Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Spanish Hills Wellness Suites during CMS and state inspections, most recent first.
Unsanitary Kitchen Conditions and Improper Frozen Food Storage: Surveyors observed a malfunctioning handwashing sink in the food prep area that did not dispense hot water, heavy grease and food debris on kitchen equipment, dusty and greasy hood filters, and dried food spillage on floors beneath multiple pieces of equipment. The oven, dishwasher exhaust, and toaster were also visibly soiled, and several frozen food items were stored in the walk-in refrigerator instead of the freezer, contrary to manufacturer instructions. A cook and the Dietary Manager acknowledged the unsanitary conditions and improper storage.
Kitchen sanitation was poor, with heavy food debris and dried spillage observed under multiple pieces of equipment, along with residue in the oven and heavy soilage in the toaster. Three live cockroaches were seen in the dish area, at a sink drain, and at the walk-in refrigerator door, while pest control reports showed ongoing cockroach activity and recommended regular cleaning. The MDS confirmed pest control could be ineffective if kitchen staff did not keep the area properly cleaned.
A resident admitted with CHF, chest pain, and AFib was discharged, but the medical record lacked documented evidence that the LTC Ombudsman was notified. The Director of Case Management said discharged residents were listed monthly and faxed to the Ombudsman, but there was no proof, tracking, or documentation kept to verify the notifications. The DON stated case management handled the reporting, while the facility policy required written discharge notification to the LTC Ombudsman to be documented in the resident's medical record.
A resident with bilateral lower extremity pain, onychomycosis, cellulitis of the right big toe, and morbid obesity had extensive flaky skin dryness with visible scaling on both lower extremities. Although an order directed staff to apply antifungal cream daily and PRN for dryness, the medical record lacked evidence of a care plan for the skin condition. The DON confirmed a corresponding care plan should have been in place.
A resident with CVA-related weakness and contractures was observed without ordered splints in place, even though the MAR had been signed as if they were applied; the RN confirmed the splints were not on the resident and had been charted before application. Another resident with bilateral leg pain, onychomycosis, and skin dryness had antifungal ointment documented as administered on the TAR even though the medication was not in the cart and was not applied, and the DON confirmed it should not have been charted as given.
A resident with dysphagia and a physician order for no added salt, chopped received a meal tray that did not match the meal ticket and was not prepared to the ordered texture. The tray contained a chicken patty on a bun cut into quarters, fries, green beans, and pie instead of the ordered chopped items, and the resident began coughing while eating. Staff, including a CNA and the DON, confirmed the tray was incorrect and did not meet the chopped diet order.
Expired and unlabeled food items were found in resident refrigerators, including unopened yogurt, bottled drinks, and undated pie, along with a ham and cheese sandwich with an unclear date. A CNA placed the sandwich back in the refrigerator for possible later use, while an RN and the DON stated expired items should be discarded and that foods in resident refrigerators should be labeled and stored for only a limited time per facility policy.
Uncovered and overfilled outdoor dumpsters were observed in the waste-handling area, with 3 of 3 dumpsters left uncovered. The Maintenance Director confirmed the observation and stated the dumpsters should have been kept covered at all times. The facility policy required waste containers and dumpsters to remain covered.
A facility failed to thoroughly complete a report to the state agency regarding a sexual abuse allegation by a resident with multiple diagnoses. The resident alleged inappropriate touching by a staff member fitting a specific description. Although an RNA matching the description was suspended during the investigation, this was not documented in the final report. The facility's policy required comprehensive investigations, but the report contained inaccuracies and omissions.
The facility's kitchen was found in unsanitary conditions with aged oil, greasy surfaces, and expired food products during an inspection. The fryer, stove, toaster, and mixer were coated with grease and food debris, while the floor was greasy and dusty. Expired food items, including apple juice, sour cream, peanut butter, and hot dogs, were discovered, along with dented cans in storage. The kitchen manager acknowledged these issues, which violated the facility's policies on food safety and cleaning.
A resident was unable to use a urinal bottle independently at night due to the lack of a working over-the-bed light, as the remote control was sent for repair without a replacement. The Maintenance Director and ADON acknowledged the oversight, which contradicted the facility's policy on promoting resident independence.
The facility failed to maintain a clean and sanitary environment in 16 residents' rooms, as dust and debris were found at the edges between the wall and the floor, despite daily cleaning. A resident raised concerns about the cleanliness, and both housekeeping staff and the supervisor confirmed the oversight. The facility's cleaning policy required thorough cleaning, including dusting and moving furniture weekly.
