Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Trellis Paradise during CMS and state inspections, most recent first.
Nursing staff did not document physician notification, change in condition, or nursing interventions for a resident who developed a high fever, despite facility policy requiring such actions. The resident, with a history of respiratory illness and pneumonia, had a temperature of 102.9°F recorded, but no further temperature checks or interventions were documented for over 15 hours. Interviews with LPNs, CNAs, an RN, and the DON confirmed that standard practice would have included prompt notification, interventions, and documentation, none of which occurred in this case.
A resident with chronic respiratory failure, COPD, and pneumonia experienced a significant fever, but the facility failed to ensure timely and complete documentation of nursing interventions, provider notification, and follow-up monitoring. Although a physician progress note acknowledged the fever and recommended monitoring, this note was not promptly transferred to the facility's software, and staff could not clarify the timing or provide documentation as required by policy.
The facility failed to secure medication and treatment carts, leaving them unlocked and unattended, which posed a risk of unauthorized access to medications and supplies. A treatment cart was left outside a nourishment room, and a medication cart was found unsecured in front of a resident's room. Staff acknowledged the carts should be locked, citing lost keys and potential lock issues.
A resident with multiple health conditions was discharged with a plan for follow-up care from a home health agency, but the agency never contacted the resident. The case manager failed to follow up with the agency or the resident, despite known issues with the agency's performance. The facility's policy required a post-discharge plan, which was not effectively executed.
A facility failed to protect a resident's PHI when a medication cart was left unattended with a laptop screen displaying sensitive information. The RN responsible was in training and did not lock the screen. Both an LPN and another RN confirmed that nurses are trained to secure laptops to protect PHI, as per the facility's confidentiality policy.
The facility failed to maintain proper linen handling procedures, risking patient exposure to infections. CNAs were observed carrying clean linen against their uniforms, contrary to facility policy requiring linen to be protected from contamination. The ADON confirmed the correct procedure was not followed.
A resident with malnutrition was not adequately monitored for hydration, leading to visible signs of dehydration such as dry, cracked lips and sunken eyes. Despite these symptoms, nursing staff failed to report the condition to the medical provider or document it, resulting in a significant fluid intake deficit. The Registered Dietician was unaware of the issue due to a lack of communication, and the Medical Director was not informed, preventing timely intervention.
A resident with severe malnutrition and other health issues received TPN through a midline IV catheter instead of a central line, contrary to manufacturer's recommendations. Despite the risks of complications due to high osmolarity, the facility proceeded with midline administration after consulting with a pharmacist and physician, leading to pain and edema in the resident's arm.
A resident with muscle weakness and recent back surgery was not repositioned as required, leading to discomfort and potential skin integrity issues. The resident also expressed a preference against using incontinence briefs, but this was not documented or communicated effectively by staff. The facility's policies did not adequately address these issues, resulting in a deficiency related to resident rights.
A resident's privacy was compromised when their body weight was posted on a board visible from the hallway. The resident, who was alert and oriented, expressed concern over this privacy issue. A nurse confirmed the visibility and removed the information. The DON mentioned a family request for the posting, but no documentation supported this. Facility policy prohibits posting clinical information without resident or family request.
A resident with severe malnutrition and other conditions received TPN administered by LPNs instead of RNs, contrary to state regulations. The facility's DON was unaware of this requirement, and LPNs documented administering TPN despite it not being in their job description.
A resident with multiple health issues was not discharged to a licensed group home as per physician's order. Despite the resident's agreement to move to a group home with hospice services, the discharge summary indicated a different address, which was not a licensed group home. The facility's case manager did not verify the home's licensing, leaving it to the insurance social worker, resulting in a deficiency.
A resident with a right humerus fracture was not provided with the prescribed arm brace and sling, as per physician orders and the care plan. The resident reported significant pain and indicated that the brace helped alleviate discomfort. The Physical Therapy Director confirmed the necessity of the brace and sling, which should have been in place at all times. The facility's policy required the maintenance and supervision of assistive devices, but the resident was found without the prescribed equipment, potentially impacting their recovery.
