported hot room temperatures. A CNA said some rooms on the first and second floors were shut down and hot, and the DON noted one resident was moved because of warm room conditions. The Administrator stated the system kept shutting down and had to be reset repeatedly, with room temperatures reaching 83 to 84 degrees Fahrenheit and about 17 residents potentially affected.
Failure to provide fingernail care was identified for four residents with bilateral hand contractures and significant medical needs, including cerebral infarction, chronic respiratory failure with tracheostomy, urinary catheter-related infection, and anoxic brain damage with dependence on a respirator. Staff observed long fingernails on each resident, and wound care nurses, an RN, the nursing supervisor, the ADON, and the IP all confirmed the nails were long and needed trimming or routine care. Staff also stated nail care was assigned to CNAs and/or nursing and should be addressed during shower days.
Two residents with severe neurologic impairment and dependence on a respirator had a physician order for bilateral PRAFO boots for contracture management every shift, but repeated observations found both residents without the boots. Staff stated the boots were meant to support alignment and prevent heel ulcers and foot drop, yet the MAR was not transcribed correctly and there was no documentation that nursing applied the devices as ordered.
A resident with a Foley catheter, UTI history, and catheter-related infection/inflammation had a physician order for monthly catheter changes and daily catheter care. The MAR did not show the catheter was changed for 2 months, and the RN, ADON, and DON confirmed there was no documented evidence explaining why the ordered changes were not completed.
A resident re-admitted with UTI and chronic respiratory failure was observed with two IV lines, including a PICC and a heplock, but the EMR lacked physician orders for their care and maintenance. The left heplock was undated and the PICC dressing was dated earlier than the readmission; an LPN confirmed the missing orders, and the DON agreed the orders were entered only after the IV access was identified on readmission.
Failure to obtain ordered glaucoma eye drops: A resident with glaucoma reported that a prescribed bedtime eye drop from home had been requested from the facility but had not been received. The physician ordered Bimatoprost for increased ocular pressure, but the med remained on order with no documented delivery, and the ADON found that the pharmacy had not filled it because a prescription was needed and had not been provided. The DON confirmed the med had been ordered but not obtained and noted it was used to prevent raised intraocular pressure.
Failure to maintain EBP and water management provisions. A resident with a Foley catheter, trach, vent, and G-tube was observed having the Foley bag emptied by a CNA wearing gloves but no gown, despite EBP orders. The facility also had an incomplete water management program: leadership was not familiar with it, Legionella was not addressed, required water flow details and risk locations were missing, and documentation for temperature checks, ice machine cleaning, device sanitizing, and annual review was not provided.
A resident with multiple chronic conditions was subjected to abuse when a CNA unplugged the resident's room phone and placed it out of reach after the resident repeatedly called the front desk. The CNA admitted to this action, which was found to be willful punishment resulting in the resident's mental anguish. The incident was substantiated through interviews and documentation, confirming a failure to protect the resident from abuse.
A CNA took a resident's phone away and placed it out of reach after the resident repeatedly called the front desk, causing the resident mental anguish. The facility's policy required ongoing abuse prevention training, but staff did not receive additional training after the incident, and some could not recall when they last had abuse and neglect training.
A resident with multiple health conditions was directed by a CNA to urinate in their incontinence brief, violating their dignity. Interviews revealed that this practice was not isolated, as another resident reported similar experiences. The DON confirmed that such instructions are inappropriate and compromise resident dignity.
A facility failed to clarify discrepancies in an appeal decision, leading to inadequate discharge planning for a resident with mobility issues. The resident was discharged without necessary skilled therapy, and the facility did not review the appeal decision before providing it to the resident. Discussions with the resident and spouse were not documented, and caregiver training did not occur due to the spouse's inability to provide care. The resident was discharged home with hospice services without proper coordination.
A resident with dementia did not receive scheduled showers or bed baths for several weeks, despite requiring minimal assistance. Facility staff failed to document refusals or provide alternative hygiene care, leading to a deficiency in care.
Two free-standing portable oxygen cylinders were improperly stored in a resident's room, one empty and the other half full. The resident and a CNA were unaware of the reason for their presence. An RN stated that cylinders should be on a stand or stored in a closet, as per facility policy. The DON confirmed that cylinders should not be left free-standing without proper storage.
A medication security lapse occurred when a cream was left unattended in a resident's room. The resident, with multiple health conditions, had an order for Moisture Barrier Cream with Zinc 10%, which should only be applied by the Wound Care Nurse. Both the RN and Wound Care Nurse confirmed the cream should not have been left in the room.
The facility did not follow the planned menu for a breakfast service, affecting all residents. On a specific morning, breakfast served included items meant for the following day due to a cook's error in reading the menu. The Dietary Manager acknowledged the mistake and stated that residents would be informed of the change by updating the menus in the hallways.
The facility exhibited several deficiencies in food handling and hygiene practices, including improper storage of personal items with resident food, failure to wear hairnets and wash hands in the kitchen, and inadequate food storage temperatures. Additionally, thermometers were not properly sanitized between uses, increasing the risk of foodborne illnesses among residents.
The facility failed to maintain a homelike environment in four dining rooms by storing medical equipment such as hoyer lifts, vital sign monitors, and wheelchair scales in these areas. Staff, including CNAs, RNs, and the DON, confirmed that the equipment was stored in the dining rooms for convenience, despite available storage areas. Residents and staff acknowledged that this practice detracted from a homelike environment, contrary to the facility's policies.