A resident with schizoaffective disorder, anxiety disorder, depression, and PTSD was readmitted to the facility without a completed PASARR Level II referral, despite these diagnoses indicating the need for such a screening. The Social Services Director acknowledged the responsibility for making the referral but failed to do so, as required by the Medicaid Services Manual for Nursing Facilities Policy.
A facility failed to create a baseline care plan for a resident with a nephrostomy tube, leading to improper management of the dressing. The resident, under palliative care, experienced issues with a peeling and soiled dressing that was not changed after becoming wet during a shower. The RN was unsure of the hospice nurse's responsibilities, and the medical records lacked a care plan. The Charge Nurse and DON confirmed the absence of a care plan, which was required by facility policy within 48 hours of admission.
The facility failed to implement and develop comprehensive care plans for several residents, including one who needed restorative hand splinting services, another using side rails, a resident with significant weight loss, and a resident with a heel wound. These deficiencies were acknowledged by the DON and other staff, highlighting lapses in care plan management.
The facility failed to provide an ongoing program of activities to meet residents' interests, as evidenced by the lack of community outings and outdoor activities. Two residents expressed a desire for more trips and improved transportation, with one resident lacking an Activity Evaluation. Activity calendars lacked documentation of outings, and previous months' calendars were unavailable. Despite having transportation resources, outings were not scheduled, and a requested shopping trip had not occurred since August.
A resident with multiple diagnoses, including hypertension, was administered expired Hydralazine HCL 10 mg tablets for elevated blood pressure. The expired medication was found in the medication cart, and both an LPN and the Assistant DON confirmed it should have been discarded. The facility's policy required checking expiration dates before administration, which was not followed in this instance.
A resident with a history of CVA and right-side weakness did not receive appropriate contracture management due to the facility's failure to obtain a new physician order for a hand splint after hospital readmission. The care plan required the use of a splint, but it was not implemented, and staff interviews confirmed the oversight.
A resident with a nephrostomy tube experienced a deficiency in care due to the facility's failure to obtain a physician's order and monitor the insertion site. The resident's dressing was soiled and peeling, and there were no documented care or monitoring orders, despite the resident being on hospice care. This lack of documentation and monitoring was confirmed by facility staff, highlighting a gap in continuity of care.
A resident experienced significant weight loss without a proper nutritional assessment due to the absence of a Registered Dietitian. Despite being at nutritional risk, the resident's nutritional needs were not evaluated or documented, leading to a lack of interventions. The facility's policy requiring comprehensive nutritional assessments was not followed.
A facility failed to provide proper dialysis care for a resident requiring hemodialysis. The Dialysis Communication Records were not consistently completed, and assessments of the shunt or dialysis access and vital signs were not consistently conducted pre- and post-dialysis. Despite the resident's intact cognitive status and a care plan requiring monitoring, vital signs were inconsistently taken upon arrival at the facility. The DON confirmed the lack of documented evidence for shunt assessments and vital signs, increasing the risk of complications.
A resident with Parkinson's disease and other conditions was observed using bed side rails without a physician order. The facility's policy required obtaining and transcribing physician orders, but the medical record lacked such documentation. Both a nurse and the DON confirmed the oversight, acknowledging that a physician order should have been obtained when the side rails were reviewed and consented.
An expired punch card of Hydralazine HCL 10 mg tablets was found in a medication cart, which was confirmed by an LPN and the Assistant DON. The facility's policy mandates the immediate removal and disposal of outdated medications.
The facility failed to implement proper infection control measures for two residents, leading to potential cross-contamination. A resident with a dialysis shunt was not provided with appropriate enhanced barrier precautions (EBP), and staff did not follow hand hygiene protocols. Another resident with a nephrostomy lacked EBP signage and PPE. Additionally, empty hand sanitizer dispensers were found near resident rooms, compromising hand hygiene compliance.
A facility failed to establish a baseline care plan for a resident requiring an Aspen collar for a cervical vertebra fracture. Despite documentation of the collar's necessity, there was no physician order or care plan in place. Staff interviews revealed that the admitting nurse should have initiated the care plan within 48 hours, but this was not done, contrary to facility policy.
A facility failed to document a physician order for a cervical (Aspen) collar for a resident with a cervical vertebra fracture. Despite recommendations for the collar to be worn at all times, there was no care plan or physician order in place. The facility's policies required documentation of such devices, but the medical record lacked evidence of compliance, as confirmed by the DON.
