Above average — CMS composite of the measures below.
The next survey window likely opens 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 College Park Rehabilitation Center during CMS and state inspections, most recent first.
Resident mail was not delivered on Saturdays for one sampled resident and two other residents. A resident with intact cognition and two other residents stated Saturday mail was held until Monday, while staff gave conflicting accounts of who was responsible for sorting and delivering resident mail. The facility policy stated the designated individual delivered mail to residents on the date it was received.
Soiled mattresses and feeding equipment were left uncleaned in two resident rooms. Two floor mattresses and a pole used for gastrostomy feeding formula were visibly soiled with dried formula residue, dust, and other stains, and another floor mattress in a separate room was also visibly dirty. An RN and the IP confirmed the observations, and the IP stated the items should have been cleaned daily and as needed.
A resident with severe cognitive impairment was discharged to the hospital, but the facility could not provide documentation that the discharge notice was sent to the LTC Ombudsman. The SSD stated she believed Ombudsman notification was only required for community discharges, while the Administrator confirmed all discharge notices should have been sent and documented in the medical record.
Inaccurate MDS Psychiatric Diagnosis Coding: A resident with dementia, depression, and schizophrenia had an MDS that mis-coded psychiatric diagnoses. The record included a psych consult documenting schizoaffective disorder, bipolar type, but later MDS entries listed schizophrenia only and then added bipolar disorder without supporting psych or MD documentation. Staff later confirmed the bipolar entry appeared to be a data entry error.
Failure to initiate a baseline care plan within 48 hours for a resident admitted with CVA sequelae, metabolic encephalopathy, NSTEMI, CAD, and hemiplegia/hemiparesis, despite hospice being in place for end-of-life care. The chart lacked documentation of a baseline care plan including hospice services, and the ADON stated the facility relied on the hospice binder to align care plans.
Care Plan Not Updated for Hand Mitten Use: A resident with Parkinson's disease and dyskinesia had repeated episodes of disconnecting from the ventilator and pulling at trach-related equipment, leading to orders for a right-hand mitten to prevent removal of tubing. The facility did not update the resident's comprehensive person-centered care plan when the mitten orders were placed, and the care plan was not created until later, despite staff confirming mittens were used to protect residents from pulling on tubes, ventilators, tracheostomy, or wires.
Failure to apply ordered heel protectors for a resident with a left heel PU was identified. The resident had multiple comorbidities, was assessed as at moderate risk for pressure injury development, and had a physician order for heel protectors to be worn in bed with daily placement checks. Staff observed the resident in bed without the protectors, and an RN later confirmed the order was not being followed; a WCP also confirmed the resident had a Stage 3 left heel PU and that the protectors should be applied whenever the resident was in bed.
Medication administration errors exceeded the allowed rate during observed passes. An RN gave Fluticasone without directing a resident to rinse the mouth as ordered, and another RN administered Aspirin in the wrong form and Vitamin D3 in the wrong dose for a second resident. The nurses acknowledged the discrepancies, and the facility policy required staff to verify the physician order and match the medication and MAR before administration.
Improper Food Storage in Kitchen Refrigerators: Employee food was found stored in the prep and walk-in refrigerators with resident food, and raw shrimp, raw chicken, and raw turkey were stored above cooked food. The Asst Kitchen Mgr stated raw meats should not be placed above cooked food and employee food was not allowed where resident foods were stored. The Admin stated staff personal food belonged in the employee refrigerator in the breakroom, consistent with facility food safety and safe food handling policies.
A resident missed multiple doses of Methocarbamol and Thiamine HCl due to unavailability, despite the facility having access to these medications through their Omnicell system and house stock. The facility's policy to contact the pharmacy and notify the physician for alternatives was not followed.
A resident with multiple diagnoses, including degenerative diseases of the nervous system and muscle weakness, did not receive a physical therapy evaluation as ordered by a physician. The Director of Rehabilitation and the physical therapist acknowledged the lack of documentation for the evaluation, and the facility's policy was not followed, as there was no record of the resident's refusal or discharge of the order.