The facility failed to remove expired, unsealed, and discontinued medications from medication carts and storage rooms. Expired IV solution bags and a vial of Humalog Lispro were found on the Valley unit, while expired Geri-Lanta and Sodium Bicarbonate were found on the Lake unit. An unsealed syringe of Lovenox was discovered on the Mount unit, and discontinued Morphine doses belonging to a discharged resident were not removed from the Lake unit's medication cart. These deficiencies were confirmed by nursing staff and the DON.
The facility failed to inform residents about the rules for leaving on pass, affecting all 129 residents. A resident felt imprisoned after being told they would be discharged if they left. During interviews, residents and staff confirmed that leaving required a physician's order, which was difficult to obtain. The DON admitted the facility did not follow its policy requiring both physician and interdisciplinary team approval for passes, and residents were not informed of these rules upon admission.
A facility failed to provide a resident or their representative with information about the right to formulate an advance directive. The resident, admitted with severe medical conditions, had no documented evidence of an advance directive or information provided about it. The DON confirmed the oversight, which contradicted the facility's policy requiring such information to be given upon admission.
The facility failed to develop care plans for three residents with specific needs, including a resident on hospice, a resident with anxiety, and a resident dependent on a respirator. The absence of care plans for these conditions was confirmed by the DON, highlighting a failure to adhere to the facility's policy requiring comprehensive care plans.
A resident's medication was left unsecured at their bedside by an LPN, who exited the room without ensuring the medication was taken. The resident, with acute osteomyelitis and COPD, was at risk of not receiving the therapeutic benefits of the medication. The DON confirmed that staff should remain with residents until all medications are taken, as per facility policy.
The facility failed to ensure accurate documentation of DNR status in electronic health records for four residents, who were incorrectly listed as 'full code' despite having POLST forms indicating DNR. Staff relied on these records during emergencies, leading to potential violations of residents' wishes. The DON confirmed the discrepancies, which contradicted the facility's policy on respecting and documenting advance directives.
A resident with type two diabetes mellitus was not provided with the ordered heart healthy consistent carbohydrate (CCHO) diet due to a failure in updating the meal card. The facility's electronic system update led to manual entry of diets, and the resident's therapeutic diet was missed, resulting in the resident receiving a regular diet instead. This discrepancy was confirmed by staff and highlighted the importance of adhering to diet orders for diabetic residents.
A resident receiving hemodialysis did not have dialysis communication forms maintained in their clinical record, as required by facility policy. Despite being sent to dialysis with a binder containing these forms, the binder did not return with the resident. The DON confirmed the absence of these forms, which are crucial for monitoring any complications during dialysis. The facility's policy mandates coordination with the dialysis center and obtaining communication sheets after each appointment, which was not followed.
A resident received an unnecessary medication due to the facility's failure to discontinue it after receiving a physician's order. The resident was prescribed two medications from the same drug class for bladder issues. Despite a physician's instruction to discontinue one of the medications, the order was not documented, and both medications continued to be administered. An LPN discovered the oversight, and the DON confirmed the expectation for staff to document and follow physician orders.
A resident with anxiety disorder was prescribed Hydroxyzine Pamoate for 14 days, but it was administered for 20 days without proper side effect or behavior monitoring. Staff interviews revealed a lack of adherence to monitoring requirements, and the DON incorrectly believed the 14-day limit did not apply to long-term residents.
A facility failed to maintain a medication error rate below 5%, with a reported rate of 19.35%. An RN administered medications to a resident with acute respiratory failure and seizures at 11:04 AM, beyond the scheduled 9:00 AM time, violating the policy of administering within one hour before or after the scheduled time. The DON confirmed this timing as late, contributing to the high error rate.
A facility failed to maintain complete and accurate records for a resident with chronic kidney disease and malnutrition due to inconsistent weighing methods. The resident's weight was recorded using different scales, leading to inaccuracies in monitoring significant weight changes. The facility's policy required consistent use of the same weighing device, which was not followed, and the CNA responsible for weighing was unavailable during the survey.
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with chronic wounds, as required by their policy, and did not ensure proper hand hygiene during medication administration for another resident. The lack of EBP signage and PPE cart for the resident with wounds and the failure of an LPN to perform hand hygiene after glove removal and between resident interactions were identified as deficiencies.
A Certified Nursing Assistant at the facility did not complete mandatory training on preventing, identifying, and reporting abuse, neglect, misappropriation of property, and exploitation since their hire. This oversight was confirmed by the Director of Human Resources, despite the facility's policy requiring such training.
Failure to Prevent Staff Verbal Abuse During Resident–CNA Altercation
Penalty
Summary
The deficiency involves the facility’s failure to maintain professional boundaries and protect a resident from verbal abuse. The affected resident was admitted with quadriplegia, immunodeficiencies, protein-calorie malnutrition, and difficulty walking, and had a BIMS score of 15 indicating intact cognition. According to a nurse’s progress note, the resident reported to the DON that they became frustrated with waiting times and began yelling and using foul language toward a CNA, and that the CNA responded in a similar manner before leaving the room. The resident later apologized and stated they were simply frustrated. Interviews with staff present during the incident confirmed that both the resident and the CNA exchanged profane language. A PTA who entered the resident’s room for a scheduled therapy session observed the resident appearing agitated and then witnessed the resident and the CNA exchanging words, including repeated use of the F word, and reported the incident to the DON. Another CNA reported hearing noise from the room, entering, and observing the resident yelling, followed by a verbal exchange between the resident and the CNA in which both used profanity before the CNA exited the room. Additional documentation and interviews described the resident as frequently becoming upset, using profane language toward staff, and having a history of behavioral issues and non-cooperation with nursing staff. An LPN recalled an incident in which the resident yelled at a staff member and stated, “I have gotten one staff fired; do you want to get fired also?” before later apologizing. Despite the resident’s known behavioral history, the CNA involved in the incident admitted to responding to the resident with profanity out of frustration, resulting in a verified incident of staff-to-resident verbal abuse and a failure by the facility to protect the resident from such abuse.
