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 Mission Pines Nursing And Rehab Center during CMS and state inspections, most recent first.
Incomplete Water Management Program: The facility’s WMP included a water flow narrative and diagram, but the diagram did not identify control points, control measures, control limits, corrective actions, or areas of limited flow. The Maintenance Director stated the facility did not monitor disinfectant levels and relied on the dishwasher and laundry washing machine for temperature monitoring, while the IP stated there had been no residents with Legionella since the last survey.
Medication Storage and Labeling Deficiencies: Surveyors found an Arformoterol Tartrate medication that required refrigeration stored in an OTC cabinet at room temperature, an opened Lorazepam MDV without an opened date, and expired OTC eye drops and earwax softener in medication storage areas. The ADON confirmed the storage and labeling issues, and the DON stated night shift staff were expected to check medication rooms monthly and discard expired and discontinued meds.
Facility Assessment Missing Staffing Plan: The facility assessment tool did not include a staffing plan. Instead, it contained a sample staffing schedule with staff names for each unit and shift, and the Administrator confirmed it lacked the required plan identifying the number of LPNs and CNAs needed on every shift. The staff scheduler said staffing was based on the sample schedule and training from the former HR director rather than a formal staffing plan.
The facility failed to serve meals at an appetizing temperature, affecting several residents. Meals initially had acceptable temperatures but cooled significantly by the time they were served due to improper handling, as confirmed by test trays and resident feedback. The Dietary Director acknowledged the issue, which violated the facility's policy referencing the FDA Food Code.
The facility failed to complete PASARR Level II referrals for three residents with mental illness diagnoses, potentially depriving them of necessary behavioral health services. Despite having conditions such as schizoaffective disorder and schizophrenia, the residents' medical records lacked evidence of the required referrals, as confirmed by the Social Services Director and Medical Records Staff.
The facility failed to label an opened MDV of Tubersol with an open date, as observed during an inspection of the medication refrigerator. The ADON confirmed that all MDV vaccines should be labeled with an open date, and the discard date should follow the manufacturer's instructions. The product inserts for Tubersol indicate that the vial is good for 30 days once accessed, while the facility's policy requires MDVs to be dated and discarded within 28 days unless otherwise specified.
A resident with a dairy allergy was served a meal lacking a protein due to both available options containing dairy. The meal also had discrepancies, such as missing herbed rice and including hamburger toppings without a hamburger. The Dietary District Manager confirmed the oversight and acknowledged the mistake in serving meatloaf, which contained dairy. The facility's policy requires meals to conform to diet orders and preferences, which was not followed.
The facility failed to store food according to safety standards, with an open box of unbaked cookies found in a nourishment freezer accessible to various staff, risking contamination. Additionally, a handwashing sink was blocked by a dish cart and a plunger, preventing proper hand hygiene practices.
A resident with a history of homelessness and mental health diagnoses requested assistance from the facility's social worker to retrieve personal mail from a shelter. Despite multiple requests, the Social Services Director did not communicate the issue to the inter-disciplinary team, assuming transportation was unavailable. The Administrator acknowledged the request was reasonable and could have been accommodated, highlighting a failure to honor the resident's rights.
A facility failed to verify the professional license of an employee, leading to an unqualified individual working as an RN for over six months. The employee, identified as E9, used another person's RN license and performed duties such as health assessments and medication administration. Despite discrepancies in identification, the facility employed E9 without proper verification, placing residents at risk.
A resident with dementia and behavioral disturbances was involved in multiple altercations with other residents, but the facility failed to update the care plan to reflect these incidents or implement new preventative strategies. Despite documented interventions, the care plan was not revised, leading to a deficiency in care planning and risk management.