Unsanitary Kitchen Conditions and Improper Frozen Food Storage
Penalty
Summary
The facility failed to ensure the kitchen food preparation area was maintained in sanitary condition and that food was stored appropriately. During an initial kitchen tour on 02/24/2026, surveyors observed that the designated handwashing sink did not dispense hot water because the hot water handle was malfunctioning, preventing appropriate handwashing and sanitation practices. Heavy grease buildup and food debris were present on the sides of the fryer, the ventilation hood filter on the cook line was visibly dusty and greasy, and heavy food debris and dried food spillage were observed on the floors beneath multiple pieces of kitchen equipment, including the stove, fryer, oven, toaster, cook line table, tray line steam table, dishwasher, walk-in refrigerator, and dry storage shelving. Additional observations included visible residue from old, burned food and grease inside the oven, a visibly soiled dishwasher machine exhaust with grease and dust, and a toaster heavily soiled with food debris. Multiple frozen food items, including milkshakes, luncheon loaf, cheese omelets, buttermilk pancakes, and pork sausage, were stored in the walk-in refrigerator instead of the freezer, contrary to manufacturer instructions requiring frozen storage. A cook acknowledged the kitchen and equipment were required to be cleaned weekly and confirmed the unsanitary conditions and improper storage. The Dietary Manager stated the kitchen should have been cleaned daily and acknowledged that items requiring frozen storage should have been stored per manufacturer recommendation.
Kitchen Sanitation and Pest Control Deficiency
Penalty
Summary
The facility failed to maintain effective sanitation practices in the kitchen and did not implement the pest control contractor’s recommendations to prevent insect proliferation in the food service area. During the kitchen tour, heavy food debris and dried food spillage were observed on the floors beneath multiple pieces of equipment, including the stove, fryer, oven, toaster, cook line table, tray line steam table, dishwasher, walk-in refrigerator, and dry storage shelving. The oven contained visible residue from old, burned food and grease, and the toaster was heavily soiled with food debris. Three live cockroaches were observed in the kitchen area: one on the floor in the dishwashing area, one in the floor drainage under a sink at the cook line, and one at the door of the walk-in refrigerator. Pest control reports from multiple service visits documented consistent cockroach activity and included a recommendation to clean regularly. The Maintenance Director stated pest control services were provided every other week and as needed, and confirmed that pest control interventions could be ineffective if kitchen staff did not maintain proper cleaning in the area. The facility policy on pest control stated that proper sanitation would be maintained and clutter reduced to prevent food and harborage for pests.
Failure to Document LTC Ombudsman Discharge Notification
Penalty
Summary
The facility failed to ensure a copy of the discharge notice was sent to the Office of the State Long-Term Care Ombudsman for Resident 150, who was admitted with diagnoses including unspecified diastolic congestive heart failure, chest pain, and atrial fibrillation and was discharged on 01/08/2026. The resident's medical record lacked documented evidence that the State LTC Ombudsman was notified of the discharge. During interview, the Director of Case Management stated the process was to generate a monthly list of discharged residents and fax it to the LTC Ombudsman, and confirmed there was no proof, tracking, or documentation kept to verify that the Ombudsman was notified of any resident discharges. The Director of Nursing stated that case management was responsible for reporting discharges to the LTC Ombudsman and was unaware of how those notifications were tracked. The facility policy titled Discharge notification, revised on 05/09/2025, stated Social Services staff or designee were responsible for ensuring written notification of transfer or discharge to the LTC Ombudsman and that the notifications were documented in the resident's medical record.
Care Plan Not Developed for Lower Extremity Skin Dryness
Penalty
Summary
Facility staff failed to develop and implement a care plan for Resident 119’s extensive skin dryness of the bilateral lower extremities. The resident was admitted with diagnoses including bilateral lower extremity pain, onychomycosis, cellulitis of the right big toe, and morbid obesity. On 02/24/2026 at 11:00 AM, an observation showed extensive flaky skin dryness with visible scaling on both lower extremities. A physician order dated 01/12/2020 directed staff to apply antifungal cream to the bilateral lower extremities daily and as needed for dryness, but the medical record did not contain documented evidence that a care plan was developed and implemented to address the resident’s dry skin condition. On 02/27/2026 at 10:30 AM, the DON confirmed the antifungal medication could be given any time between 6:00 AM and 6:00 PM as ordered and stated a corresponding care plan should have been developed for the resident’s skin condition.