Air Conditioning Not Maintained in Resident Room Halls
Penalty
Summary
The facility failed to ensure the air conditioning units in 1300 Hall and 2300 Hall were maintained in good working condition. Resident Council Meeting Minutes documented that residents complained the air conditioning was not working in the Valley of Fire Unit and Mount [NAME] Unit, and cooling fans throughout the building did not alleviate the situation. The facility map showed these units contained resident rooms on the first and second floors, including the affected halls. A CNA stated that in June 2025 the air conditioning in some rooms on the first and second floors was shut down and not working, and that it was hot in the affected resident rooms. The CNA confirmed residents were complaining about the hot room temperature. The DON stated Resident 181 was transferred from one room to another on 05/28/2025 at 2:10 PM due to a complaint of warm temperature in the room, and the nurse's notes documented the room change from room 2201 to room 2608 at 2:11 PM. The Administrator stated an electric power surge in June 2025 shut down the air conditioning unit in 1300 Hall and 2300 Hall. The Administrator reported the facility called the contracted HVAC company immediately, but after the repair the system continued shutting down and needed to be reset every two hours. The Administrator also stated portable fans and portable air conditioning units were provided, the temperature in the resident rooms was 83 to 84 degrees Fahrenheit when the air conditioning was shut down, and around 17 residents in the two halls could have been affected, with five residents choosing to stay in the unit.
Failure to Provide Fingernail Care for Residents with Hand Contractures
Penalty
Summary
The facility failed to ensure fingernail care was provided for 4 of 40 sampled residents. Resident 10, Resident 13, Resident 12, and Resident 9 were each observed lying in bed with bilateral hand contractures and fingernails that were approximately a quarter of an inch long or longer. On 08/19/2025, two wound care nurses confirmed the long fingernails for Residents 10, 13, and 9, and the nursing supervisor assessed Resident 12 and agreed that the resident needed nail care. The nursing supervisor stated fingernail care could be provided by both nurses and CNAs, and that fingernail length and the need for trimming should be assessed during shower days. Resident 10 had diagnoses including cerebral infarction and dependence on a respirator. Resident 13 had diagnoses including chronic respiratory failure and tracheostomy. Resident 12 had diagnoses including urinary tract infection and infection/inflammation reaction due to other urinary catheter. Resident 9 had diagnoses including anoxic brain damage and dependence on a respirator. On 08/21/2025, an RN stated CNAs were responsible for fingernail care and that nail care should be provided during shower days, and acknowledged long nails could dig into skin and cause a wound for a resident with hand contractures. The ADON later inspected Resident 12’s hands and confirmed the fingernails were long and could use trimming. The Infection Preventionist stated nail care was important for proper hygiene and that long nails could harbor microorganisms and pose an infection risk. The facility policy titled Nail Care, adopted 05/01/2024, stated it was the policy of the facility to promote cleanliness, safety, and neat appearance of residents.
PRAFO Boots Not Implemented as Ordered
Penalty
Summary
The facility failed to ensure a physician order for bilateral lower extremity PRAFO boots was implemented as ordered for two residents. One resident had diagnoses including cerebral infarction and dependence on a respirator, and the other had diagnoses including anoxic brain damage and dependence on a respirator. A physician order dated 08/13/2025 directed both residents to wear bilateral lower extremity PRAFO boots as needed for contracture management, every shift. During multiple observations on 08/19/2025, 08/20/2025, 08/21/2025, and 08/22/2025, both residents were observed not wearing the PRAFO boots. Staff interviews indicated the boots were intended to prevent heel ulcers and foot drop and were to be applied by nursing staff or CNAs. Review of the MAR showed the licensed nurse did not sign off that the boots were applied as ordered, and the ADON and DON confirmed the physician order was not transcribed to the MAR and no documentation of application was present.
Missed Monthly Foley Catheter Changes
Penalty
Summary
The facility failed to ensure a physician order for monthly urinary catheter change was completed for one sampled resident who had diagnoses including urinary tract infection and infection/inflammation reaction due to another urinary catheter. The resident was observed in bed with urinary tubing and a collection bag hanging on the side of the bed. A physician order dated 05/01/2025 directed that the indwelling Foley or suprapubic catheter be changed every 30 days on the 1st day of the month, with Foley catheter care/maintenance provided daily starting on the 1st and ending on the 1st of each month. The resident’s comprehensive care plan, revised 08/07/2025, documented use of an indwelling catheter and risk for trauma, infection, and other complications related to obstructive uropathy. The MAR lacked documented evidence that the catheter was changed for June and July 2025. An RN confirmed the June and July catheter-change orders were not signed off as completed and stated that if the catheter was not changed, the nurse should notify the physician and document the reason in the progress note. The ADON and DON also reviewed the record and confirmed there was no documented evidence explaining why the catheter changes were not completed as ordered.