Incomplete Water Management Program
Penalty
Summary
The facility did not ensure its Water Management Program (WMP) was complete and included all required elements. Review of the WMP showed the team included the Director of Maintenance, the Infection Preventionist/DON, the Administrator, the Assistant Administrator, and the Maintenance Assistant. The WMP contained a written narrative describing water flow in the building, including 109 resident rooms, 56 rooms with two shared shower rooms on the North side, and 53 rooms with [NAME] and [NAME] shower set up on the South side. It also identified nine 100-gallon water heaters and three 100-pound ice machines, and included a flow diagram for the path of water through the facility. The flow diagram did not identify locations where potentially dangerous conditions or limited flow could occur, and it did not specify control points, control measures, control limits, or corrective actions. The WMP stated that bacteria growth is more likely in rarely flowed piping systems, dead legs, fixtures that see little use, and shower heads and faucet aerators that collect debris, but these areas of limited flow were not identified in the WMP. On interview, the Maintenance Director stated the facility had five ice machines and nine water heaters, did not monitor disinfectant levels, and relied on the dishwasher and laundry washing machine to monitor water temperatures because they would not operate if temperatures were not within acceptable limits. The Infection Preventionist stated the facility had not had any residents with Legionella since the last survey.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not consistently labeled and stored according to accepted professional principles. During an inspection of the OTC cabinet in the 200-Hall medication storage room, surveyors found two boxes of Arformoterol Tartrate 12 mcg/2 ml labeled with a blue sticker indicating refrigeration and identified for an active resident, but the medication was stored in the OTC cabinet at room temperature rather than in a refrigerator. The product insert directed storage between 36 degrees Fahrenheit and 46 degrees Fahrenheit, and the recorded room temperature was 68.2 degrees Fahrenheit. The ADON confirmed the medication had been stored at room temperature even though it required refrigeration, and stated the resident’s Arformoterol had been discontinued on 10/09/2025 and should have been discarded. Surveyors also found one opened MDV of Lorazepam injection 2 mg/ml with remaining contents that was not labeled with an opened date, and the ADON confirmed it had been accessed but not dated even though MDVs were to be dated and were good for 28 days once opened. In addition, expired OTC medications were present in the 500-Hall medication room, including 30 vials of lubricating eye drops with an expiration date of August 2025 and a box of earwax softener drops with an expiration date of August 2025. The ADON confirmed the expired medications and stated uncertainty about who was responsible for inspecting medication rooms and how often inspections were completed. The DON stated night shift staff should check medication rooms at least once a month and discard expired and discontinued medications, and confirmed the improperly stored medication, the unlabeled MDV, and the expired medications were an oversight.
Facility Assessment Missing Staffing Plan
Penalty
Summary
The facility failed to ensure its facility assessment tool contained a staffing plan. The facility assessment policy and procedure dated 2025 stated the facility would conduct a facility-wide assessment to determine the resources needed to care for residents competently day-to-day and during emergencies, and that the assessment would be used to inform staffing decisions based on resident needs, unit needs, and staffing needs for each shift, including day, evening, and night. During review of the Facility Assessment Tool on 08/28/2025, documented evidence of a staffing plan was not present. On 11/06/2025, the Administrator confirmed the tool did not include a staffing plan and instead contained a sample staffing schedule with staff names, including licensed nurses and CNAs, for each unit and shift. The Administrator stated a staffing plan should identify the number of licensed nurses and CNAs needed for every shift in each unit. The staff scheduler stated on 11/06/2025 that the sample staffing schedule was used as a guide for staffing the units, and on 11/07/2025 explained that the former HR director trained the scheduler to staff the units based on the sample staff schedule rather than a formal staffing plan.
Deficiency in Meal Temperature Control
Penalty
Summary
The facility failed to ensure that meals were served at a preferable and appetizing temperature, affecting both sampled and unsampled residents. Observations and interviews revealed that several residents expressed dissatisfaction with the temperature of their meals, describing them as cool or cold. A test tray conducted by the Dietary Director (DD) and surveyors confirmed that the food temperatures were significantly lower than expected by the time they reached the residents. The initial temperatures of the meals were within acceptable ranges when they left the kitchen, but by the time they were served, the temperatures had dropped considerably. The process of meal delivery contributed to the deficiency, as meals were transferred from an insulated cart to an uninsulated one before being served, leading to a loss of heat. The DD acknowledged that the food should have been served directly from the insulated cart to maintain proper temperatures. The facility's policy, which references the FDA 2022 Food Code for Time/Temperature Control for Safety, was not adhered to, resulting in meals being served at temperatures that were not appetizing or safe, as confirmed by both resident feedback and temperature checks conducted by the surveyors.