Failure to Apply Ordered Splints and Inaccurately Document Antifungal Ointment
Penalty
Summary
The facility failed to ensure prescribed splints were applied as ordered for a resident with a history of cerebrovascular accident, left-side weakness, atrial fibrillation, and hypertension. A physician order directed use of a waffle boot to the left lower extremity and a carrot orthosis to the left hand for 6 hours or as tolerated, and the care plan identified the splints as needed to prevent further contracture. During observation, the resident was found in bed without the prescribed splints in place, including on two separate observations on 02/25/2026. The Medication Administration Record had been signed to indicate the splints were applied, but the assigned RN confirmed the resident was not wearing them and acknowledged the MAR had been signed before the splints were actually applied. The RN also checked the room and could not locate the splints. The facility also failed to accurately document administration of antifungal ointment for a resident with bilateral lower extremity pain, onychomycosis, cellulitis of the right big toe, and morbid obesity. The resident was observed with extensive flaky skin dryness and visible scaling of both lower extremities. A physician order directed antifungal cream to the bilateral lower extremities daily and as needed for dryness, but the record lacked evidence of a care plan for the dry skin condition. The TAR showed the medication signed as administered, yet the assigned RN confirmed the antifungal ointment was not available in the medication cart, had to be retrieved from the supply room, and had not been applied even though it was documented as given. The DON confirmed the medication could have been administered any time between 6:00 AM and 6:00 PM and acknowledged it should not have been documented as administered when it was not available.
Incorrect Therapeutic Diet Tray Served to Resident with Chopped Diet Order
Penalty
Summary
The facility failed to ensure therapeutic diet orders were followed for a resident with a physician order for no added salt and chopped consistency. The resident had diagnoses including spinal stenosis, anorexia, morbid obesity, history of stroke, dysphagia, and altered mental status. The resident’s care plan also included diet as ordered by the physician: no added salt, chopped. On observation, the resident was eating lunch in bed with the head of bed elevated, and the meal ticket documented no added salt-chopped with chicken tenders, mashed potatoes with gravy, chopped cabbage, and chopped lemon meringue pie. The meal tray provided to the resident did not match the meal ticket and contained a chicken patty on a bun cut into four quarters, French fries, green beans, and chocolate cream pie. The resident stated the tray items were not the foods listed on the ticket and began coughing while eating the chicken sandwich. A CNA confirmed the food on the plate did not match the meal ticket, and another CNA acknowledged the tray was incorrect and not chopped. Staff and the DON stated trays were to be checked against meal tickets and returned to the kitchen if they did not match, and the DON confirmed that a chicken sandwich cut into four quarters did not meet a chopped diet order. The facility policy required therapeutic and mechanically altered diets to be prepared and served as planned and all trays checked for accuracy before serving.
Expired and Unlabeled Food Left in Resident Refrigerators
Penalty
Summary
The facility failed to ensure expired and unlabeled food items were removed from resident refrigerators. During observation, one resident room refrigerator contained an unopened yogurt expired 12/18/2025, two unopened Starbucks Vanilla Frappuccino bottles expired 12/15/2025, and two slices of blueberry pie in clamshell containers that were not dated. A CNA confirmed the findings and stated CNA staff were responsible for cleaning resident refrigerators and removing expired food items as part of daily room-cleaning duties. The CNA stated expired items should have been discarded to prevent residents from consuming them and getting sick. In another resident room, a ham and cheese sandwich wrapped in cellophane had a handwritten date that was smeared and could not be clearly read. The resident stated the sandwich had been in the refrigerator for a while. A CNA identified the date as 02/01/2026 and placed the sandwich back in the refrigerator, stating it could remain there in case the resident wanted to eat it later. An RN confirmed the sandwich and stated the writing was unclear, then said the item would be discarded and that food items should be in the refrigerator less than 3 days. The DON stated resident refrigerators should not contain expired food items, that night shift staff checked refrigerators weekly and removed expired items, and that expired food should be discarded regardless of whether it was opened. The facility policy stated foods brought from outside sources were to be labeled with the resident's name, contents, and preparation date, stored for three days, and expired or unlabeled items discarded.
Uncovered and Overfilled Outdoor Dumpsters
Penalty
Summary
Dispose of garbage and refuse properly. The facility failed to maintain proper waste management practices by allowing 3 of 3 outdoor waste dumpsters to remain uncovered and overfilled. On 02/24/2026 at 8:40 AM, surveyors observed the three outdoor garbage dumpsters uncovered and overfilled in the waste-handling area. At 9:30 AM, the Maintenance Director confirmed the observation and stated the garbage service company picked up waste weekly, and acknowledged the dumpsters should have been kept covered at all times to prevent pest activity and odors. The facility policy titled Waste Disposal, dated 10/16/2025, stated waste would be disposed of in a manner that prevents transmission of disease, nuisances, or breeding areas for insects and feeding areas for animals such as rodents, and that staff should ensure waste containers and dumpsters remain covered.