The facility failed to maintain sanitary conditions in the kitchen, potentially exposing residents to foodborne illnesses. Observations included a cook without a beard cover, soiled kitchen equipment, undated and spilled milk, dented cans, and a dirty ice machine. A fan was improperly placed in the food prep area, and another cook was observed without a beard cover.
Failure to Document and Respond to Resident's High Temperature
Penalty
Summary
Nursing staff failed to document physician notification, a change in condition, nursing interventions, or attempts to obtain a physician order to manage a resident's high temperature, as required by facility policy. The resident, who had a history of chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and pneumonia, was admitted with these diagnoses. On the evening of 08/14/2025, the resident's oral temperature was recorded at 102.9°F, but there was no further temperature documented until the following afternoon, over 15 hours later. During this period, there was no documentation of any interventions, physician or family notification, or a change in condition assessment in the medical record. Interviews with nursing staff, including LPNs, CNAs, an RN, and the DON, revealed that the facility's standard practice was to consider a temperature above 100.3°F as high and to implement interventions such as cooling measures, hydration, and notifying the physician for further orders, including medication like Tylenol. Staff also indicated that a change in condition assessment would be completed, the physician and family would be notified, and the temperature would be rechecked within an hour. However, in this case, none of these actions were documented for the resident with the high temperature. A review of the facility's policy on changes in a resident's condition confirmed that prompt notification of the physician, resident, and representative was required, along with detailed documentation of observations and interventions. The DON and physician both confirmed that the medical record lacked evidence of a change in condition, nursing interventions, or physician notification related to the resident's high temperature. The absence of documentation and follow-up actions was inconsistent with both facility policy and staff statements regarding standard procedures.
Incomplete and Delayed Medical Record Documentation Following Change in Condition
Penalty
Summary
The facility failed to ensure complete and accessible medical record documentation for one resident with multiple serious diagnoses, including chronic respiratory failure, COPD, and pneumonia. The resident experienced a significant change in condition, evidenced by an elevated oral temperature of 102.9°F, which was documented by an LPN. However, the medical record lacked evidence of timely and complete documentation of nursing interventions, follow-up monitoring, and provider notification related to this change in condition. Although a physician progress note acknowledged the fever and recommended monitoring and Tylenol as needed, this note was not transferred to the facility's software until several days later, and the Director of Nursing was unable to clarify the timing of the note's entry. Additionally, the DON refused to provide a copy of the note, citing HIPAA privacy, despite policy allowing surveyor access. Interviews with nursing staff and the physician confirmed that a temperature above 100.3°F should have triggered provider notification, interventions, and documentation, but the medical record did not contain evidence of these actions. The physician also expected documentation of interventions and rechecking of the temperature, but did not recall being updated by the covering physician. The facility's policies required documentation of changes in condition and provider notification, but there was no evidence in the record that these requirements were met. Furthermore, the physician services policy did not address accountability for timely electronic documentation or software transfers.
Unsecured Medication and Treatment Carts
Penalty
Summary
The facility failed to secure medication and treatment carts, which were left unlocked and unattended, posing a risk of unauthorized access to medications and treatment supplies. On multiple occasions, a treatment cart was observed outside the nourishment room, unlocked and unattended, with contents such as scissors, ointments, creams, and dressings easily accessible to residents or visitors. A Certified Nursing Assistant confirmed the cart was unlocked and expressed concerns about resident safety due to the unsecured contents. A Registered Nurse acknowledged the cart was unsecured and mentioned that the key was lost, indicating the cart should be locked to prevent unauthorized access. Additionally, a medication cart was found unattended and unsecured in front of a resident's room, with an intravenous bag of Saline and Meropenem left on the counter. The Registered Nurse responsible for the cart was inside the room and not in view of the cart, and it was noted that the nurse was new and in training. Another medication cart was also found unlocked, with a Registered Nurse confirming the lock system might be broken and acknowledging the need for the cart to be locked to prevent residents from accessing medications. The Assistant Director of Nursing confirmed the medication cart should have been locked and was unaware of the inability to lock the carts in the south hallway. The facility's policy requires medication carts to be securely locked when out of the nurse's view.