Missing Physician Orders for IV Access Care and Maintenance
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids when needed was deficient for one resident who was re-admitted with diagnoses including urinary tract infection and chronic respiratory failure. On observation, the resident was seen with two IV lines: a right upper arm IV access with two ports and a left mid arm IV access with one port. The medical record did not contain documented evidence that a physician order had been obtained for the care and maintenance of either IV access. On subsequent observation, both IV lines were still present. The left arm heplock was not dated, and the right arm PICC line dressing was dated 08/03/2025. An LPN confirmed the two IV lines were present and verified in the EMR that there were no physician orders for either line. The LPN also stated the PICC dressing should have been replaced when the resident was re-admitted and that orders to maintain the IV accesses should have been initiated upon return from the hospital. The DON later reviewed the orders and confirmed the IV access orders were entered on 08/20/2025, agreeing they should have been placed when the IV access was identified during the readmission nursing assessment.
Failure to Obtain Ordered Glaucoma Eye Drops
Penalty
Summary
The facility failed to provide Bimatoprost Ophthalmic Solution 0.01% as ordered for a resident with glaucoma. The resident was admitted with diagnoses including abscess of the liver, was responsible for self and medical decisions, and had good memory function on the MDS. On 08/22/2025, the resident stated that routine home medications included an eye drop used at bedtime to control glaucoma and reported asking the facility to furnish it, but said the medication had not been received. The resident also expressed concern about being at risk of visual loss if the medication was not used consistently. A physician order dated 08/08/2025 directed that Bimatoprost Ophthalmic Solution 0.01% be instilled as 1 drop in both eyes at bedtime for increased ocular pressure. The order audit showed the medication was ordered on 08/08/2025 and reordered on 08/13/2025, but on 08/22/2025 it was still listed as on order and there was no documented evidence that it had been delivered. The ADON was unable to locate the eye drop on the unit and stated staff had attempted to order it, but it had not been delivered. The ADON spoke with a pharmacist who said the request had not been filled because a prescription was needed and had not been provided. The ADON stated 14 days had passed since the order was received and that the lack of medication should have been addressed within a day or two. The DON verified the medication had been ordered but not obtained, and stated the eye drop was used to prevent raised intraocular pressure and needed to be given consistently.
Failure to Maintain EBP and Water Management Program
Penalty
Summary
Enhanced barrier precautions were not maintained during care for one resident who was re-admitted with diagnoses including urinary tract infection and pneumonia due to gram negative bacteria. The resident’s physician ordered enhanced barrier precautions for tracheostomy, ventilator, gastrostomy tube, and indwelling Foley catheter care. During observation, a CNA was seen emptying the resident’s Foley catheter bag while wearing gloves but not a gown. When interviewed, the CNA stated a gown should have been worn for emptying a Foley catheter bag for a resident on enhanced barrier precautions and acknowledged the risk of splatter and cross contamination. The Infection Preventionist stated staff had been educated on transmission-based precautions and the appropriate PPE to use during care activities, and acknowledged that not following these precautions posed a risk of cross contamination for residents and staff. The facility also failed to implement provisions in its water management program for prevention of Legionella growth. The Administrator stated the Maintenance Director was responsible for the water management plan, and the Maintenance Director said the facility had a water management plan but did not think it addressed Legionella, noting the facility intended to include Legionella in the plan the following month. The Infection Preventionist was not familiar with the water management plan. Review of the program showed it cited the CDC toolkit, but many required components were missing, including a text and diagram of water flow in the building, specific locations and numbers for applicable risks such as showerheads, ice machines, water heaters, and eyewash stations, and documentation of required temperature checks, monthly ice machine inspections, weekly sanitizing of medical devices, and annual review of the program.
Resident Not Protected from Abuse by CNA
Penalty
Summary
A resident with multiple chronic conditions, including type 2 diabetes mellitus, chronic obstructive pulmonary disease, end stage renal disease, and heart failure, was re-admitted to the facility. The resident reported that a Certified Nursing Assistant (CNA) took away their room phone after the resident repeatedly called the front desk. The CNA admitted to unplugging the phone and placing it out of the resident's reach, instructing the resident to stop calling downstairs. The facility's investigation substantiated the allegation of abuse, documenting that the CNA willfully inflicted punishment, resulting in the resident's mental anguish. The resident described the CNA as being bossy and giving attitude, stating that the CNA was upset due to frequent use of the call light and phone. The resident's behavioral care plan noted distress related to feelings of powerlessness and difficulty adjusting to life in the facility, with interventions focused on calm communication and staff professionalism. During the incident, the resident still had access to their cell phone and call light. The facility's policy requires an environment free from abuse, corporal punishment, involuntary seclusion, and other forms of mistreatment. The deficiency was identified through interviews, record review, and documentation, confirming that the resident was not protected from abuse as required.
Failure to Implement Abuse Prevention Policies Following Substantiated Abuse Incident
Penalty
Summary
A deficiency occurred when a staff member failed to implement the facility's abuse prevention policies and procedures for a resident who had multiple medical conditions, including type 2 diabetes mellitus, chronic obstructive pulmonary disease, end stage renal disease, and heart failure. The incident involved a Certified Nursing Assistant (CNA) who admitted to taking away the resident's room phone and placing it out of reach after the resident repeatedly called the front desk. This action was substantiated as abuse, as it resulted in the resident experiencing mental anguish. Interviews and record reviews revealed that, despite the facility's policy requiring ongoing abuse prevention training, staff did not receive additional abuse training following the incident. While some staff recalled completing annual abuse and neglect training, others could not remember when such training last occurred. The Director of Nursing acknowledged that ongoing abuse training should have been provided in response to the event, as outlined in the facility's policy, but this did not happen.