A facility failed to maintain a safe environment for a resident with multiple health issues. Maintenance requests for a wall phone and bed foot board were not completed as documented, leading to potential harm. The facility's policy on routine maintenance was not followed, resulting in unresolved issues in the resident's room.
A facility failed to administer Docusate Sodium as prescribed for a resident with Alzheimer's and constipation due to medication unavailability. The LPN and ADON did not notify the physician for an alternative, and the medication was sometimes given in tablet form instead of the prescribed liquid. The facility's policy on medication management was not followed, resulting in a deficiency in care.
Resident Mail Not Delivered on Saturdays
Penalty
Summary
The facility failed to ensure residents’ mail was delivered on Saturdays for one sampled resident and two unsampled residents. Resident 12 was admitted with acute and chronic respiratory failure with hypoxia, metabolic encephalopathy, and other specified sepsis, and had a BIMS score of 14 indicating intact cognition. During a resident council meeting, Resident 12 stated mail was not delivered to residents on Saturdays and that mail delivered to the facility on Saturday would not be received by residents until Monday. Two other residents, Resident 54 and Resident 57, also stated they did not receive mail from the post office on Saturday, and Resident 54 reported that Amazon orders were delivered to resident rooms. On interview, the Social Services Director stated the mail was delivered to the front desk, then given to the Business Office Manager to sort between facility mail and resident mail, after which the Social Services Director collected and delivered resident mail; any mail received on Saturday would be held until Monday. The Administrator stated the receptionist would separate Saturday mail and activity staff would be notified to deliver resident mail, while the Activity Director stated activity staff had not delivered resident mail since working at the facility and believed the charge nurse was responsible on Saturdays. The Charge Nurse stated resident mail had not been given to nursing to distribute on Saturdays. The facility policy stated the designated individual delivered mail to residents on the date it was received.
Soiled mattresses and feeding equipment left uncleaned in resident rooms
Penalty
Summary
The facility failed to ensure that mattresses and equipment used in resident rooms were maintained in a clean and sanitary condition in 2 resident rooms. In one room, two floor mattresses were observed placed bilaterally on the floor near a resident's bed, close to the door, and a pole used to hang gastrostomy feeding formula was located on the right side of the bed. The mattresses and the pole were visibly soiled with dried feeding formula residue, dust, and other unidentified stains. In another resident room, a floor mattress was observed on the left side of the bed near the window and was visibly soiled with dust and other unidentified stains. The floor mattresses and the pole remained unchanged when reobserved the next day, and an RN and the Infection Preventionist confirmed the observations. The Infection Preventionist stated the mattresses and pole should have been cleaned daily and as needed, especially when formula or other fluids were spilled. The Environmental Services Supervisor stated resident rooms were cleaned twice daily and as needed, and that the floor mattresses should have been cleaned as part of housekeeping while nurses should have cleaned the pole. The facility policy for resident room cleaning described routine cleaning and disinfection to provide a clean, safe decontaminated environment.
Failure to Send Discharge Notice to Ombudsman
Penalty
Summary
The facility failed to ensure that a copy of the discharge notice was sent to a representative of the Office of the State Long-Term Care Ombudsman for Resident 11 when the resident was discharged to the hospital. Resident 11 was re-admitted with diagnoses of metabolic encephalopathy, cellulitis of the abdominal wall, gastrostomy malfunction, and pain, and had a BIMS score of 0, indicating severe cognitive impairment. Record review showed the facility could not provide documentation that the discharge notice had been sent to the Ombudsman when the resident left for the hospital. During interview, the Social Services Director stated she was not aware that discharge notices for residents discharged to the hospital had to be submitted to the Ombudsman’s office and believed only notices for residents discharged to the community were required. The Administrator later confirmed that all discharge notices, regardless of discharge destination, should have been sent to the Ombudsman, and the facility policy required written notification of transfer or discharge to the resident, family member or legal representative if known, and the Long-Term Care Ombudsman, with documentation in the medical record.