Failure in Coordination of Care for Discharged Resident
Penalty
Summary
The facility failed to ensure proper coordination of care for a resident discharged to a home health agency, leading to a potential risk for an unsafe discharge. The resident, who had multiple health conditions including chronic obstructive pulmonary disease, muscle weakness, and multiple sclerosis, was discharged with a plan for follow-up care involving physical therapy, occupational therapy, and nursing services from a specified home health agency. However, the resident reported not being contacted by the agency within the expected 24 to 48 hours post-discharge, and the agency confirmed that the resident was never under their care. The case manager admitted to not following up with the home health agency or the resident to ensure services were provided, despite acknowledging previous issues with the agency's performance. The Director of Nursing confirmed the importance of follow-up calls to maintain continuity of care. The facility's policy required the care planning team to develop a post-discharge plan with arrangements for follow-up care, which was not effectively executed in this case.
Failure to Protect Resident's Protected Health Information
Penalty
Summary
The facility failed to protect a resident's protected health information (PHI) when a medication cart was left unattended and unsecured in front of a resident's room. On the cart, a laptop computer screen was left open, displaying the resident's name, medication profile, and diagnoses, which were visible to the public or other residents passing by. The Registered Nurse (RN) responsible for the cart was in the resident's room and had not locked the computer screen to safeguard the resident's medical information. The RN explained that this was only the employee's fourth day and they were still in training. Both a Licensed Practical Nurse (LPN) and another RN confirmed that nurses are trained to lock or close laptops to protect PHI. The facility's policy on confidentiality, revised in October 2017, mandates the protection and safeguarding of residents' personal and medical records.
Improper Linen Handling Procedures
Penalty
Summary
The facility failed to maintain proper linen handling procedures, which placed patients at risk for exposure to infections. On March 26, 2025, a Certified Nursing Assistant (CNA1) was observed carrying clean linen beneath their left arm and against their uniform while entering a resident's room. Later that morning, two CNAs were seen exiting the linen room with clean linen held against their chests and uniforms, confirming they were transporting it to resident rooms. CNA2 acknowledged that staff should hold clean linen away from their bodies or use a plastic bag during transport to prevent contamination. The Assistant Director of Nursing (ADON) observed the incident and indicated that the CNAs should have transported the clean linen away from their bodies to prevent contamination from potentially unclean uniforms. The facility's policy on Soiled Laundry and Bedding, revised in September 2022, requires that clean linen be protected from dust and soiling during transport and storage to ensure cleanliness.
Failure to Monitor and Maintain Resident Hydration
Penalty
Summary
The facility failed to adequately monitor and maintain the hydration status of Resident 255, who was admitted with diagnoses including malnutrition. Observations on multiple occasions revealed the resident exhibited signs of dehydration, such as dry, cracked lips, sunken eyeballs, and dry flaking skin on the lower extremities. Despite these visible symptoms, the nursing staff, including a CNA and an LPN, did not report the resident's condition to the medical provider or document the symptoms in the resident's records. The Registered Dietician (RD) had not completed a full dietary evaluation for Resident 255, and the resident was receiving 700ml less fluid per day than the recommended intake of 1975ml. The RD was unaware of the resident's dehydration symptoms as the nursing staff had not communicated this information. The facility's Medical Director confirmed that they were not informed of the resident's condition, which prevented timely medical intervention such as intravenous hydration. The resident's care plan identified a risk for dehydration and included interventions like encouraging increased oral fluids and monitoring for signs of dehydration. However, these interventions were not effectively implemented, as evidenced by the lack of documentation and communication regarding the resident's fluid intake deficits and dehydration symptoms. The facility's policies on change in condition and hydration were not followed, as there was no notification to the physician or the resident's representative about the significant change in the resident's condition.
