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 Silver Hills Health Care Center during CMS and state inspections, most recent first.
A resident with dementia reported that a staff member, described as a friend, used the resident's bank card to withdraw cash, resulting in unauthorized withdrawals and missing items. The facility did not thoroughly investigate the incident, failed to document interviews with the CNA involved, and did not report the CNA to the State Board of Nursing as required by policy.
A resident with Alzheimer's disease and dementia had an allegation of misappropriation of property documented by nursing staff, but the facility did not report the incident to the State Agency within the required timeframe. Staff interviews confirmed knowledge of the policy requiring immediate reporting, but the process used—entering information into the electronic health record—resulted in a delay, and the report was not submitted until two days after the allegation was documented.
Sanitizer Solution Below Required Concentration in Kitchen Sink: The facility did not ensure dishware was sanitized according to food safety protocols in the main kitchen’s 3-compartment sink area. An ADDS and the DODS performed sanitizer strip tests that showed no color change or a faded brown color, and the DODS confirmed the solution measured below the required concentration, with less than 150 ppm instead of the required 200-400 ppm. The facility policy required immersion for at least 30 seconds in a quaternary ammonia sanitizing solution at 220 ppm or hotter.
Missing or outdated psychotropic medication consent forms were found for three residents receiving psychotropic meds. One resident had Quetiapine reduced with no new consent for the changed dose, another had Quetiapine increased without a new consent, and a third had Risperdal ordered with no informed consent in the chart. LPNs stated consent should be obtained when the resident can understand it and that dose changes require a new form; the DON confirmed the missing consents.
A resident with distal tibial impacted fracture and MS reported a fall from a chair, and the record showed swelling, pain, and a change in condition with x-ray and non-weight bearing orders. Although the resident had a fall risk care plan, the record lacked evidence that it was updated to reflect the actual fall, and an LPN and the DON stated care plans should be updated after a fall or change in condition.
Missing Orders for Central and Peripheral Line Care: A resident had both a central line and a peripheral IV line, but staff were unaware of the lines and the record contained no physician orders for flushing, dressing changes, or site monitoring. The RN confirmed the peripheral dressing was peeling and undated, and the central line dressing date was illegible. The DON and NP both confirmed the lack of maintenance orders, while the facility policy addressed dressing changes for IV sites.
A resident with asthma, COPD, hypertensive heart disease, and anemia kept yogurt in a mini fridge-like unit for medication, but the unit did not keep items cold like a traditional refrigerator. The ADON found no temp log and no thermometer in the unit, and the fridge measured 64°F while the yogurt measured 60°F. Facility policy required internal thermometers and staff monitoring/documentation of personal food storage units, and the DON and Administrator acknowledged the yogurt was not safe for consumption at that temperature.
Incomplete and Missing Resident Medical Records: The facility failed to keep complete and accurate medical records for three residents. Hard charts were missing key documents such as the face sheet, MAR, advanced directives, order summary, and H&P, and one RN was unaware a resident had a central line because the record lacked treatment orders and other required information. The Medical Records Supervisor and DON confirmed the missing records and stated the required items were not stored in the Medical Records Dept.
Missing QAPI Plan: The facility failed to have a specific QAPI plan in place and instead used its QAPI policy as the plan. The Administrator acknowledged the absence of a tailored QAPI plan and stated that the plan should reflect the facility’s specific units, programs, departments, and resident population as identified in the facility assessment.
Enhanced barrier precautions were not in place for two residents with invasive devices, including a resident with a feeding tube and a resident with a dialysis access site. Staff were observed providing care without the required PPE, and an LPN changed a dialysis dressing without hand hygiene between glove changes and without wearing a gown. Staff were also observed entering contact precaution rooms without proper PPE or hand hygiene, and the infection prevention manual in use was last updated in May 2024.
A resident was found with melatonin gummies at their bedside without a completed assessment or physician's order for self-administration. The RN was unaware of the medication, and the DON confirmed the lack of necessary documentation and approval. Facility policy requires a nurse's evaluation, interdisciplinary assessment, physician's approval, and secured storage for self-administration, which were not followed.
A resident reported rough handling and rude behavior by staff during care, but the facility failed to conduct a thorough investigation. The Social Services Assistant identified the staff member involved, and the Director of Nursing adjusted the staff schedule. However, no interviews with staff or other residents were conducted, and the facility did not complete a thorough investigation as required by their policy.
The facility failed to document adequate discharge planning for two residents, leading to deficiencies in ensuring safe discharges. One resident with multiple medical conditions did not have documented discharge planning before a Medicare Non-Coverage notice, and the second resident with paralysis had discharge planning notes kept on a personal tracker, not in the medical record. The facility lacked a formal discharge planning policy.