Incomplete Reporting of Sexual Abuse Allegation
Penalty
Summary
The facility failed to ensure a thorough completion of a report submitted to the state agency regarding an allegation of sexual abuse involving a resident. The resident, who was admitted with diagnoses including a closed fracture of the right femur, schizoaffective disorder, major depressive disorder, and an anxiety disorder, alleged being touched inappropriately by a staff member described as a white male with a ponytail. The initial report submitted to the state agency did not substantiate the allegation, stating that no staff member matched the description provided by the resident. However, it was later revealed that a Restorative Nurse Assistant (RNA) with a beard and ponytail, who had provided services to the resident, was suspended for one day due to the investigation. The Director of Nursing confirmed the suspension was related to the investigation, as the RNA was the only male staff member fitting the description. The facility's final report lacked documentation of the RNA's suspension, and the Director of Nursing acknowledged the report contained inaccurate information. The facility's policy required prompt and comprehensive investigations, but the report failed to include all relevant details, compromising the thoroughness of the investigation.
Unsanitary Kitchen Conditions and Expired Food Products
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during an inspection with the Kitchen Manager. The fryer was found with visibly aged and contaminated oil, and food debris was prevalent, contributing to unsanitary conditions. The surfaces of the fryer, stove, toaster, and mixer were coated with grease and food debris. The floor under the stove and oven was greasy, dusty, and littered with food debris. Additionally, the potable water dispenser and ice maker machine showed white calcium buildup, and the exhaust vent of the dishwasher was heavily soiled with dust. Expired food products and dented cans were also found during the inspection. A breadcrumbs container, cartons of thickened apple juice, containers of sour cream, peanut butter, and hot dogs were all past their expiration dates. Two dented cans of cheese sauce and a can of sliced pickled beets were found in dry storage. A container of gravy was found on the food preparation table without a date. The kitchen manager acknowledged these findings as unsanitary conditions that should have been corrected timely. The facility's policies on food safety and cleaning were not adhered to, as evidenced by the presence of expired food and unsanitary equipment and surfaces.
Failure to Provide Working Over-the-Bed Light
Penalty
Summary
The facility failed to provide a working over-the-bed light for a resident, identified as Resident 125, which impacted the resident's ability to use a urinal bottle independently overnight. Resident 125, who was admitted with diagnoses including hemiplegia affecting the left nondominant side, hereditary and idiopathic neuropathy, and cerebrovascular disease, reported moving into a new room two weeks prior without being provided a remote control for the over-the-bed light. The resident explained that the lack of light prevented independent use of the urinal bottle at night, necessitating assistance from staff. The issue was confirmed by the Maintenance Director, who acknowledged that the remote control had been sent for repair without an expected completion date. The Maintenance Director also noted that a remote control could have been sourced from an empty room or the resident could have been moved to another room to avoid disruption of care. The Assistant Director of Nursing confirmed that the resident should have been provided with a light to maintain independence and self-care. The facility's policy on resident room environment emphasized promoting and preserving resident independence and self-sufficiency, which was not adhered to in this case.
Failure to Ensure Proper Floor Cleaning Procedures
Penalty
Summary
The facility failed to provide a clean and sanitary homelike environment by not ensuring proper floor cleaning procedures in 16 of 90 residents' rooms, specifically rooms 406 to 422. This deficiency was identified through observations, interviews, and document reviews. A resident expressed concerns about the cleanliness of their room, noting that dust and debris remained at the edges between the wall and the floor at the baseboard, despite daily cleaning. A housekeeping staff member confirmed that the room had been cleaned but acknowledged that the edges were not addressed. The housekeeping supervisor corroborated these observations and confirmed that all surfaces should have been cleaned according to the facility's policy. The facility's cleaning policy, dated March 2006, required routine cleaning and disinfection to ensure a clean and safe environment, including dusting areas above eye level and moving furniture weekly to clean underneath and behind.
Failure to Complete PASARR Level II Referral for Resident
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level II referral was completed for one of the sampled residents, identified as Resident 69. This resident was readmitted with multiple diagnoses, including schizoaffective disorder, anxiety disorder, depression, and post-traumatic stress disorder (PTSD). Despite these diagnoses, a PASARR Level I document from 2021 indicated that the resident did not have any mental illness, intellectual disability, or related condition, and was deemed appropriate for nursing facility placement. However, the resident's medical notes revealed diagnoses of schizoaffective disorder and PTSD, which should have triggered a PASARR Level II screening. The Social Services Director (SSD) acknowledged responsibility for referring residents who meet the criteria for PASARR Level II by completing the online request. The SSD agreed that the resident's diagnoses would indicate the need for such a referral. The Medicaid Services Manual for Nursing Facilities Policy requires a PASARR Level II screening when indicators of mental illness or related conditions are present. The medical record for Resident 69 lacked documented evidence of a referral for a PASARR Level II screening, indicating a failure in the facility's process to ensure necessary behavioral health services were considered for the resident.