Inaccurate MDS Psychiatric Diagnosis Coding
Penalty
Summary
The facility failed to ensure the accuracy of the MDS assessment for one resident by inaccurately coding a psychiatric diagnosis. Resident 4 was admitted with diagnoses including dementia, depression, and schizophrenia. A psychiatric consult note documented schizoaffective disorder, bipolar type, and a nursing progress note later documented transfer to the hospital for G-tube replacement. However, the MDS discharge assessment listed schizophrenia as the only psychiatric diagnosis and non-Alzheimer's dementia as a neurological diagnosis, without including bipolar disorder despite the earlier psychiatric documentation. After the resident returned to the facility, the hospital discharge summary listed a history of schizophrenia but did not include bipolar disorder. The MDS quarterly assessment later newly documented bipolar disorder, but the medical record did not contain evidence of a psychiatric evaluation or physician documentation supporting that diagnosis. During interviews, the Social Services Assistant stated the resident had been admitted with schizoaffective disorder, bipolar type, and had not been diagnosed with bipolar disorder alone, and acknowledged the bipolar diagnosis in the MDS appeared to be an error. The MDS Coordinator also confirmed the resident did not have a current diagnosis of bipolar disorder and that the entry in the MDS was likely a data entry error.
Failure to Initiate Baseline Care Plan for Hospice Resident
Penalty
Summary
The facility failed to ensure a baseline care plan was initiated within 48 hours of admission for one sampled resident, who was re-admitted with diagnoses including other sequelae of other cerebrovascular disease, metabolic encephalopathy, non-ST elevation myocardial infarction, atherosclerotic heart disease, and hemiplegia and hemiparesis. Hospital discharge records documented that the resident was to be transferred to a nursing facility with hospice for end-of-life care. A nursing progress note dated 05/13/2025 at 5:28 PM documented that the resident was seen by the hospice nurse, who stated the resident was officially under hospice and that the family had already been informed and signed consents. Hospice consent was signed by the family representative on 05/14/2025 and by hospice staff on 05/13/2025 with an effective date of 05/13/2025. On 09/19/2025, the Medical Records Director was unable to find documentation of a baseline care plan that included hospice care or services, and the ADON stated that once a resident was on hospice, the hospice provider would give the facility a binder containing the resident's care plan, which the facility would then use to align its own care plans. The facility policy titled Care Plan Process, Person-Centered Care, revised May 5, 2023, stated the baseline person-centered care plan would be developed and implemented within 48 hours of admission and include the minimum healthcare information necessary to properly care for the resident, including initial goals based on admission orders, dietary orders, therapy services, social services, and PASARR recommendations if applicable.
Care Plan Not Updated for Hand Mitten Use
Penalty
Summary
The facility failed to ensure that Resident 1 had an updated comprehensive person-centered care plan. Resident 1 was admitted with a diagnosis of Parkinson's disease with dyskinesia and was observed on 09/17/2025 with a mitten on the right hand. Physician orders dated 07/08/2025 and 07/23/2025 documented the use of a right-hand mitten to prevent the resident from pulling out tubing for 14 days. Record review showed multiple events involving the resident disconnecting from the ventilator and pulling at respiratory equipment, including a behavior note on 07/10/2025 documenting the resident disconnected from the ventilator four times in 20 minutes and was observed pulling at the tracheostomy, a progress note on 07/22/2025 documenting the ventilator alarm was going off and the resident pulled off the ventilator circuit and removed the pulse oximeter sensor, and a progress note on 08/17/2025 documenting the resident pulled off the closed suction catheter and disconnected from the ventilator. On 09/17/2025, an RN stated the facility used mittens to protect residents from pulling on tubes, ventilators, tracheostomy, or wires, and provided a hard copy care plan showing the mitten care plan was created that day. On 09/18/2025, the ADON stated the care plan should have been updated when the mitten orders were placed on 07/08/2025 and 07/23/2025, and verified it was not updated at that time.