Failure to Complete PASARR Level II Referrals
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) Level II referral was completed for three residents, which could potentially deprive them of necessary behavioral health services. Resident 39 was readmitted with diagnoses including schizoaffective disorder, vascular dementia with behavioral disturbance, and anxiety disorder. Despite these diagnoses, the PASARR Level I document did not reflect any mental illness or related conditions, and no Level II referral was completed. Similarly, Resident 50, admitted with schizophrenia, unspecified dementia with behavioral disturbance, and major depressive disorder, also lacked a PASARR Level II referral despite the presence of mental illness diagnoses. Resident 82, with diagnoses including schizoaffective disorder, vascular dementia with behavioral disturbance, anxiety disorder, and major depressive disorder, was also not referred for a PASARR Level II screening. The Social Services Director acknowledged the responsibility for referring residents who meet the criteria for PASARR Level II, which should be completed during their morning meetings. However, the medical records lacked evidence of such referrals for the residents in question. The Medicaid Services Manual requires a PASARR Level II screening for individuals with indicators of mental illness, intellectual disabilities, or related conditions to determine the need for specialized services in a nursing facility. The absence of documented referrals for these residents indicates a failure to comply with this requirement, as confirmed by the Social Services Director and Medical Records Staff.
Failure to Label Opened Multi-Dose Vial of Tubersol
Penalty
Summary
The facility failed to ensure that an opened multi-dose vial (MDV) of Tubersol, used for intradermal Tuberculosis (TB) testing, was labeled with an open date. This deficiency was identified during an inspection of the 200-Hall medication refrigerator, where an opened MDV of Tubersol was found without a label indicating the date it was opened. The Assistant Director of Nursing (ADON) confirmed the observation and stated that all MDV vaccines should be labeled with an open date, and the discard date should follow the manufacturer's instructions. According to the product inserts for Tubersol, each one-milliliter vial is good for 10 tests and must be discarded 30 days after being accessed. The facility's Medication Storage and Labeling policy, although undated, requires that once MDVs are accessed, they must be dated and discarded within 28 days unless the manufacturer specifies a different timeframe.
Failure to Honor Resident's Dietary Preferences and Allergies
Penalty
Summary
The facility failed to honor a resident's food preferences, which could have resulted in an allergic reaction. During a meal service, a Certified Nursing Assistant (CNA) provided a lunch tray to a resident with a known dairy allergy. The meal ticket indicated the resident should receive seasoned green peas, herbed rice, a dinner roll, and caramel apple upside-down cake, but the tray lacked the herbed rice and included hamburger toppings without a hamburger. The CNA confirmed the discrepancies and noted that such issues were common. The resident was initially served without a protein due to the main protein options containing dairy, which the resident is allergic to. The Dietary District Manager (DDM) confirmed the oversight, explaining that the system did not populate a protein option because both available proteins contained dairy. The DDM also acknowledged the mistake in serving the resident meatloaf, which contained dairy, and the absence of rice on the plate. The DDM was unsure why the resident received hamburger toppings without the hamburger. The facility's policy requires meal assembly to conform to the individual's diet order, preferences, and plan of care, which was not followed in this instance.
