Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Spring during CMS and state inspections, most recent first.
Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, labeling, and disposal, including multiple dry, refrigerated, and frozen items that were past best-by/use-by dates or lacked required labels such as item description, received date, and use-by date. Opened and prepared foods were stored without proper dating or identification, despite posted instructions requiring complete labeling. The DM, contracted dietary leadership, dietician, and ADMN all acknowledged that foods should be labeled and discarded per policy and that all residents ate from the kitchen, but the observed practices did not match these stated expectations or the facility’s written storage policies and the FDA Food Code.
Surveyors found that two residents on pureed diets did not receive all items listed on the posted pureed menu during a dinner meal, specifically missing pureed cornbread while receiving pureed beef stew, vegetables, and baked apples. Both residents had documented nutritional problems and were at risk for or experiencing poor intake and weight issues, with one resident requiring increased calories for wound healing and another having most meals at or below 50% intake. The DM acknowledged overlooking the cornbread because it was stored separately, and CNAs reported checking diet texture but not detecting the missing item. The dietitian, DON, and administrator all stated that residents were expected to receive all menu items, and facility policy assigned nursing responsibility for verifying meal accuracy against diet orders.
A resident with multiple complex medical conditions experienced a fall during toileting and was moved by staff without a nurse assessment. Staff did not immediately report the resident's pain, and the nurse failed to perform a timely pain assessment, only administering acetaminophen and later conducting a full assessment after the family reported the incident. The resident was later diagnosed with a femoral fracture at the hospital. Incomplete documentation and lack of communication regarding the resident's mobility needs contributed to the deficiency.
A resident with multiple complex medical conditions experienced an assisted fall shortly after admission. Nurse aides moved the resident without a nurse assessment, and staff failed to promptly communicate the resident's pain complaint to the LPN. The LPN did not fully assess the resident's pain before administering medication, and critical information about the fall was not relayed during shift change. The resident was later diagnosed with a femoral fracture in the ER. These failures demonstrated a lack of staff competency in fall assessment, pain management, and communication.
The facility failed to complete quarterly MDS assessments for three residents, leading to a backlog in required evaluations. Interviews revealed that the Administrator and DON were unaware of the delays, while the MDS Coordinator attributed the issue to a flood earlier in the year. The facility's policy mandates timely assessments, which were not adhered to.
The facility failed to store and discard spoiled food properly, as observed in the kitchen where spoiled cucumbers, broccoli, lettuce, and bell peppers were found. The DM and ADMN acknowledged the expectation to discard spoiled food, attributing the failure to staff turnover and lack of oversight.
A resident's room was found to have dusty blinds, which irritated her allergies. The facility's housekeeping staff failed to follow cleaning protocols, leading to this deficiency. The housekeeping manager and administrator acknowledged the oversight, attributing it to staff rushing and inadequate supervision.
A medication cart on Hall 500 was found unlocked and unattended, containing various medications including narcotics, while RN A was in a resident's room. The cart was not within the nurse's line of sight, allowing a resident and a visitor to pass by. Despite being trained on security protocols, RN A admitted to leaving the cart unsecured, and the DON confirmed the requirement for carts to be locked when unattended.
A facility failed to maintain proper infection control during incontinent and wound care. A CNA did not change gloves or perform hand hygiene between tasks, risking cross-contamination. An LVN used contaminated gloves during wound care after handling unclean items. Both staff members acknowledged their errors, despite having completed relevant training.
A facility failed to protect a resident's privacy by disclosing her BIMS score and medical diagnosis to a notary and employees during a court-related incident. The administrator admitted to sharing this information to manage a situation involving a notary attempting to have the resident sign documents. The resident, with a history of cognitive impairment, was involved in an ongoing court case, and the breach was reported by a family member to the ombudsman.
A facility failed to develop a baseline care plan within 48 hours for a newly admitted resident with end-stage renal disease, hyperlipidemia, and hypertension. The resident was admitted on a Friday and left AMA early Monday, but the required care plan was not completed. Staff interviews confirmed the oversight, despite the facility's policy mandating timely completion.