A resident with a fracture and muscle weakness required maximal assistance for bathing. The facility failed to adhere to the scheduled twice-weekly bathing, as documentation showed missed bathing days. Staff confirmed the schedule, but records lacked entries for several days, indicating a deficiency in care.
The facility failed to properly label, date, and store food and cleaning agents, and did not maintain clean ice machines. Expired water cartons were found in the cooler, and a spray bottle with an unidentified liquid was improperly stored. Ice machines had debris buildup, indicating a failure to maintain sanitary conditions.
The facility failed to provide necessary assistance with ADLs for three residents, leading to potential health risks. One resident was not repositioned or assisted during night shifts, another was left in urine for hours, and a third was not checked or changed for long periods. The MDS Director and DON confirmed the lack of documentation and assistance.
A resident with a pulmonary embolism did not receive their prescribed Lovenox medication on time due to it being out of stock. An LPN was unable to find the medication in the cart or back-up supply, leading to a delay of more than 12 hours in administration. The physician noted that this delay increased the risk of another embolism. The facility's policy lacked guidance on managing low or unavailable medications.
A resident with muscle wasting and weakness was not administered Gabapentin as scheduled, compromising pain management. The medication was often given outside the prescribed one-hour window, as confirmed by the DON and an LPN, contrary to the facility's policy.
The facility failed to properly label and store personal food items brought in by family or visitors for two residents. Despite being within the manufacturer's expiration date, food items were discarded after three days, causing frustration for residents with specific dietary needs. The facility's policy required prepared food to be consumed within three days, but unopened items with manufacturer dates should not have been relabeled or discarded prematurely. This inconsistency led to the improper handling of residents' food.
A facility failed to follow infection control practices when an LPN administered a contaminated pill to a resident. The pill fell onto the bedding, and the LPN, unaware of the facility's policy, picked it up with bare hands and gave it to the resident. The facility's policy lacked specific guidance on handling contaminated medications.
A resident identified as high risk for falls did not receive appropriate fall interventions upon admission, leading to a fall incident. The facility failed to investigate the fall circumstances or notify the physician and family in a timely manner. Additionally, after the resident returned from the hospital with a fractured wrist, the facility did not complete an assessment or obtain care orders to manage the injury.
A resident with chronic conditions was found unresponsive, and an anonymous report alleged that the DSD did not perform CPR when needed. The Administrator recognized this as an allegation of neglect but did not report it to the state agency, contrary to facility policy. An investigation was conducted, and the DSD was suspended during this process.
A facility failed to develop a baseline care plan within 48 hours for a resident at high risk for falls, who had a history of falling and was diagnosed with conditions like Parkinson's disease and muscle weakness. Despite a high fall risk assessment score, the care plan was not formulated, as confirmed by staff interviews. The facility's policy required such a plan, but it was not implemented, leading to inadequate management of the resident's fall-related injuries.
A resident, admitted with a right femur fracture and head contusion, required maximum assistance with bathing. The DON confirmed that the resident's showers were scheduled twice weekly, but there was no documentation of showers or bed baths being provided or refused on two occasions. A family member reported the missed showers, and the facility's ADLs policy required care based on comprehensive assessments.
A facility failed to properly assess and document a resident's surgical incision site and skin condition, resulting in a deficiency. The resident had a right femur fracture with surgical incisions and staples, but the location of the staples was unclear. Physician orders for wound care were not followed with thorough assessments or documentation. Interviews revealed that the wound team did not complete baseline or weekly skin assessments as required by facility policy.
A resident with a surgical wound on the right hip did not receive wound care treatment as ordered, leading to a deficiency in care. The treatment was scheduled for specific days but was not performed on one occasion, despite being documented as completed. The lapse was confirmed by the Wound Coordinator and Wound Care Treatment Nurse, and the importance of timely wound care was emphasized by the Wound Care Nurse Practitioner.
Failure to Investigate and Report Staff Misappropriation of Resident Property
Penalty
Summary
The facility failed to conduct a thorough investigation and did not report an allegation of misappropriation involving a certified nursing assistant (CNA) to the State Board of Nursing. A resident with Alzheimer's disease and dementia was found to have multiple twenty dollar bills and explained to a nurse that a staff member, identified as a friend, had used the resident's bank card to withdraw cash. The nurse documented the incident and secured the cash, but the debit card was not returned. Further review revealed that the staff member, who was assigned to care for the resident and spouse, had also taken other items such as a garage remote and keys, and significant unauthorized withdrawals and expenses were made from the resident's account. The facility's investigation file lacked documentation of interviews with the CNA, did not identify the CNA as the resident's friend, and did not include a determination of the outcome of the in-house investigation. Additionally, there was no evidence that the CNA was reported to the State Board of Nursing, despite facility policy requiring notification of relevant licensing boards when an employee is found to have committed abuse, neglect, exploitation, or misappropriation. The deficient practice had the potential to place all residents at risk for unreported financial exploitation.