Failure to Formulate Baseline Care Plan for Nephrostomy Tube
Penalty
Summary
The facility failed to ensure a baseline care plan was formulated for a resident with a nephrostomy tube, which is crucial for managing the resident's care. The resident, who was admitted and readmitted with diagnoses including palliative care, dysuria, and malignant neoplasm of the prostate, experienced issues with the nephrostomy dressing. On a specific date, the resident complained to a Registered Nurse (RN) about a peeling and soiled dressing, which had become wet during a shower and was not changed, leading to itchiness on the surrounding skin. The RN was unsure if the hospice nurse was responsible for changing the dressing, and the resident's medical records lacked documented evidence of a baseline care plan for the nephrostomy management. The Charge Nurse and the Director of Nursing (DON) confirmed the absence of a baseline care plan, which should have included management instructions for the nephrostomy tube. The facility's policy, dated May 2023, required the development and implementation of a baseline care plan within 48 hours of admission to provide effective, person-centered care. However, this was not done, and the DON indicated that licensed nurses were responsible for formulating the care plan, which should have been overseen by nursing leadership. The lack of a baseline care plan could have led to an increased risk of complications related to improper management and a lack of continuity in care.
Deficiencies in Care Plan Implementation and Development
Penalty
Summary
The facility failed to implement a care plan for restorative hand splinting services for a resident who had a cerebrovascular accident and was at risk for contractures. The resident was observed without the prescribed hand splint, and the care plan indicated the need for a splint to be worn up to eight hours a day. However, after the resident's discharge and readmission, the physician's order for the splint was not renewed, and the restorative program was not performed. The Director of Nursing and the Physical Therapy Director acknowledged the oversight, noting that the resident was not reassessed upon readmission. The facility also failed to develop comprehensive care plans for three other residents. One resident, who used side rails for bed mobility, did not have a care plan addressing the use of side rails, despite a consent form being completed. Another resident experienced significant weight loss, but a care plan addressing nutritional needs was not developed until after the weight loss occurred. The Director of Nursing confirmed the absence of a timely care plan could have impacted the resident's care. Additionally, a resident with a right heel wound did not have a comprehensive care plan developed for wound care. The wound, which was positive for MRSA, was being treated according to a physician's order, but the lack of a care plan was acknowledged by the Director of Nursing. The absence of these care plans placed residents at risk for worsening health conditions related to their specific needs.
Deficiency in Resident Activity Programming
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the interests of its residents, as evidenced by the lack of community outings and outdoor activities for two sampled residents and seven unsampled residents. Resident 26, who had been at the facility for about six years, expressed a desire for more trips out of the facility to events and shopping places. An Activity Evaluation for this resident indicated a need for programming focused on community outings, large groups, independent activities, and outdoor activities. Resident 117, who had been at the facility for about two months, also expressed a desire for improved transportation to facilitate outings, noting that the facility had not taken residents out for shopping trips in a while. The medical record for Resident 117 lacked an Activity Evaluation to document the resident's identified needs. The activity calendars for December and January lacked documentation of any outdoor activities or outings, and previous months' activity calendars were unavailable. The Activity Director explained that outings were not scheduled due to the need to coordinate with in-house transportation, despite the facility having two buses/vans and two drivers, as well as access to outside transportation contractors. The Resident Council Minutes from December documented a request for an outing to a specific shopping center, which was agreed to be added to the January schedule, but residents acknowledged that no such trip had occurred since August. The facility's policy on Activity/Recreation Programming emphasized the importance of resident-centered activities to maintain and improve various aspects of well-being, which was not being met according to the findings.
Expired Medication Administered to Resident
Penalty
Summary
The facility failed to ensure that an expired medication was not administered to a resident, identified as Unsampled Resident 02 (UR2). UR2 was admitted with diagnoses including sequelae of cerebral infarction, anxiety disorder, chronic kidney disease stage 3, and dementia with mood disturbance. During an observation, a punch card of Hydralazine HCL 10 mg tablets, which had expired, was found in the medication cart. A Licensed Practical Nurse (LPN) and the Assistant Director of Nursing confirmed the expiration and acknowledged that the medication should have been discarded for resident safety. The expired Hydralazine HCL 10 mg tablets were documented to have been administered to UR2 for elevated blood pressure. The physician's order specified that the medication should be given as needed for systolic blood pressure greater than 160. The facility's policy on medication management required nurses to check expiration dates before administering medications. Despite this policy, the expired medication was administered, indicating a lapse in adherence to the facility's procedures for medication management.