Failure to Apply Ordered Heel Protectors
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for a resident admitted with atrial fibrillation, congestive heart failure, diabetes mellitus, and NSTEMI. The resident had a left heel pressure ulcer documented on the wound management record and PUSH chart, and a Braden Scale assessment identified the resident as being at moderate risk for pressure ulcer development. The care plan included pressure injury prevention interventions such as a low air loss mattress, daily mattress setting checks, repositioning with draw sheets or similar devices, and use of pillows or pads to offload pressure from bony prominences. A physician order dated 05/05/2025 directed staff to apply heel protectors, check placement daily, and replace as needed. However, on 09/16/2025 the resident was observed in bed without heel protectors in place. The next day, an RN confirmed the resident was not wearing heel protectors and acknowledged the physician order to protect the heels while the resident was in bed. A wound care physician later confirmed the resident had a Stage 3 pressure ulcer on the left heel and stated heel protectors were ordered to prevent further deterioration and should be applied whenever the resident was in bed.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure residents were free from medication errors exceeding 5 percent during observed medication administration passes. During an observation on 09/18/2025 at 8:15 AM, RN1 administered Fluticasone 200 mcg, 1 puff via inhalation, to Resident 13. The physician order dated 07/02/2025 specified Fluticasone 200 mcg, 1 puff once daily for COPD, with special instructions to rinse the mouth with water after administration and not to swallow. RN1 did not direct the resident to rinse the mouth after the medication was given. Later that day, RN1 acknowledged the omission and stated that Fluticasone could cause oral fungal infections if the mouth was not rinsed after use. During the same medication pass observation, RN2 administered medications to Resident 49 that did not match the physician orders. RN2 gave Aspirin 81 mg in chewable form even though the order dated 12/08/2024 specified Aspirin delayed-release/enteric-coated 81 mg once daily for cerebral infarction. RN2 also administered Vitamin D3, 1 tablet, although the order dated 01/08/2025 directed 2 tablets of 25 mcg each once daily for vitamin D deficiency. RN2 acknowledged the discrepancies and stated the physician orders should have been verified prior to administration. The facility policy titled Medication Management Program required staff to validate the physician order, match the medication and label with the MAR, and read the medication label before removing it from the drawer and again before and after administration.
Improper Food Storage in Kitchen Refrigerators
Penalty
Summary
The facility failed to ensure that raw food, resident food, and staff food were stored according to guidelines and facility policies. During observation, employee food was found stored in the prep refrigerator, including a container of blueberries and a protein drink, and additional employee food was found in the walk-in refrigerator, including kimchi, an avocado, and a cucumber. The walk-in refrigerator also contained a box of raw shrimp, raw chicken, and raw turkey stored above cooked food. The Assistant Kitchen Manager stated that raw meats should not be placed above cooked food and that employee food was not allowed where resident foods were stored. The Administrator stated that employees were not allowed to store personal food items in the kitchen refrigerators and were to use the employee refrigerator in the breakroom. Facility policies titled Food Safety in Receiving and Storage and Safe Food Handling stated that raw animal foods must be stored by cooking temperature, with higher-temperature items such as chicken on the lowest shelf, and that employee foods and beverages must be stored in designated employee areas and labeled with the employee's name and date.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to ensure timely administration of medications for a resident, leading to a deficiency in pharmaceutical services. The resident, who was admitted with diagnoses including degenerative diseases of the nervous system, pain, vitamin deficiency, and major depressive disorder, had a physician order for Methocarbamol to be administered four times daily. However, the resident missed the 1:00 PM and 5:00 PM doses on the day of the order, with the first dose only being administered at 9:00 PM due to the medication being unavailable. Additionally, a dose of Thiamine HCl for vitamin deficiency was missed that morning for the same reason. The Assistant Director of Nursing confirmed that Methocarbamol was available in the facility's Omnicell system, which could have been used for the resident. The Director of Nursing also confirmed that Thiamine HCl was a house-stocked item and could have been obtained over the counter if necessary. The facility's policy requires contacting the pharmacy and notifying the physician for alternatives if a medication is unavailable, which was not adhered to in this instance.