Delayed Reporting of Misappropriation Allegation
Penalty
Summary
The facility failed to ensure that an allegation of misappropriation of resident property involving a certified nursing assistant was reported to the State Agency within the required timeframe. A resident with Alzheimer's disease and dementia was admitted and later had a nursing progress note documenting an allegation of misappropriation on 07/27/2025. However, the facility did not report this allegation to the State Survey Agency until 07/29/2025, exceeding the required reporting window as outlined in facility policy and regulatory requirements. Interviews with staff, including an LPN, the DON, and the Administrator, confirmed knowledge of the abuse reporting policy, which requires immediate reporting of such allegations, defined as within two hours for abuse involving physical harm or within 24 hours for other allegations, including misappropriation. The Administrator explained that the nurse notified the abuse coordinator by entering information into the electronic health record, which only generated an alert for the next user login, rather than immediate notification. The Social Services Director initiated an investigation the following day, and the initial report to the State Agency was delayed, not meeting the facility's policy or regulatory requirements.
Sanitizer Solution Below Required Concentration in Kitchen Sink
Penalty
Summary
The facility did not ensure that dishware was sanitized according to food safety protocols in the three-compartment sink area of the main kitchen. During observation on 08/12/2025, the Assistant Director of Dietary Services performed a sink sanitizer strip test by dipping the test strip into the sink with the sanitizer solution for 5 seconds, then comparing it to the canister chart after 10 seconds. No color change was observed, and when the test was repeated, the strip again showed no color change, indicating the sanitizer was ineffective. Later that morning, the Director of Dietary Services observed the same testing process and dipped a test strip into the sink sanitizer solution for 5 seconds. After 10 seconds, the strip showed a faded brown color, and when repeated it again showed a faded brown color. The Director confirmed the strip measured below the required concentration of the solution in the sink, with the result not meeting the minimum manufacturer-required color and indicating less than 150 ppm when the required range was 200-400 ppm. The Assistant Director was not sure why the test strip was not reading, and the Director was not sure why the solution in the sink and test strip was not accurate. The facility policy titled Manual Cleaning and Sanitizing, effective February 2017, documented immersion for at least 30 seconds in a sanitizing solution of 220 ppm of quaternary ammonia at 75 degrees Fahrenheit or hotter.
Missing or outdated psychotropic medication consent forms
Penalty
Summary
The facility failed to ensure psychotropic medication consent forms were obtained and/or updated for 3 of 39 sampled residents. Resident 12 was admitted with diagnoses including major depressive disorder, unspecified dementia, unspecified psychosis, and traumatic brain injury. The record showed a physician note on 06/11/2025 directing a gradual dose reduction of Quetiapine from 400 mg to 300 mg, and a physician order the same day for Quetiapine 300 mg at bedtime. The chart contained a psychotropic informed consent for Quetiapine 400 mg dated 04/01/2025, but it lacked documented evidence that informed consent was obtained for the new dosage. Resident 14 was admitted with diagnoses including unspecified dementia, anxiety, and schizoaffective disorder. The record showed a psychotropic informed consent signed on 07/07/2025 for Quetiapine 50 mg twice daily, followed by a physician order on 07/17/2025 for Quetiapine 100 mg twice daily. The medical record lacked documented evidence that a new informed consent was obtained before the dose change. Resident 15 was admitted with diagnoses including schizoaffective disorder, depression, anxiety, and bipolar disorder. A physician order dated 08/30/2024 documented Risperdal 2 mg at bedtime for schizophrenia, but the record lacked documented evidence of informed consent for Risperdal. During interviews, LPNs stated psychotropic consent would be obtained if the resident could understand it and that medication changes required a new consent form. The DON confirmed the dose changes for Residents 12 and 14 should have had new consent forms and confirmed there was no informed consent for Risperdal for Resident 15.