Improper Administration of TPN via Midline IV
Penalty
Summary
The facility failed to ensure the safe administration of total parenteral nutrition (TPN) for a resident, leading to complications. The resident, who had severe protein-calorie malnutrition, dementia, dysphagia, and a history of venous thrombosis and embolism, was initially admitted with a recommendation for TPN through a central line. However, due to unsuccessful attempts to insert a central line, the TPN was administered through a midline IV catheter, which is not recommended for solutions with high osmolarity like TPN. Despite the manufacturer's recommendation for central line administration due to the high osmolarity of the TPN solution, the facility proceeded with midline administration after consulting with a pharmacist and the attending physician. The resident experienced pain and edema in the arm where the midline was inserted, indicating potential complications. The decision to use a midline was made after the resident returned from the hospital with a midline instead of a central line, and the family requested TPN administration before hospice care. The facility's actions were based on the inability to place a central line and the family's wishes, but this led to the administration of TPN in a manner contrary to the manufacturer's guidelines. The pharmacist and physician acknowledged the risks associated with midline administration of high osmolarity solutions, yet the TPN was continued temporarily. This practice resulted in the resident experiencing pain and potential complications, highlighting a deficiency in adhering to safe administration protocols for TPN.
Failure to Honor Resident Rights in Repositioning and Incontinence Care
Penalty
Summary
The facility failed to honor resident rights related to repositioning and the use of incontinence briefs for one resident, identified as R252. The resident was admitted with diagnoses including muscle weakness and was at risk for pain following recent back surgery. The care plan for R252 included goals for comfort using non-pharmaceutical methods and interventions such as repositioning every two hours to prevent skin integrity impairment. However, observations and interviews revealed that R252 was not repositioned as required, with the resident expressing discomfort from lying on their back continuously. The Turn and Reposition daily log showed multiple instances where R252 was not repositioned during various shifts. Additionally, the facility did not adequately address the resident's preferences regarding the use of incontinence briefs. R252, who was alert and able to communicate, stated a preference for not using the briefs, although they were willing to do so for the convenience of the staff. The CNA caring for R252 was unaware of the resident's preferences and did not know how to check them on the computer. The care plan lacked documentation regarding the use of incontinence briefs, and the facility's policy on urinary incontinence did not address resident preferences for using such briefs.
Privacy Breach: Resident's Weight Information Publicly Displayed
Penalty
Summary
The facility failed to safeguard the privacy of a resident by posting their body weight on a room's board that was visible from the hallway. This incident involved a resident who was alert, oriented, and capable of making their own decisions. The resident, who had been admitted with diagnoses including COPD, acute hypoxic respiratory failure, prediabetes with steroid-induced hyperglycemia, and sleep apnea, expressed concern that their weight information should not be visible to everyone due to privacy issues. A Registered Nurse confirmed the visibility of the weight information and removed it from the board. The Director of Nursing later indicated that a family member had requested the weight to be documented on the board, but there was no documented evidence of such a request in the medical record. The facility's policy on dignity stated that signs indicating a resident's clinical status or care needs should not be openly posted unless requested by the resident or family member.
Improper Administration of TPN by LPNs
Penalty
Summary
The facility failed to ensure that total parenteral nutrition (TPN) was administered by qualified Registered Nurses (RNs) for one of the sampled residents. The resident, who was admitted with severe protein-calorie malnutrition, dementia, dysphagia, and a history of venous thrombosis and embolism, had a physician's order for TPN to be administered intravenously. However, the medication administration record (MAR) for August and September revealed that TPN was documented as administered by Licensed Practical Nurses (LPNs) on multiple occasions, despite the Nevada Nursing Practice Act specifying that LPNs are not authorized to administer TPN. Interviews with LPNs and the Director of Nursing (DON) confirmed that LPNs had documented administering TPN, although they were only supposed to monitor the infusion. The DON was unaware that LPNs could not administer TPN according to state regulations. A review of personnel records showed that TPN administration was not included in the LPNs' job descriptions. This oversight in ensuring compliance with professional standards of quality had the potential to expose the resident to medication errors and health complications.