Failure to Implement Contracture Management for Resident
Penalty
Summary
The facility failed to provide appropriate contracture management for a resident who had experienced a cerebrovascular accident (CVA) resulting in weakness on the right side of the body. The resident was observed without a hand splint, which was previously used to prevent contractures. The care plan indicated the resident should have been wearing a resting hand splint for up to eight hours a day, but this was not implemented. The physician's order for the splint was discontinued when the resident was transferred to a hospital, and no new order was obtained upon the resident's readmission to the facility. Interviews with facility staff revealed that the oversight occurred because the order for the splint was not carried over after the resident's hospital discharge and subsequent readmission. The Director of Nursing and the PT Director acknowledged the lapse in reassessment and the absence of a new physician order for the splint. The facility's policy required assessments for joint mobility upon admission, re-admission, and with significant changes, but this was not followed, leading to the deficiency in care for the resident.
Failure to Document and Monitor Nephrostomy Tube
Penalty
Summary
The facility failed to ensure proper management and documentation for a resident with a nephrostomy tube. The resident, who was receiving hospice care, had a nephrostomy tube with a soiled and peeling dressing that had not been changed after becoming wet during a shower. The resident's medical records lacked a physician's order for the nephrostomy tube, and there were no documented care or monitoring orders in place. This oversight was confirmed by a Registered Nurse and the Director of Nursing, who acknowledged the absence of necessary orders and monitoring for signs of infection. The facility's policy required a qualified licensed nurse to obtain and transcribe physician orders upon a resident's admission, including routine care orders. However, in this case, the orders were not documented in the resident's electronic records, leading to a lack of continuity in care and shared responsibility between hospice and facility staff. The Director of Nursing confirmed that the nephrostomy tube had not been monitored for signs of infection, and dressing changes were inconsistent, increasing the risk of infection and complications.
Failure to Assess Nutritional Status During Significant Weight Loss
Penalty
Summary
The facility failed to assess a resident's nutritional status during a period of substantial weight loss. A resident was admitted with diagnoses including encephalopathy, nausea with vomiting, and drug-induced subacute dyskinesia. Upon admission, the resident weighed 150 pounds, but by the following month, the weight had decreased to 120.1 pounds, indicating a significant weight loss of 19.93%. Despite a positive score for nutritional risk on a Malnutrition Screening Tool, the Nutritional Assessment at Admissions lacked critical information such as estimated nutritional needs, nutritional diagnosis, interventions, goals, monitoring, and evaluation. The medical record showed no documented evidence of a nutritional assessment or review from the time of admission until three months later, despite the resident's significant weight loss. The Director of Nursing acknowledged the absence of documented nutritional assessments during this period, attributing it to the Registered Dietitian being on medical leave. The Administrator also recognized the issue, noting that excessive weight loss needed to be addressed with dietary needs, food preferences, intake percentages, and supplements, in collaboration with the physician. The facility's policy required a comprehensive nutritional assessment upon admission, annually, and whenever a significant change in status occurred, which was not adhered to in this case.
Failure to Ensure Proper Dialysis Care for a Resident
Penalty
Summary
The facility failed to ensure proper dialysis care for a resident, identified as Resident 16, who required hemodialysis treatment. The deficiency was identified through observation, interviews, and record reviews, revealing that the Dialysis Communication Records were not consistently completed. Additionally, assessments of the shunt or dialysis access and vital signs were not consistently conducted pre- and post-dialysis. This lapse in protocol was noted from October 2024 to January 2025, during which the resident received dialysis treatments multiple times each month. The Director of Nursing confirmed the lack of documented evidence for shunt assessments and vital signs, despite staff being aware of the protocol. Resident 16 was admitted with chronic kidney disease, hypertension, and dependence on renal dialysis. The resident's cognitive status was intact, and they were receiving dialysis treatment three times a week. The care plan required monitoring the patency of the shunt and vital signs as ordered. However, the resident reported that vital signs were inconsistently taken upon arrival at the facility. The physician emphasized the importance of assessing the dialysis access for patency, signs of infection, and monitoring for bleeding post-dialysis, which was not consistently done, increasing the risk of complications.