Care Plan Not Updated After Resident Fall
Penalty
Summary
The facility failed to ensure a comprehensive care plan was revised to reflect interventions after a fall incident for one resident. The resident was originally admitted in 2003 and re-admitted with diagnoses including distal tibial impacted fracture and multiple sclerosis. During an interview, the resident stated being dependent on staff for care and reported having a fall in January 2025 with fractures. The resident was observed sitting in a wheelchair and stated that staff assisted the resident out of bed and into the wheelchair during the day. The medical record showed the resident was sent to the hospital and returned on 01/10/2025. A change in condition report dated 01/05/2025 documented swelling and pain in the left thigh, left knee, and left foot, and the physician recommended an x-ray and non-weight bearing status for the left leg. A progress note documented that a CNA reported the resident had pain in the left thigh, with swelling of the left knee and left foot, and the resident reported falling from a chair on 01/01/2025. Although the resident had a fall risk care plan with an intervention to follow the facility fall protocol, the record lacked evidence that the care plan was updated to include the actual fall. Nursing staff and the DON stated that care plans should be updated after a fall or change in condition, and the facility policy stated resident progress is regularly evaluated and approaches revised or updated as appropriate.
Missing Orders for Central and Peripheral Line Care
Penalty
Summary
The facility failed to ensure there were physician orders for the care and maintenance of a central line and a peripheral line for Resident 153, who was admitted with diagnoses including acute respiratory failure with hypoxia, acute post hemorrhagic anemia, and atherosclerotic heart disease. On 08/12/2025, the resident had a peripheral line on the back of the right hand with a dressing that was peeling away and not dated. On 08/13/2025, the resident was observed in bed with a family member present, and the family member stated they did not know why the peripheral line was present. The family member also identified a central line port in the right upper chest with sutures and a brownish red stained dressing that was peeled halfway back from the tubing with an illegible date written on it. During the same observation, an RN stated they did not know the resident had a central line and was unaware of the peripheral line. The RN confirmed the peripheral line dressing was peeling off and undated, and later confirmed the date on the central line dressing could not be determined. Record review showed there were no orders for maintaining either line, including flushing, dressing changes, or observation. The DON confirmed there were no orders for maintenance and daily assessment of the central line or peripheral line, and the NP stated staff were expected to clean, flush, change dressings, and monitor the sites when a resident had a central or peripheral line. The facility policy titled Catheter Insertion and Care stated peripheral IV dressings were changed when needed to prevent catheter-related infections associated with contaminated, loosened, or soiled catheter site dressings.
Personal Refrigerator Temperature Not Monitored
Penalty
Summary
The facility failed to ensure the temperature in a resident’s personal refrigerator was monitored for 1 of 30 sampled residents, Resident 97, who was admitted with diagnoses including moderate persistent asthma, chronic obstructive pulmonary disease, hypertensive heart disease, and anemia. The resident reported having a mini fridge-like machine with yogurt inside for taking medication and stated that the machine did not keep items cold like a traditional refrigerator. When the Assistant Director of Nursing checked the room, there was no temperature log for the refrigerator and no thermometer inside it. The refrigerator temperature was 64 degrees Fahrenheit and the yogurt inside measured 60 degrees Fahrenheit. The facility policy titled Personal Food Storage required all refrigeration units to have internal thermometers and for staff to monitor and document individual room storage and refrigeration units. The Administrator and Director of Nursing acknowledged that yogurt held at a prolonged temperature greater than 41 degrees Fahrenheit was not safe for consumption according to state and federal standards for safe food handling.
Incomplete and Missing Resident Medical Records
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for 3 of 30 sampled residents, including Residents 153, 156, and 157. For Resident 156, the hard chart was missing the face sheet, MAR, advanced directives, order summary, and facility history and physical, with only limited laboratory and diagnostic information available. Resident 157’s medical record was also missing the face sheet, MAR, advanced directives, order summary, and facility history and physical, and only limited laboratory and diagnostic information was present in the hard chart. For Resident 153, an RN was unaware the resident had a central line and reviewed the record, confirming there were no orders for treatments, no face sheet, no advanced directive, no facility history and physical, and limited laboratory and diagnostic information in the paper medical record hard chart. The Medical Records Supervisor confirmed the missing items were required to be included in the hard chart binder and stated there were no records for the residents of concern stored in the Medical Records Department. The DON later confirmed there were no face sheets, no MARs, no advanced directives, no order summaries, and no facility history and physicals, and explained that MARs were kept on nurse medication carts while other resident assessments and documentation were expected to be filed in the paper medical record hard chart.
Missing QAPI Plan
Penalty
Summary
The facility failed to ensure a Quality Assurance Performance Improvement (QAPI) plan was in place. During interview, the Administrator acknowledged that the facility did not have a specific QAPI plan and stated the facility was using its QAPI policy as the plan. The facility policy titled Quality Assurance and Performance Improvement (QAPI) Program, revised in February 2020, described that the QAPI committee oversees implementation of the QAPI plan, that the plan should describe how the facility conducts QAPI functions and the activities of the QAPI committee, and that it should identify and correct quality deficiencies. The policy also stated the QAPI committee met monthly to review reports, evaluate data, monitor QAPI-related activities, and adjust the QAPI plan, and that the plan was to be presented to the state survey agency annually during the recertification survey. The Administrator later confirmed the facility did not have a specific QAPI plan and provided a QAPI PowerPoint presentation stating the nursing home would have a QAPI plan that adhered to the core principles of the QAPI program. The Administrator also acknowledged the QAPI policy could be part of the plan, but the plan should be tailored to reflect the specific units, programs, departments, and unique population the facility serves, as identified in the facility assessment.