Resident Directed to Urinate in Brief, Violating Dignity
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect, as evidenced by staff directing a resident to urinate in their incontinence brief. This deficiency was observed in one of the sampled residents, who was admitted with diagnoses including hypertension, end-stage renal disease with hemodialysis, and congestive heart failure. During interviews, a CNA acknowledged that staff are not supposed to instruct incontinent residents to use their briefs as a bathroom, but admitted it does occur. Another resident confirmed having been told to urinate on themselves in the past, expressing feelings of upset and noting that other residents have experienced similar instructions. The affected resident reported that a CNA on the night shift instructed them to urinate in their brief if they had to wait for assistance, which caused emotional distress. The Director of Nursing confirmed that such instructions are inappropriate and result in dignity issues.
Discharge Planning Deficiency Due to Appeal Decision Discrepancy
Penalty
Summary
The facility failed to clarify discrepancies in the appeal decision for a resident's discharge, resulting in a lack of well-coordinated discharge planning. The resident, who had difficulty walking and other lower extremity issues, was discharged without the necessary skilled therapy to improve functional ability. The appeal decision inaccurately stated that the resident could walk 100 feet without an assistive device, which was not consistent with the resident's actual condition as documented by the Director of Rehabilitation and the Interdisciplinary Team. The facility did not review the appeal decision before providing it to the resident, leading to a discharge without proper coordination of care. The case manager did not document discussions with the resident and their spouse regarding the discharge plan, and caregiver training did not occur because the spouse was unable to provide care. The resident was financially overqualified for Medicaid services and declined additional placement options, leading to a decision to discharge home with hospice services. The lack of documentation and coordination in the discharge process resulted in a deficiency, as the facility did not ensure the resident received the necessary provisions for continuation of care.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that showers were provided as scheduled for a resident diagnosed with major vascular neurocognitive disorder-dementia. The resident required minimal assistance with showering and was scheduled to receive showers twice a week, on Mondays and Thursdays. However, documentation revealed that the resident did not receive a shower or bed bath on the scheduled days for several weeks, including the week of January 11 through January 15, and on January 18 and January 22. The only recorded instances of hygiene care were a bed bath on January 8 and a shower on January 16. Interviews with staff members indicated that if a resident refused a shower or bed bath, the CNAs were expected to notify the nurse and document the event. However, there was no documentation of refusals or alternative hygiene care being provided on the missed days. The Director of Nursing confirmed that the facility's policy was to accommodate residents' preferences and provide bed baths if showers were refused. Despite this policy, the resident's hygiene needs were not met according to the established schedule, leading to a deficiency in care.
Improper Storage of Oxygen Cylinders in Resident Room
Penalty
Summary
The facility failed to ensure the safe storage of two free-standing portable oxygen cylinders in a resident's room, which were left unattended. During an observation, it was noted that one cylinder was empty and the other was half full. The resident was unaware of the reason for the presence of the oxygen cylinders in their room. A Certified Nursing Assistant (CNA) confirmed that the cylinders were placed correctly but should have been stored in the closet with other oxygen cylinders. The CNA was not aware of the status of the cylinders, whether they were empty or not. A Registered Nurse (RN) stated that oxygen cylinders should be on a stand or taken by Respiratory Therapy to be stored in the closet with empty cylinders. Another RN explained that oxygen cylinders are typically left in the oxygen storage room unless needed for resident transport, and if kept in a resident's room, they should be placed on a stand for storage. The facility's policy on oxygen handling and storage, last revised in 2024, requires that oxygen cylinders be secured to a wall with a chain or cable or stored in a stationary rack. The Director of Nursing (DON) confirmed that oxygen cylinders should never be left free-standing inside a resident's room or hallway without proper storage.
Medication Security Lapse for a Resident
Penalty
Summary
The facility failed to ensure the security of medications for one resident, which was identified during an observation. A white/pink cream in a medication cup was left unattended on the dresser of a resident's room. The resident had been admitted with multiple diagnoses, including type II diabetes mellitus with diabetic neuropathy, hypertension, and chronic kidney disease. The Registered Nurse confirmed that the medication cup should not have been left in the resident's room. The Wound Care Nurse also stated that only they were authorized to apply the Moisture Barrier Cream with Zinc 10% and that it should not be left in the resident's room. The treatment administration record indicated that the cream was applied by the wound care nurse earlier that morning.
Menu Not Followed for Breakfast Service
Penalty
Summary
The facility failed to adhere to the planned menu for a breakfast service, which had the potential to affect all residents. On the morning of September 26, 2024, breakfast was delivered to residents in the Valley of Fire Unit, consisting of cereal, fruit, pancakes, and sausage. However, the menu for that day was supposed to include assorted juice, a choice of hot or cold cereal, cheesy eggs, hashbrowns, banana, toast, margarine or jelly, and milk or another beverage. The breakfast served was actually intended for the following day, Friday, which included pancakes and sausage. The Dietary Manager explained that the cook mistakenly prepared the Friday menu instead of the Thursday menu due to looking at the wrong day on the menu. The facility's policy on Honoring Resident Choice and Self-Directed Living at Meals stated that residents should be offered all food and beverage components planned in the approved menu. This error in following the menu was acknowledged by the Dietary Manager, who mentioned that residents would be informed of the change by updating the menus in each unit hallway.