Failure to Obtain Physician Order for Bed Side Rails
Penalty
Summary
The facility failed to obtain a physician order for the use of bed side rails for one resident, identified as Resident 62. This resident was admitted with diagnoses including Parkinson's disease, chest pain, and syncope. On a specific date, the resident was observed in a wheelchair beside their bed, with bed side rails raised on both sides. The resident indicated that the side rails were used to facilitate movement. A review and consent form dated prior to the observation documented the consideration of side rails for conditions such as syncope and hypertension to aid with repositioning and transfers. However, the medical record did not contain documented evidence of a physician order for the use of these side rails. During interviews, a nurse confirmed the use of side rails for the resident's bed mobility and acknowledged the absence of a physician order in the medical record. The Director of Nursing also confirmed the lack of a physician order and stated that such an order should have been obtained when the side rails review and consent were completed. The facility's policy on physician orders, revised earlier, required that a qualified licensed nurse obtain and transcribe orders according to facility guidelines, including confirming orders with a physician and requesting additional orders as needed.
Expired Medication Not Discarded
Penalty
Summary
The facility failed to ensure that an expired punch card of medications was discarded, which could potentially lead to the administration of non-viable medication to a resident. During an observation, a punch card of Hydralazine HCL 10 mg tablets was found expired in the 400-hall medication cart. A Licensed Practical Nurse confirmed the expiration and acknowledged that the medication should have been discarded for resident safety. The Assistant Director of Nursing also verified the expiration and the need for disposal. The facility's policy on medication storage requires that outdated, contaminated, or deteriorated medications be immediately removed from stock and disposed of according to procedures for medication destruction.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were implemented for two residents, leading to potential cross-contamination and transmission of infectious diseases. Resident 16, who had a dialysis shunt access, was not provided with appropriate enhanced barrier precautions (EBP) during care. A registered nurse assisted the resident without wearing personal protective equipment (PPE), and a certified nursing assistant (CNA) failed to perform hand hygiene, wore gloves without a gown, and handled the privacy curtain with soiled gloves. The CNA admitted to not following the infection control protocol despite recent education on the matter. Resident 98, who had a nephrostomy, did not have EBP signage or PPE available at the door entry. The charge nurse and infection preventionist confirmed that EBP was required for residents with devices such as catheters or wounds. Additionally, three hand sanitizer dispensers near resident rooms were found empty, and the housekeeping supervisor acknowledged that they should have been refilled to ensure compliance with hand hygiene protocols.
Failure to Implement Baseline Care Plan for Aspen Collar
Penalty
Summary
The facility failed to establish and implement a baseline care plan for a resident who required an Aspen collar for the management of a cervical vertebra fracture. The resident was admitted with multiple fractures, including a cervical vertebra fracture, and was documented to have a neck collar in place. However, there was no physician order documented for the use of the Aspen collar, and the medical record lacked evidence of care orders or a baseline care plan regarding the collar's management. Interviews with facility staff revealed that the admitting nurse was responsible for initiating the baseline care plan, which should have included immediate care needs within 48 hours of admission. The Director of Nursing acknowledged the absence of a baseline care plan for the Aspen collar and explained that the admission assessment should identify areas for the baseline care plan, including special devices like the Aspen collar. The facility's policy required the development and implementation of a baseline care plan to provide effective and person-centered care, which was not followed in this case.
Failure to Document Physician Order for Cervical Collar
Penalty
Summary
The facility failed to ensure that a cervical (Aspen) collar was ordered as recommended for a resident who had sustained multiple fractures, including a cervical vertebra fracture, following a motor vehicle accident. The resident was admitted with a recommendation for non-operative management with an Aspen collar to be worn at all times for 8-10 weeks. However, there was no physician order documented for the resident to wear the collar, nor was there a care plan in place for its use. The facility's policies required that residents be assessed for joint mobility limitations upon admission and that necessary devices be documented in the care plan. Despite the resident wearing the collar, the medical record lacked evidence of a physician's order or a care plan detailing the collar's use, skin assessment procedures, or wearing schedule. The Director of Nursing confirmed these omissions, indicating that the special instructions should have been included in the care plan to guide nursing staff.
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.
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What surveyors actually found near you
We read the 536 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) |
|---|---|---|---|---|
| Sandstone Spring Valley | 0.7 mi | ★★★★★ | 42 | 0 |
| Advanced Health Care Of Las Vegas | 1.8 mi | ★★★★★ | 10 | 0 |
| Canyon Vista Post Acute | 2.3 mi | ★★★★★ | 16 | 0 |
| Torrey Pines Post Acute And Rehabilitation | 5.1 mi | ★★★★★ | 7 | 0 |
| Silver Ridge Healthcare Center | 5.5 mi | ★★★★★ | 14 | 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.