Failure to Use Enhanced Barrier Precautions and Follow Infection Control Protocols
Penalty
Summary
The facility failed to ensure enhanced barrier precautions were in place for two residents with invasive devices. One resident was admitted with diagnoses including gastrostomy and cerebral infarction affecting the left non-dominant side and was observed with a feeding tube, but there was no Enhanced Barrier Precautions sign on or around the door and staff provided care without wearing PPE. A RN, the DON, and the IP each acknowledged that an EBP sign should have been posted and that gowns and gloves were required when providing care related to the feeding tube. Another resident was admitted with hypertensive chronic kidney disease and Type 2 diabetes mellitus and was observed with a dialysis shunt in the chest. There was no EBP sign on the door, and staff were observed providing care without PPE. During dialysis access care, an LPN wore gloves to access the site, removed the dressing, removed gloves without performing hand hygiene, left the room to retrieve a new dressing, re-entered with new gloves, applied the dressing, and again removed gloves without performing hand hygiene. The LPN also did not wear a gown during the procedure and acknowledged that hand hygiene had not been performed and that this created a significant risk for infection. Staff were also observed not following infection control protocols in rooms on contact precautions. Housekeeping staff entered a room with only mask and gloves while mopping, entered another room without a gown and later returned to the room without removing gloves or performing hand hygiene, and a Laundry Supervisor was observed in a contact precaution room without PPE. The IP stated that contact precautions required all staff regardless of resident contact to wear PPE, while EBP required PPE for high-risk procedures such as changing catheters or providing wound care. The infection prevention manual in use was last reviewed or updated in May 2024, and the IP confirmed that was the current manual; the DON was unable to provide further information on the latest update to infection control policies and procedures.
Failure to Assess Self-Administration of Medication
Penalty
Summary
The facility failed to complete an assessment for the self-administration of medication for one resident, leading to a deficiency. The resident, who was admitted with diagnoses including gout, Type 2 diabetes, and generalized muscle weakness, was found with a bottle of melatonin gummies on their bedside table. The resident's family had brought the medication to the facility two days prior, and the resident had taken two gummies the previous night. However, there was no documented evidence of an assessment for self-administration of medication or a physician's order in the resident's medical record. A Registered Nurse confirmed the presence of the medication and was unaware of its existence at the bedside, indicating that the family should have informed the nursing staff about the medication. The Director of Nursing verified the absence of a physician's order and a self-administration assessment. According to the facility's policy, a resident must have a nurse's evaluation, an interdisciplinary team's assessment, physician's approval, and secured bedside storage to self-administer medication, none of which were in place for this resident.
Failure to Investigate Alleged Abuse Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical and verbal abuse involving a resident who reported that two staff members were rough and spoke rudely during care. The incident was documented in a Grievance/Complaint Resolution Report, but the date was initially incorrect. The Social Services Assistant (SSA) attempted to gather more details from the resident, who could not recall specifics due to the incident occurring at night. The SSA identified the staff member based on the resident's description and informed the Director of Nursing (DON), who agreed to remove the staff member from the resident's care. Despite the grievance being confirmed and adjustments made to the staff schedule, the facility did not conduct interviews with the alleged staff or other residents, nor did they complete a thorough investigation as per their policy. The Director of Staff Development (DSD) and the Administrator, who is the Abuse Coordinator, confirmed that no documentation of interviews or a complete investigation was available. The facility's policy requires immediate reporting and thorough investigation of abuse allegations, including interviews with all involved parties, but these steps were not followed in this case.
Inadequate Discharge Planning Documentation
Penalty
Summary
The facility failed to provide and document adequate discharge planning for two residents, leading to a deficiency in ensuring safe transfers or discharges. For the first resident, who had multiple medical conditions including a urinary tract infection and chronic obstructive pulmonary disease, the discharge planning process was not initiated until after a Notice of Medicare Non-Coverage was issued. Despite the resident's family successfully appealing two previous discharge notices, the facility did not document any discharge planning prior to the third notice. The Social Services Director only became involved after conflicts arose between the family and the Case Manager, and the medical record lacked evidence of discharge planning before the notice was issued. For the second resident, who had partial left-side paralysis due to a stroke, the facility also failed to document discharge planning prior to the resident's insurance coverage ending and subsequent discharge. The Case Manager admitted to keeping discharge planning notes on a personal tracker, which were not included in the electronic medical record and were destroyed after discharge. The Director of Nursing confirmed that the medical record lacked documentation of discharge planning, and the facility did not have a formal policy for discharge planning, relying instead on a best practice document that was not followed.