Failure to Discharge Resident to Licensed Group Home
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 161, was discharged to a licensed group home as per the physician's order. Resident 161 had multiple diagnoses, including restless leg syndrome, generalized muscle weakness, diabetes mellitus, unspecified protein-calorie malnutrition, legal blindness, and adult failure to thrive. The resident was admitted to the facility after being discharged from the emergency department due to uncontrolled muscle spasms and reported not having food at home. The resident required assistance with placement and expressed a desire to be discharged to a group home in a specific area of town. Throughout the resident's stay, various notes documented the resident's condition and discharge planning. The interdisciplinary team and case management were involved in discussing discharge options with the resident, who was agreeable to moving into a group home with hospice services. The resident's family was willing to assist with group home expenses, and the resident was evaluated and accepted to a group home. However, the discharge summary indicated that the resident was discharged to a home, and a review of the Bureau of Health Care Quality and Compliance Health Facility Locator website revealed that there was no licensed group home at the address provided. The facility's case manager indicated that the resident was alert and oriented and chose the discharge address. However, the case manager did not verify if the home was a licensed group home, leaving it to the insurance social worker to ensure compliance with the physician's order. The medical record lacked documented evidence that the resident was discharged to a licensed group home, as required, or that the discharge plan was altered based on the resident's preference to go to a private residence with hospice services.
Failure to Provide Prescribed Arm Brace and Sling
Penalty
Summary
The facility failed to ensure that a resident with a right humerus fracture was provided with the necessary arm brace and sling as per the physician's orders and care plan. The resident, identified as Resident #98, was admitted with a diagnosis of a right humerus fracture and had a physician's order dated 09/05/2024, which specified the use of a [NAME] brace and a sling with an abduction pillow at all times. On 09/17/2024, it was observed that the resident was not wearing the prescribed brace and sling, which had been removed by a staff member the previous night and could not be located. The resident reported significant pain and indicated that the brace helped alleviate the discomfort caused by the fracture. The care plan dated 08/30/2024, and a physician progress note from 09/12/2024, confirmed the necessity of the brace and sling for the resident's condition. The Physical Therapy Director also confirmed that the brace and sling should have been in place at all times until 10/14/2024. The facility's policy on Assistive Devices and Equipment required the maintenance and supervision of assistive devices as dictated by the resident's care plan. The failure to adhere to these orders and policies resulted in the resident not receiving the appropriate treatment and care, as evidenced by the absence of the prescribed brace and sling, potentially leading to complications in the resident's recovery process.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which could potentially expose residents to foodborne illnesses. During an inspection, it was observed that a cook was preparing meals without wearing a beard cover, despite having facial hair. The top surfaces of both the oven and the dishwasher were visibly soiled with greasy matter, dust, and yellowish debris. Additionally, an open bottle of milk was found undated in the walk-in refrigerator, and a milk carton was found spilled on the floor under a rack with dairy products. In the dry storage area, a 4-pound can of tuna and two 6-pound cans of pineapple chunks were visibly dented. The ice machine lid had white stains, and the inside rim was dirty and stained, despite the kitchen manager's claim that it was cleaned two weeks prior. Further observations during a tray line inspection revealed a fan placed on the floor blowing air into the food preparation area, which the kitchen manager acknowledged could lead to potential food contamination with dust. Additionally, another cook with a beard was observed setting up meal trays without wearing a beard cover. The kitchen manager confirmed these observations and acknowledged that the beard cover should have been worn, and the fan should not have been placed in the preparation area.
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 560 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) |
|---|---|---|---|---|
| Harmon Hospital - Snf | 0.1 mi | ★★★★★ | 14 | 0 |
| Life Care Center Of South Las Vegas | 0.1 mi | ★★★★★ | 6 | 2 |
| Premier Health & Rehabilitation Center Of Lv, Lp | 2 mi | ★★★★★ | 20 | 0 |
| Las Vegas Post Acute & Rehabilitation | 2.3 mi | ★★★★★ | 2 | 0 |
| Advanced Health Care Of Paradise | 2.8 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Trellis Paradise.
100% money-back within 48 hours.
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.