Improper Food Storage, Labeling, and Disposal in Kitchen Food Service
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and disposal of food items in the kitchen. During a kitchen observation, they found multiple dry storage items that were not handled according to facility policy and professional standards, including an opened bag of chips in a plastic bag labeled with a use-by date that was 11 days past, an unopened bag of hamburger buns with no received date, use-by date, or item description, and an opened box of flour tortillas with several bags bearing a best-by date that had already passed. The facility’s posted instructions in the kitchen stated that everything must have a label with received date, open date, and use-by date, but these requirements were not consistently followed. In the refrigerated storage, surveyors observed additional issues, including two cartons of heavy whipping cream with best-by dates that had passed, two bags of corn tortillas with best-by dates that were more than a month past, and an opened bag of shredded white cheese labeled only with a date and no use-by date or item description. They also found an opened container of pimento spread with no received date and an illegible use-by date, an unopened bag of what appeared to be hot dogs with only a handwritten date and no use-by date or item description, and two containers of prepared food (one in a see-through plastic container and one in a metal tin) without preparation dates, use-by dates, or item descriptions. In the freezers, surveyors found an opened bag of what appeared to be french fries that was not sealed and lacked any delivery date, use-by date, or item description, and three unopened bags of what appeared to be garlic toast labeled only with a date and no use-by date or item description. Interviews with facility and contracted dietary staff confirmed that these practices did not align with the facility’s policies and expectations. The dietary manager stated that all food items stored outside their original containers should have a received date, item description, and, when applicable, a use-by date, and that items should not be stored past their best-by dates. The contracted Director of Operations for dietary services and the dietitian both stated that foods should be labeled with descriptions and expiration or use-by dates when stored outside original packaging and discarded after those dates, and that the dietary manager was responsible for monitoring labeling and storage. The administrator stated that all residents ate from the kitchen, that dietary services were contracted, and that his expectation was that foods be stored, labeled, and discarded per policy. Facility policies on dry goods and cold food storage required that all goods be appropriately date-labeled and that foods be wrapped, covered, or contained within labeled and dated packages or containers, and the FDA Food Code was cited regarding required food labeling and consumption or disposal of refrigerated foods by their expiration date.
Failure to Follow Posted Pureed Menu Items for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow the posted Fall/Winter Week 5 Wednesday pureed menu for two residents on a pureed diet. The menu for that meal specified pureed beef stew, pureed garden salad with dressing, pureed cornbread, and pureed baked apple slices. Observations on the survey date showed that the dietary manager (DM) plated trays for two residents on pureed diets with pureed beef stew, pureed mixed vegetables, and pureed baked apples, but did not include the pureed cornbread listed on the menu. The trays were then sent out for service without the missing menu item being identified or corrected at the time of plating. Resident #14 was an elderly female with dementia, history of stroke, weakness, reduced mobility, and coordination deficits, with a BIMS score indicating moderate cognitive impairment. Her care plan and nutrition assessment documented nutritional problems related to depression, a need for more calories than provided by meals alone, and risk for malnutrition due to a dysphagia pureed diet and a wound, with daily caloric needs of 1618 kcals and use of supplements to promote healing. Physician orders included a regular diet with dysphagia pureed Level 1 texture and nectar-thick liquids, with assistance for feeding. During the observed dinner meal, her tray did not contain the pureed cornbread that was on the menu, and she was no longer in the dining room when the omission was discovered. In a later interview, she stated she liked cornbread and would have eaten it if it had been on her tray. Resident #79 was an elderly male with metabolic encephalopathy, diabetes mellitus, urologic conditions, dementia, and cognitive communication deficits, with an MDS BIMS score of 0 indicating he was unable to complete the interview. His care plan and nutrition documentation identified nutritional problems related to depression, goals for maintaining weight and adequate PO intake, and more recent notes showing poor intake with most meals at or below 50%, risk for unavoidable weight loss, dehydration, and skin decline related to disease progression, and a goal focused on comfort with house supplements offered. For the same pureed meal, his tray was prepared without the pureed cornbread and placed on a cart for room delivery. CNAs distributing trays reported they checked for correct diet texture but did not detect the missing cornbread. The DM later acknowledged she overlooked the cornbread because it was stored separately from other pureed foods and confirmed that all residents should receive all items listed on the menu. The facility’s policy stated that nursing staff are responsible for verifying meal accuracy against diet orders and that meals are to be prepared according to individual meal cards, but interviews with the DON, administrator, and dietitian confirmed that the residents were not provided all menu items as expected.