Failure to Adhere to Scheduled Bathing for a Resident
Penalty
Summary
The facility failed to provide scheduled bathing for a resident, identified as Resident 1, who was admitted with diagnoses including a displaced intertrochanteric fracture of the right femur, muscle weakness, and difficulty walking. The Admission Minimum Data Set indicated that Resident 1 required maximal assistance for bathing activities. The facility's records showed that Resident 1 was scheduled to receive showers twice a week, specifically on Wednesdays and Sundays. However, documentation revealed that Resident 1 only received a bed bath on two occasions and a shower on two other occasions during the month of May 2024, missing several scheduled bathing days. Interviews with facility staff, including a Registered Nurse, a Restorative Nurse Assistant, and a Certified Nursing Assistant, confirmed the twice-weekly bathing schedule. The Director of Nursing also confirmed that shower activities were to be documented in the electronic medical record and on shower day skin inspection sheets. Despite this, there was a lack of documentation for several scheduled bathing days, indicating a failure to adhere to the resident's bathing schedule, which could potentially impact the resident's overall well-being.
Deficiencies in Food Storage and Ice Machine Sanitation
Penalty
Summary
The facility failed to ensure proper labeling, dating, and storage of food and cleaning agents, as well as the cleanliness of ice machines. During a walkthrough of the kitchen, surveyors observed a box of thickened liquid lemon-flavored water cartons in the walk-in cooler with an expiration date of the previous day. The Dietary Manager acknowledged that the water cartons should have been discarded and had them disposed of during the survey. Additionally, a spray bottle containing an unidentified liquid was found in the utility room, which the Dietary Manager identified as a de-limer and stated it would be labeled and stored properly. Further observations revealed issues with the cleanliness of ice machines. A water/ice machine in the kitchen and an ice machine in the 200-hall nourishment room both had a wet brownish debris buildup on the ice spouts. The Dietary Manager explained that the ice machines are cleaned periodically and had been recently cleaned. However, the presence of debris indicated a failure to maintain sanitary conditions as outlined in the facility's Ice Machine Sanitation policy. These deficiencies posed a potential risk to safety and health standards, potentially leading to contamination and foodborne illness.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents, leading to potential risks for their health and well-being. Resident 225, who was admitted with conditions such as muscle wasting and weakness, required assistance with bed mobility, transfer, and toilet use. However, there was no documented evidence of repositioning or assistance during the night shifts on specific dates, and the resident expressed feeling insecure and neglected. The Minimum Data Set (MDS) Director confirmed the lack of documentation and noted that the resident had not refused assistance. Resident 226, admitted with muscle weakness and chronic pain, required substantial assistance with toileting hygiene. The resident's family member reported that the resident was often left lying in urine for extended periods. A review of the ADL Flowsheet revealed no documented evidence of toileting hygiene assistance during several night shifts. The MDS Director confirmed these findings, indicating the resident's need for help with toileting hygiene, including changing adult briefs. Resident 229, who had a BIMS score indicating cognitive intactness, required assistance with bed mobility and toileting hygiene. The resident reported not being checked by staff for long periods, especially during night shifts, and having to wait for hours without being changed, even after a bowel movement. The ADL Flowsheet review confirmed the lack of documented assistance on a specific night shift. The Director of Nursing (DON) acknowledged that the resident was not using a low air loss mattress, which could have aided in repositioning.
Failure to Administer Blood-Thinning Medication Timely
Penalty
Summary
The facility failed to follow physician's orders for a resident diagnosed with a pulmonary embolism, which required the administration of blood-thinning medication, Lovenox, every 12 hours. On the morning of September 5, 2024, an LPN was unable to locate the resident's Lovenox medication and found none in the back-up supply. The LPN was uncertain about when the medication would arrive, resulting in a delay in administration. The medication was eventually delivered at 4:00 PM, more than 12 hours after the last dose was administered the previous evening. The physician confirmed that the resident was placed on Lovenox because Warfarin alone was not providing adequate therapeutic effects. The physician emphasized that missing a dose for more than 12 hours significantly increased the risk of another pulmonary embolism. The Director of Nursing acknowledged that the medication should have been reordered by the nurse who administered the last dose, and the situation could have been avoided with timely ordering. The facility's medication administration policy did not provide guidance on handling situations when medications were running low or unavailable.