Deficiencies in Food Handling and Hygiene Practices
Penalty
Summary
The facility failed to adhere to proper food storage and handling practices, as evidenced by multiple observations and interviews. A dietary aide's purse was found stored with resident food in the dry storage area, despite previous warnings from the Dietary Manager. This practice was acknowledged by both the Dietary Aide and the Administrator as a potential source of contamination, yet no specific policy was in place to prevent personal items from being stored with food. Additionally, staff failed to comply with hygiene protocols in the kitchen. An LPN entered the kitchen without wearing a hairnet and did not wash hands upon entry, contrary to the facility's policy on employee hygiene. Similarly, a Dietary Aide donned gloves without washing hands first, which was confirmed as a breach of protocol by the Dietary Manager. These lapses in hygiene practices increase the risk of foodborne illnesses among residents. The facility also did not maintain safe food storage temperatures, as observed with a refrigerator in the satellite kitchen. The refrigerator's thermometer was malfunctioning, and internal temperatures of stored food items were above the safe threshold of 41°F. Furthermore, the improper sanitation of thermometers between uses was noted, with a Dietary Aide using a dirty rag to wipe the thermometer, potentially contaminating food. These deficiencies in food handling and storage practices pose a significant risk to resident safety.
Inappropriate Storage of Medical Equipment in Dining Rooms
Penalty
Summary
The facility failed to maintain a comfortable, homelike environment in four dining rooms by storing medical equipment in these areas, which is against the facility's policies. Observations revealed that various medical equipment, including hoyer lifts, vital sign monitors, wheelchair scales, and other items, were stored in the Lake [NAME], Red Rock, Valley of Fire, and Mount [NAME] dining rooms. Interviews with staff, including CNAs, RNs, and the Director of Nursing, confirmed that the equipment was stored in the dining rooms for staff convenience, despite the availability of designated storage areas such as cubbies in hallways and rooms adjacent to the dining areas. Residents and staff acknowledged that the presence of medical equipment in the dining rooms detracted from a homelike environment. A resident eating breakfast in the Lake [NAME] dining room noted the constant presence of medical equipment, while a CNA and a Respiratory Therapist confirmed the inappropriate storage practices in the Red Rock dining room. The Director of Nursing and the Administrator admitted that storing medical equipment in dining areas was a common practice, which they had not previously considered as detrimental to creating a homelike environment for residents. The facility's policies emphasize the importance of maintaining residents' dignity and providing comfortable dining areas, which were not adhered to in this instance.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure that expired medications were removed from medication carts and storage rooms, as observed during inspections. On the Valley of Fire unit, three IV solution bags containing Pantoprazole and a vial of Humalog Lispro were found to be expired. These items were confirmed by an LPN to be past their expiration dates and were subsequently moved to a designated bin for expired or discontinued medications. Additionally, on the Lake unit, a bottle of Geri-Lanta and a bottle of Sodium Bicarbonate were found to be expired and should have been removed from the medication carts prior to their expiration dates. An unsealed medication was also found during an inspection of a medication cart on the Mount unit. A syringe of Lovenox was discovered with a broken seal, which was confirmed by an LPN to be inappropriate for storage in the medication cart. The LPN explained that the medication should have been discarded as the broken seal could indicate contamination or compromise the safety of the medication. Furthermore, discontinued medications were not removed from a medication cart on the Lake unit. Four doses of Morphine belonging to a resident who had been discharged were found stored in the cart. The RN present during the inspection explained that the Morphine was discontinued and was being stored until it could be given to a unit manager for disposal. However, there was no specific timeframe for when this should occur, and the medication had been discontinued the previous month. The facility's Director of Nursing confirmed that it was the facility's process to discard outdated, expired, or discontinued medications, and that medications belonging to discharged residents should have been removed and discarded.
Failure to Inform Residents of Leave Policies
Penalty
Summary
The facility failed to inform residents both orally and in writing about the rules related to leaving the premises on pass, which had the potential to affect all 129 residents. Resident #347, admitted for surgical aftercare, expressed feeling imprisoned due to being told they would be discharged if they left the facility. During a resident council interview, five residents reported being informed that leaving the facility would be considered against medical advice (AMA) and result in discharge unless they obtained a physician's permission. Staff, including a CNA and an LPN, confirmed that residents needed a physician's order to leave and that recent changes had made it difficult for residents to obtain such permission. The Director of Nursing (DON) acknowledged that the facility's policy required both the physician and the interdisciplinary team to determine if a resident could leave on pass, but this was not being followed. The DON admitted that residents were not informed of the facility's rules regarding leaving on pass upon admission, nor was there documentation to support that residents were informed of these rules. The facility's admission packet lacked evidence of written communication about the rules and processes for going out on pass, and the facility policy indicated that the decision should involve both the physician and the interdisciplinary team.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that a resident or their representative was provided with information about the right to formulate an advance directive. This deficiency was identified for one of the 29 sampled residents, who was admitted with diagnoses including anoxic brain damage, acute respiratory failure with hypoxia, and severe persistent asthma with acute exacerbation. The clinical record for this resident lacked documented evidence of an advance directive or any information provided to the resident or their representative regarding the right to formulate one. On a specific date, the Director of Nursing confirmed that the facility had not determined if the resident had an advance directive or if the necessary information had been provided. The facility's policy, adopted earlier in the year, required that residents and/or their representatives be informed of advance directive options upon admission, with documentation of this information in the resident's record.