Failure to Conduct Physical Therapy Evaluation
Penalty
Summary
The facility failed to ensure that a resident received a physical therapy evaluation as ordered by a physician. The resident, who was admitted with diagnoses including degenerative diseases of the nervous system, pain, muscle weakness, lack of coordination, and major depressive disorder, had a physician's order dated 11/13/2024 for a physical therapy evaluation and treatment. However, the resident's medical record lacked documented evidence that this evaluation had been completed. The Director of Rehabilitation and the physical therapist acknowledged the absence of documentation for the physical therapy evaluation. The Director of Rehabilitation stated that they were informed the resident had refused the evaluation, but there was no documentation of this refusal. The facility's policy required that a qualified medical personnel take and implement orders according to guidelines, but the physical therapist did not document the refusal or discharge the order, nor did they inform nursing or the physician. This oversight resulted in the failure to complete the evaluation as per the physician's order.
Failure to Maintain Safe and Functional Environment for Resident
Penalty
Summary
The facility failed to maintain a safe and functional environment for a resident, identified as Resident #1, who was admitted with multiple diagnoses including degenerative diseases of the nervous system, pain, vitamin deficiency, muscle weakness, lack of coordination, and major depressive disorder. Upon admission, several maintenance issues were identified in the resident's room, including the need for an overbed table, a working TV, a wall phone, and a secure bed foot board. While the overbed table and TV were documented as completed on the day of admission, the work orders for the wall phone and bed foot board were not marked as completed until several days later. The Maintenance Assistant confirmed that the work orders for the phone and foot board were not initially completed, despite being marked as such. The assistant was unsure why duplicate work orders were submitted if the issues had been resolved previously. This lack of documentation and follow-through on maintenance requests indicates a failure to adhere to the facility's policy on routine maintenance, which requires regular upkeep of floors, walls, fixtures, and equipment. This oversight could have led to unusable devices and potential harm to the resident.
Failure to Administer Prescribed Medication Due to Unavailability
Penalty
Summary
The facility failed to ensure physician orders were followed for the administration of Docusate Sodium, a stool softener, for a resident with Alzheimer's Disease, unspecified dementia, cognitive communication deficit, dysphagia, and constipation. The resident, who had a gastronomy tube, was prescribed Docusate Sodium to be administered twice daily. However, the medication was not consistently available, and there was no documented evidence that the physician was notified to prescribe an alternative when the medication was unavailable. The Medication Administration Record (MAR) showed multiple instances where the medication was not administered due to unavailability, and the facility's policy required contacting the pharmacy and notifying the physician for alternatives, which was not done. The Licensed Practical Nurse (LPN) and the Assistant Director of Nursing (ADON) acknowledged the unavailability of the medication and the lack of notification to the physician. The ADON checked the house stock supply and central supply but found no Docusate available. The ADON also noted that the medication was sometimes administered in tablet form instead of the prescribed liquid form, without physician approval. The facility's policy on medication management was not followed, as the nurses did not document the unavailability properly or seek alternatives from the physician, leading to a deficiency in the resident's care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near North Las Vegas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mission Pines Nursing And Rehab Center | 0 mi | ★★★★★ | 15 | 0 |
| North Las Vegas Care Center | 0.6 mi | ★★★★★ | 31 | 0 |
| Gaye Haven Intermediate Care Facility | 3.3 mi | — | 0 | 0 |
| Horizon Health And Rehabilitation Center | 3.9 mi | ★★★★★ | 1 | 0 |
| Saint Joseph Transitional Rehabilitation Center | 5.3 mi | ★★★★★ | 28 | 0 |
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