Failure to Administer Pain Medication as Scheduled
Penalty
Summary
The facility failed to administer pain medication as scheduled for a resident, identified as R228, which compromised the effectiveness of the resident's pain management. R228 was admitted with diagnoses including muscle wasting, atrophy, muscle weakness, and malaise, and was prescribed Gabapentin to be taken three times daily at specific times. However, the Medication Administration Audit Report revealed that the medication was frequently administered outside the prescribed one-hour window before or after the scheduled times, as per the facility's policy. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed the discrepancies in medication administration times. The DON acknowledged that the medication was not consistently given within the required timeframe, which could lead to increased pain for the resident. The facility's policy required medications to be administered within 60 minutes of the scheduled time unless otherwise ordered by a physician, but this was not adhered to in the case of R228.
Improper Handling of Residents' Personal Food Items
Penalty
Summary
The facility failed to ensure that personal food items brought in by family or visitors for two residents were properly labeled and stored. Resident #77, who has a history of hypertension, protein-calorie malnutrition, type 2 diabetes, and chronic kidney disease, reported that their vegetarian food items, such as ice cream and cottage cheese, were discarded after three days despite being within the manufacturer's expiration date. Similarly, Resident #84, with diagnoses including peripheral vascular disease, type 2 diabetes, depression, and protein-calorie malnutrition, expressed frustration over their food items, like bread and butter pickles, being thrown away within three days even though they were not expired according to the manufacturer's date. The facility's policy required that prepared food items brought in by family or visitors be labeled, dated, and consumed within three days of preparation, after which they would be discarded. However, the policy also stated that unopened food in original containers with manufacturer expiration dates did not need to be relabeled and should be discarded only if past the expiration date. The Dietary Manager and other staff confirmed that they followed a three-day rule for open items, regardless of the manufacturer's date, leading to the unnecessary disposal of residents' food items. This inconsistency between the facility's policy and practice resulted in the improper handling of residents' personal food items.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to infection control practices during medication administration for an unsampled resident, identified as Resident 276. The resident was admitted with a diagnosis including a urinary tract infection and had a care plan that included strategies to reduce infection risk. On the morning of September 5, 2024, an LPN was observed administering pills to the resident using a medication cup. During the process, one pill fell onto the bedding. The LPN picked up the pill with bare hands and gave it to the resident, who ingested it. The LPN was unaware of the facility's policy regarding handling contaminated medications. The Infection Control Preventionist later confirmed that the expectation was to discard any medication that touched an unclean surface. The facility's Medication Administration Policy, revised in October 2023, stated that medications should be administered in a manner to prevent contamination, but it did not provide specific guidance on handling contaminated medications.
Failure to Implement Fall Prevention and Management
Penalty
Summary
The facility failed to implement fall interventions and management for a resident identified as high risk for falls upon admission. Despite the resident's high-risk status, no fall precautions were in place, such as low bed positioning or fall mats, which contributed to a fall incident. The Assistant Director of Nursing (ADON) confirmed that the facility had not implemented fall indicators or precautions for high-risk residents, and staff training on these measures was only beginning. The facility also failed to thoroughly investigate a post-fall incident involving the same resident. Documentation indicated the resident fell during peri-care, but the fall circumstances and root cause analysis were not determined, and no interventions were implemented based on actual causal factors. The ADON acknowledged the lack of investigation and discussion with the Interdisciplinary Team (IDT) regarding the fall incident, and there was no documented evidence of attempts to determine the root cause or implement interventions. Additionally, the facility did not timely notify the physician and family following the post-fall incident, as required by policy. The resident's medical records lacked documentation of family notification, and the attending physician was only informed about the fall after the resident's return from the hospital. Furthermore, upon the resident's return from the hospital with a fractured wrist, the facility failed to complete an assessment or obtain care orders to manage the resident's cast, resulting in inadequate management of the fall-related injury.
Failure to Report Alleged Neglect Incident
Penalty
Summary
The facility failed to report an alleged incident of neglect involving a resident to the state agency. The resident, who had chronic kidney disease, diabetes mellitus, and atherosclerotic heart disease, was admitted with a Physician's Order for Life Sustaining Treatment indicating a full code status. A certified nursing assistant found the resident unresponsive, and despite the initiation of CPR and the arrival of emergency services, the resident was declared deceased. An anonymous report alleged that the Director of Staff Development (DSD) did not perform CPR when necessary, which was recognized by the Administrator as an allegation of neglect. The Administrator conducted an investigation, including verbal interviews and written statements from staff, but did not report the incident to the state survey agency, believing it was not reportable at the time. The facility's policy required immediate reporting of such allegations to the state agency, but this was not done. The DSD was suspended during the investigation, and written statements were collected from staff members. The failure to report the incident as required by policy constituted a deficiency in the facility's handling of the situation.