Deficient Care Planning for Residents with Specific Needs
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents with specific needs, leading to deficiencies in care. Resident #57, who was admitted with diagnoses including psychotic disorder and depression, was placed on hospice care without a corresponding care plan. This lack of documentation left the resident confused about the care being provided and was confirmed by the Director of Nursing (DON) as a potential health risk. Similarly, Resident #15, diagnosed with an anxiety disorder and prescribed Hydroxyzine Pamoate for anxiety management, did not have a care plan addressing their anxiety or the medication. Both a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN) acknowledged the absence of a care plan for anxiety, which was expected to be included according to the DON. Resident #69, who was dependent on a respirator due to acute respiratory failure and pneumonia, also lacked a care plan addressing their respiratory needs. The care plan had not been updated to include objectives, goals, and interventions for the resident's respirator dependence. The DON confirmed that without a care plan, staff would be unable to implement the necessary care and services for the resident. The facility's policy required the interdisciplinary team to develop and revise comprehensive care plans as residents' needs changed, which was not adhered to in these cases.
Medication Administration Deficiency
Penalty
Summary
The facility failed to meet professional standards of medication administration by leaving medications unsecured at a resident's bedside. Specifically, a Licensed Practical Nurse (LPN) prepared medications for a resident, including ClearLax mixed in water, and placed them on the resident's bedside table. The LPN remained with the resident while they took oral tablet medications but left the room with the ClearLax still on the bedside table, contrary to the facility's policy and the Director of Nursing's (DON) expectations. The resident involved had been admitted and readmitted to the facility with diagnoses including acute osteomyelitis and chronic obstructive pulmonary disease. The incident occurred when the LPN exited the room without ensuring the resident had taken the ClearLax, which was left unsecured. The DON confirmed that nursing staff are expected to remain with residents until all medications are taken to ensure they receive the therapeutic benefits prescribed. The facility's policy mandates that medications should only be accessible to authorized staff and stored securely.
Discrepancy in Code Status Documentation for DNR Residents
Penalty
Summary
The facility failed to ensure that the code status of 'Do Not Resuscitate' (DNR) was accurately documented in the electronic health records for four residents. These residents were documented as 'full code' in their electronic charts, which indicated they were to receive cardiopulmonary resuscitation (CPR) in an emergency, despite having Provider Orders for Life-Sustaining Treatment (POLST) forms indicating DNR status. This discrepancy was identified for residents with various medical conditions, including psychotic disorder, anoxic brain damage, cerebrovascular disease, and surgical aftercare. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) revealed that staff relied on the electronic health records to determine a resident's code status during emergencies. The DON confirmed that the POLST forms and electronic health records should match, and acknowledged the discrepancies for the four residents. The facility's policy on advance directives stated that a resident's choice should be respected and accurately documented, but this was not adhered to, leading to the potential for residents with DNR status to receive unwanted life-saving measures.
Failure to Provide Ordered Therapeutic Diet
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered for a resident diagnosed with type two diabetes mellitus. The resident was admitted and readmitted with a physician's order for a heart healthy consistent carbohydrate (CCHO) diet. However, the resident's meal card documented a regular diet instead of the prescribed CCHO diet. This discrepancy was confirmed by both a Certified Nursing Assistant and the Dietary Manager, who acknowledged that the resident was served a regular diet, contrary to the physician's order. The Dietary Manager explained that the facility's electronic system, which transfers diet orders from the electronic health record to the kitchen's system, had undergone an update that disrupted the automatic updating of diet orders. As a result, the kitchen staff had to manually enter diets, and the resident's therapeutic diet was missed. The Dietician emphasized the importance of serving CCHO diets to stabilize sugar levels for diabetic residents. The facility's policy required regular verification of diet orders, but this was not adhered to, leading to the resident receiving an inappropriate diet.
Failure to Maintain Dialysis Communication Forms
Penalty
Summary
The facility failed to obtain and maintain dialysis communication forms for a resident receiving hemodialysis, which is essential for ensuring continuity of care. The resident, who was admitted with diagnoses including end-stage renal disease and heart failure, had a physician's order for hemodialysis three times a week. Despite this, the clinical record lacked evidence of dialysis communication forms being sent with the resident to dialysis appointments and returned to the facility. This deficiency was identified during a review of the resident's care plan and clinical records. The Director of Nursing (DON) confirmed that the facility could not locate any dialysis communication forms for the resident. The resident was reportedly sent to dialysis with a binder containing these forms, but the binder did not return with the resident. A call to the dialysis clinic revealed that the resident did not bring the binder to the appointment. The DON acknowledged that the absence of these forms could put the resident's health at risk, as staff would be unaware of any complications during dialysis that needed monitoring. The facility's policy required coordination with the dialysis center and obtaining communication sheets after each appointment, which was not adhered to in this case.
Failure to Discontinue Unnecessary Medication
Penalty
Summary
The facility failed to discontinue a medication for a resident after receiving an order to do so, resulting in the resident receiving an unnecessary medication. The resident, who was admitted with diagnoses including osteomyelitis of the vertebra and neuromuscular dysfunction of the bladder, was prescribed two medications from the same drug class: Oxybutynin Chloride and Tolterodine Tartrate. Both medications were intended to treat the resident's overactive bladder and urinary issues. Despite receiving a physician's order on 08/29/2024 to discontinue Tolterodine and continue Oxybutynin, the order was not entered into the resident's clinical record, and both medications continued to be administered until 09/25/2024. The deficiency was identified when an LPN, upon reviewing the resident's medication orders, noticed the duplication and contacted the physician for clarification. The LPN found a previous message on the unit's mobile phone indicating the physician's instruction to discontinue Tolterodine. However, this order was not documented in the resident's record, nor was a progress note made. The Director of Nursing confirmed that the expectation was for staff to enter such orders into the clinical record and follow them accordingly. The facility's policy on drug administration, adopted earlier in the year, required medications to be administered as prescribed by the physician.