Failure to Recognize, Assess, and Manage Pain Following Resident Fall
Penalty
Summary
A deficiency occurred when a resident who had recently been admitted to the facility experienced a fall during toileting and was subsequently moved by nurse aides and an occupational therapy assistant without a nurse first assessing the resident for pain or injuries. The nurse aides did not immediately report the resident's pain to the nurse after the fall. When the nurse was eventually notified of the resident's leg pain, a proper pain assessment was not completed at that time. Instead, the nurse administered acetaminophen and only later performed a head-to-toe assessment after being approached by the resident's family member, who reported the fall and pain. The resident involved had significant medical conditions, including metabolic encephalopathy, type 2 diabetes, cirrhosis of the liver, and sepsis due to E. coli. The resident was admitted to the facility for only a few hours before the incident occurred. There was no comprehensive care plan available for the resident, and the initial assessment documentation was incomplete, particularly regarding the resident's mobility and safety needs. Staff interviews revealed that the hospital did not communicate the need for lift assistance, and the admitting nurse did not complete the required documentation to inform other staff of the resident's assistance needs, which may have contributed to the fall and subsequent handling of the resident. Witness statements and interviews with staff indicated that the resident complained of pain during and after being moved, but the information was not promptly or adequately communicated to the nurse. The nurse did not perform an immediate assessment upon learning of the pain and only took action after the family intervened. The resident was later transported to the hospital, where a femoral fracture was diagnosed. The facility's failure to recognize, assess, and manage the resident's pain in accordance with professional standards and the lack of proper communication and documentation led to the identified deficiency.
Failure to Ensure Staff Competency in Fall Assessment and Pain Management
Penalty
Summary
The facility failed to ensure that nurses and nurse aides demonstrated the necessary competencies and skill sets to provide safe and appropriate care for residents, as evidenced by the handling of a new admission who experienced an assisted fall. The resident, who had significant medical conditions including metabolic encephalopathy, type 2 diabetes, cirrhosis of the liver, and sepsis, was admitted and within hours experienced a fall during toileting assistance. Nurse aides assisted the resident to the floor and subsequently moved her without a nurse first assessing for pain or injury, contrary to facility protocol and policy. The nurse on duty was informed of the incident but did not perform an assessment before the resident was moved, and the resident later complained of significant pain in her left leg. Communication failures were evident among staff. Nurse aides did not promptly relay the resident's complaint of pain to the appropriate nurse, and the nurse did not provide the oncoming nurse with information about the fall during shift change. As a result, the resident's pain was not fully assessed before pain medication was administered, and the incident was not properly communicated or documented in a timely manner. Multiple staff interviews confirmed that the protocol requiring a nurse to assess any resident after a fall before movement was not followed, and that there was confusion or lack of clarity about the incident among both nurse aides and licensed nurses. Record reviews and staff interviews further revealed that the facility's policy required a thorough nursing assessment after any fall, including vital signs, musculoskeletal evaluation, and pain assessment, none of which were completed prior to moving the resident. The resident was eventually sent to the emergency room, where a femoral fracture was diagnosed. The deficiency was identified as Immediate Jeopardy due to the failure to protect residents by ensuring staff competency in essential care skills, particularly in the assessment and management of falls and pain.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to conduct quarterly assessments for three residents, as required by state and CMS guidelines. Resident #1, a female with urinary tract infection, bladder dysfunction, and depression, had her last MDS assessment completed on July 11, 2024, with the next quarterly assessment in progress as of November 7, 2024. Resident #3, a male with bipolar disorder, anxiety, and dementia, had his last MDS assessment completed on June 22, 2024, with the next quarterly assessment in progress as of November 7, 2024. Resident #6, a female with dementia, depression, and heart failure, had her last annual MDS assessment completed on July 5, 2024, with the next quarterly assessment in progress as of November 7, 2024. Interviews with facility staff revealed a lack of awareness and responsibility for the timely completion of MDS assessments. The Administrator was unsure of the timeframe requirements and was unaware of the facility's backlog. The DON stated that it was the MDS Coordinator's responsibility to monitor MDS completions, while the MDS Coordinator cited a flood at the beginning of the year as the reason for the delay. The facility's policy requires assessments to be conducted within fourteen days of admission, quarterly, annually, and when there is a significant change in the resident's condition.
Failure to Properly Store and Discard Spoiled Food
Penalty
Summary
The facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation in the kitchen, several spoiled food items were found in the refrigerator, including cucumbers with a white substance, broccoli and lettuce that had turned brown, and bell peppers with black and soft spots. These findings indicate a failure to dispose of spoiled food items properly, which could place residents at risk for foodborne illnesses. Interviews with the Dietary Manager (DM) and the Administrator (ADMN) revealed that both expected spoiled or expired food to be discarded. The DM acknowledged that all kitchen staff were responsible for discarding spoiled food, but she was ultimately responsible for ensuring it was done. She attributed the failure to staff turnover and absences, which led her to work extra hours. The ADMN also stated that the DM was responsible for ensuring spoiled food was discarded and cited a lack of oversight by the DM as the reason for the failure.