Failure to Develop Baseline Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop a person-centered baseline care plan within 48 hours of admission for a resident at high risk for falls. This deficiency was identified for one of the sampled residents, who had a history of falling and was diagnosed with conditions such as Parkinson's disease, muscle wasting, and weakness. The resident's cognitive status was moderately impaired, and a fall risk assessment indicated a high risk of falling with a score of 75. Despite these indicators, the facility did not formulate a baseline care plan to manage the resident's fall risk, which was confirmed by a Registered Nurse and the Assistant Director of Nursing. Interviews with facility staff, including the Director of Staff Development, revealed that the admission nurse was responsible for initiating the care plan upon the resident's admission. However, the baseline care plan was not developed, and fall risk indicators had not been implemented at the time. The facility's policy required the development of a baseline care plan within 48 hours of admission, but this was not adhered to, resulting in inadequate management of the resident's fall-related injuries.
Failure to Provide Scheduled Showers for a Resident
Penalty
Summary
The facility failed to ensure that showers were provided as scheduled for one of the sampled residents, identified as Resident 5. Resident 5 was admitted with diagnoses including a right femur fracture and head contusion, and the admission minimum data set indicated that the resident required maximum substantial assistance with bathing. The Director of Nursing confirmed that Resident 5's showers were scheduled for Wednesdays and Sundays during the day shift. However, the medical record lacked documented evidence that Resident 5 was provided a shower or bed bath on two specific dates, May 8 and May 12, 2024. The Director of Nursing also recounted that a family member of Resident 5 had called the facility regarding the missed showers, and upon review, confirmed the absence of documentation indicating that the showers or bed baths were offered, provided, or refused on those dates. The facility's Activities of Daily Living policy, revised in October 2022, stated that care and services would be provided based on the resident's comprehensive assessment, which included bathing.
Deficient Skin Assessment and Documentation
Penalty
Summary
The facility failed to ensure proper assessment and documentation of a resident's surgical incision site and skin condition, leading to a deficiency in care. The resident, who was admitted with a displaced intertrochanteric fracture of the right femur, had three surgical incisions on the right hip with staples. However, the location of these staples was not clearly documented. Physician orders were in place for cleansing and dressing the surgical incisions, but the medical records lacked evidence of thorough assessments and documentation of the resident's skin condition both before and after the removal of the staples. Interviews with the Assistant Director of Nursing and the Wound Care Treatment Nurse revealed that the wound team was responsible for assessing and treating surgical wounds. However, the baseline skin assessment was incomplete, and weekly skin assessments were not conducted as per protocol. The Wound Care Treatment Nurse confirmed that there were no follow-through assessments of the surgical site, and the condition of the surgical site with the staples was inadequately documented. The facility's policy required routine assessments and documentation of skin integrity issues, which were not adhered to in this case.
Failure to Provide Timely Wound Care Treatment
Penalty
Summary
The facility failed to provide wound care treatment as ordered for a resident with a surgical wound on the right hip, leading to a deficiency in care. The resident, who was admitted with diagnoses including right hip arthritis due to bacteria and surgical aftercare, had a care plan initiated to address impaired skin integrity. A physician's order required the wound to be cleansed and dressed every Tuesday, Thursday, and Saturday. However, during an observation on June 13, 2024, it was discovered that the wound dressing was dated June 8, 2024, indicating that the treatment scheduled for June 11, 2024, was not performed despite being documented as completed. The Wound Coordinator and Wound Care Treatment Nurse confirmed the lapse in treatment, acknowledging that the wound care was not provided as ordered. The resident, who was alert and cognitively intact, confirmed that the last wound treatment was provided five days prior to the observation. The Wound Care Nurse Practitioner emphasized the importance of timely wound care to promote healing and prevent complications. The Assistant Director of Nursing and Director of Nursing both acknowledged the expectation for accurate documentation and timely provision of wound care treatments. The facility's policy on skin integrity, dated August 2014, highlighted the need for active management of risk and appropriate interventions to achieve positive clinical outcomes.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 485 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Neurorestorative | 0.1 mi | ★★★★★ | 3 | 0 |
| Advanced Health Care Of Summerlin | 1 mi | ★★★★★ | 1 | 0 |
| Royal Springs Healthcare And Rehab | 1.4 mi | ★★★★★ | 22 | 0 |
| Marquis Plaza Regency Post Acute Rehab | 1.7 mi | ★★★★★ | 23 | 0 |
| El Jen Skilled Care | 2.3 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.