Failure to Monitor and Limit Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper monitoring and limitation of a psychotropic medication for a resident diagnosed with anxiety disorder. The resident was prescribed Hydroxyzine Pamoate 25 mg to be administered as needed for anxiety, with an expected duration of 14 days. However, the medication was administered beyond this period, from 08/14/2024 through 09/15/2024, and the order remained active until 09/26/2024. There was no evidence of side effect or behavior monitoring related to the medication, and the resident's comprehensive care plan lacked documentation for anxiety management, including the use of Hydroxyzine Pamoate. Interviews with facility staff, including a CNA, an LPN, and the DON, revealed a lack of awareness and adherence to the requirements for monitoring psychotropic medications. The CNA was unaware of the need to monitor the resident's anxiety, while the LPN and DON confirmed the absence of orders for side effect and behavior monitoring, as well as a care plan related to the medication. The DON mistakenly believed that the 14-day limitation for as-needed psychotropic medications did not apply to long-term residents. The facility's policy on psychoactive drug use, which mandates a 14-day limit and monitoring of adverse reactions, was not followed in this case.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported error rate of 19.35% based on 31 medication administration opportunities and 6 errors. This deficiency was identified through observation, interviews, clinical record reviews, and document reviews. Specifically, the report highlights an incident involving a resident who was admitted with acute respiratory failure with hypoxia and other seizures. On a particular day, a Registered Nurse (RN) prepared and administered several medications to this resident through a feeding tube, including Cholecalciferol, Docusate Sodium, Enoxaparin Sodium, Keppra, Valproic Acid, and Metoprolol. These medications were scheduled to be administered at 9:00 AM. However, the RN administered the medications at 11:04 AM, which was beyond the facility's policy of administering medications within one hour before or after the scheduled time. The Director of Nursing (DON) confirmed that medications administered after 11:00 AM, with a scheduled time of 9:00 AM, would be considered late. The facility's policy, adopted in May 2024, required medications to be administered in accordance with the physician's orders and within the specified time frame unless otherwise directed by the physician. This failure to adhere to the scheduled administration times contributed to the high medication error rate identified in the facility.
Inconsistent Weighing Methods Lead to Inaccurate Resident Records
Penalty
Summary
The facility failed to ensure that resident records were complete and accurate for one of the sampled residents, identified as Resident #80. This deficiency was identified through interviews, clinical record reviews, and document reviews. Resident #80, who had diagnoses including chronic kidney disease, severe protein-calorie malnutrition, and muscle wasting, was admitted and readmitted to the facility on unspecified dates. The resident's weight records showed inconsistencies in the method used for weighing, alternating between a sitting scale, weights taken during dialysis, and a wheelchair scale. This inconsistency in weighing methods led to inaccurate weight records, which are crucial for monitoring the resident's nutritional status and determining significant weight changes. The facility's policy required that weights be obtained using the same device on each weigh date to ensure accuracy. However, the Registered Dietician confirmed that Resident #80 was not weighed using a consistent method, making it impossible to determine accurate weight gain or loss. Additionally, the CNA responsible for taking resident weights was not located in the facility at the time of the survey. The facility's documentation policy also required that all services and care be documented completely and accurately, which was not adhered to in this case, leading to the deficiency.
Infection Control Deficiencies in EBP and Hand Hygiene
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with chronic wounds, identified as Resident #292. This resident was admitted with diagnoses including localized swelling and chronic venous hypertension with ulcers. Observations revealed that the resident's room lacked EBP signage and a personal protective equipment (PPE) cart, which are necessary to limit the spread of infections. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that EBP was required for residents with chronic wounds, but it was not implemented for Resident #292 upon admission, despite the facility's policy indicating the need for such precautions. Additionally, the facility did not ensure proper hand hygiene during medication administration for another resident, identified as Resident #82. An LPN failed to perform hand hygiene after exiting the resident's room, before donning gloves, and after doffing gloves, which is against the facility's hand hygiene policy. The DON confirmed that hand hygiene was required before and after nursing interventions and after glove removal. These lapses in infection control practices had the potential to spread infectious illnesses to all residents.
Failure to Complete Abuse Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant, hired on 10/17/2023, completed mandatory training on preventing, identifying, and reporting abuse, neglect, misappropriation of property, and exploitation. This deficiency was identified during a review of employee records, document review, and interviews. Specifically, Employee #8's record lacked documented evidence of having completed the required abuse training since their hire date. The Director of Human Resources confirmed this oversight on 09/25/2024. The facility's policy, revised on 09/13/2022, mandates that staff receive training related to the prohibition, prevention, identification, recognition, and reporting of resident abuse, neglect, misappropriation of property, and exploitation.
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What surveyors actually found near you
We read the 520 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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 Las Vegas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spanish Hills Wellness Suites | 0.7 mi | ★★★★★ | 26 | 0 |
| Advanced Health Care Of Las Vegas | 1.5 mi | ★★★★★ | 10 | 0 |
| Canyon Vista Post Acute | 2.9 mi | ★★★★★ | 16 | 0 |
| Torrey Pines Post Acute And Rehabilitation | 4.6 mi | ★★★★★ | 7 | 0 |
| Silver Ridge Healthcare Center | 5 mi | ★★★★★ | 14 | 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 July 2026) and official state health department websites.