Failure to Maintain Clean Environment for Resident
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment for Resident #13, as evidenced by the presence of dust on the blinds in her room. Resident #13, a cognitively intact female with a history of encephalopathy, hypothyroidism, type 2 diabetes, hypertension, heart failure, and anxiety, expressed that the dust on the blinds irritated her allergies. The observation of dust on the blinds was confirmed during an interview with the resident. Interviews with the housekeeping department manager (HK DM) and the administrator (ADMN) revealed that the facility's expectation was for resident rooms to be dusted at least every other day, with blinds being cleaned daily. The HK DM acknowledged that the failure to clean the blinds was due to staff rushing and skipping steps, while the ADMN attributed the issue to a lack of supervision by the housekeeping supervisor. The facility's cleaning protocol, which includes disinfecting horizontal surfaces and using a high duster for hard-to-reach areas, was not followed, leading to the deficiency.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that medications were stored securely in locked compartments, as observed with the medication cart on Hall 500. During an observation, the medication cart was found unlocked and unattended in the hallway, while RN A was in a resident's room with the door closed. The cart contained various prescription and over-the-counter medications, including narcotics, which were not secured with the required two locks. This lapse in security allowed a resident and a visitor to pass by the unattended cart, posing a risk of unauthorized access to the medications. RN A acknowledged responsibility for the medication cart and admitted to knowing the importance of keeping it locked. Despite being trained on the facility's policy, which mandates that medication carts be locked when not in use or out of the nurse's view, RN A left the cart unsecured. The Director of Nursing (DON) confirmed that the medication carts should be locked when unattended and attributed the failure to a possible distraction. The facility's policy outlines specific procedures for securing medication carts, emphasizing the need for them to be locked and parked appropriately when not in use.
Infection Control Deficiencies in Incontinent and Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper practices observed during incontinent care and wound care for a resident. A Certified Nursing Assistant (CNA) did not change gloves or perform hand hygiene between dirty and clean tasks while providing peri-care to a resident, leading to potential cross-contamination. The CNA admitted to the oversight, acknowledging the risk of infection due to not following proper procedures. Despite having completed perineal care training, the CNA did not adhere to the established guidelines, which included changing gloves and performing hand hygiene between tasks. Additionally, a Licensed Vocational Nurse (LVN) was observed performing wound care with contaminated gloves after retrieving unclean items from her pockets. The LVN acknowledged the mistake, recognizing the potential for cross-contamination and infection. The Director of Nursing (DON) confirmed that the LVN's actions could have led to wound contamination. Despite having completed wound care competency training, the LVN did not follow the facility's wound care policy, which requires maintaining a clean field and using a no-touch technique.
Breach of Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's personal and medical information, specifically concerning the resident's BIMS score and medical diagnosis. This breach occurred when the facility's administrator disclosed this sensitive information to a notary and a group of employees during an incident involving a court case. The resident in question, a female with a history of metabolic encephalopathy, arthritis, dementia, and anxiety disorder, was involved in an ongoing court case. The administrator revealed the resident's BIMS score, which indicated moderate cognitive impairment, in an attempt to address a situation involving a notary who was trying to get the resident to sign documentation. The incident was brought to light when the resident's family member contacted the ombudsman, expressing concern that the resident's medical information had been improperly shared. The family member was unaware of who had disclosed the information until the administrator admitted to doing so, claiming it was necessary to calm the situation. The facility's policy on confidentiality, which mandates the protection of all resident information, was not adhered to in this instance, leading to the unauthorized sharing of the resident's protected health information.
Failure to Develop Baseline Care Plan for Newly Admitted Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a newly admitted resident, which is required to be completed within 48 hours of admission. The resident, a female with diagnoses including end-stage renal disease, hyperlipidemia, and hypertension, was admitted on a Friday and left against medical advice early the following Monday. Despite the short duration of stay, the facility did not complete the baseline care plan, as confirmed by the MDS Coordinator and the Director of Nursing (DON). Interviews with facility staff, including the MDS Coordinator, Administrator, and DON, revealed that the interim plan of care was completed upon admission, but the baseline care plan was not. The staff acknowledged that the baseline care plan should have been completed within the required timeframe, even though the resident's stay spanned a weekend. The facility's policy, dated December 2016, mandates that a baseline care plan be developed within 48 hours to meet the resident's immediate needs, which was not adhered to in this case.
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What surveyors actually found near you
We read the 137 citations issued within 25 miles in the last 12 months — including the 8 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
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Abilene
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hendrick Skilled Nursing Facility | 1.9 mi | ★★★★★ | 1 | 0 |
| The Oaks At Radford Hills Healthcare Center | 2.1 mi | ★★★★★ | 12 | 0 |
| Avir At Coronado | 2.5 mi | ★★★★★ | 28 | 0 |
| Northern Oaks Living & Rehabilitation Center | 2.7 mi | ★★★★★ | 9 | 0 |
| Brightpointe At Lytle Lake | 2.7 mi | ★★★★★ | 10 | 2 |
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