Deficiencies in Food Storage and Handwashing Accessibility
Penalty
Summary
The facility failed to ensure that stored foods were maintained in accordance with professional standards for food service safety. During a morning tour of the kitchen and dietary areas, an open box of unbaked cookies was discovered in the 500-hall nourishment freezer. This box was accessible to facility staff, housekeeping staff, and kitchen staff, posing a risk of contamination. The Dietary Supervisor confirmed that there were no measures in place to protect the cookies from contamination and acknowledged that the cookies should not have been stored in the nourishment room freezer. Additionally, the Dietary Manager clarified that the cookies did not belong to the Activities Department, as they do not have the means to bake them. Furthermore, the facility failed to maintain accessible handwashing areas for kitchen staff. During the same tour, a dish cart was found blocking the entrance to a handwashing sink, and a plunger was stored in the sink itself, rendering it inaccessible for proper use. The Dietary Supervisor acknowledged that the handwashing sink in the dish room was not accessible for situations requiring handwashing, as outlined in the facility's hand hygiene policy. This inaccessibility could prevent staff from adhering to necessary hand hygiene practices, increasing the risk of contamination.
Failure to Assist Resident with Personal Mail Retrieval
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence and self-determination by not following through on a request regarding personal mail. The resident, who had been admitted with diagnoses including idiopathic neuropathy, depression, and generalized anxiety disorder, had previously lived in a church-based homeless shelter. The resident expressed concern about not receiving important mail, including checks and bills, from the shelter. Despite multiple requests to the social worker for assistance in retrieving the mail, the resident did not receive any updates or assistance. The Social Services Director (SSD) acknowledged having communicated with the resident about the mail and had reached out to the shelter, which confirmed that the mail could be picked up during specific hours. However, the SSD did not communicate the resident's request to the inter-disciplinary team or facility leadership, assuming that the facility's transportation vans were unavailable during the shelter's operating hours. The Administrator later confirmed that the request was reasonable and could have been accommodated if communicated properly. The facility's failure to act on the resident's request violated the resident's rights policy, which includes the right to receive unopened mail and to have complaints addressed promptly.
Failure to Verify RN License Leads to Unqualified Employment
Penalty
Summary
The facility failed to verify the professional license of an employee, identified as Employee 9 (E9), in accordance with its abuse prevention policy. E9 was hired as a Registered Nurse (RN) and worked in the care of residents for over six months using another person's RN license. The facility's policy required verification of credentials such as licenses before an employee began work, but this was not adhered to in E9's case. The HR Administrative Assistant admitted that E9 provided an RN license number that did not match their name, and the discrepancy was not verified with the Board of Registered Nursing. Despite repeated requests for updated identification to reflect an alleged name change, E9 failed to provide the necessary documentation. The HR Director and Administrator acknowledged the failure to ensure E9's identification matched the RN license number provided. E9 was employed and performed duties such as health assessments and medication administration without proper verification of their qualifications. The Administrator confirmed that after E9's termination, it was revealed by the Board of Nursing that E9 had never been licensed as an RN. Although there were no known adverse incidents involving E9, the residents were placed at risk during E9's employment period.
Failure to Revise Care Plan After Resident Altercations
Penalty
Summary
The facility failed to revise the care plan for Resident 167 after multiple resident-to-resident altercations, which placed the resident at risk for inappropriate care, supervision, and accidents. Resident 167, who was admitted with diagnoses including Parkinson's Disease, dementia with behavioral disturbances, and anxiety disorder, was involved in several incidents of physical aggression with other residents. Despite these incidents, the care plan for physical aggression was not updated to reflect these altercations or to include new preventative strategies. The first incident involved Resident 167 hitting another resident, Resident 39, in the dining area after a misunderstanding over a cup. Although new interventions were documented, the care plan was not revised to include this altercation. Subsequent incidents involved Resident 167 pushing Resident 119 and Resident 129, causing them to fall, and another altercation with Resident 18, where both residents and a staff member fell during an attempt to separate them. In each case, an SBAR Communication form was filled out, but the care plan was not updated to reflect these events. The Director of Nursing and the Administrator acknowledged that the interventions for Resident 167 were ineffective, as evidenced by the repeated altercations. The facility's policy on care plans requires that they be revised when there is a change in the resident's condition or when desired outcomes are not met. However, the care plan for Resident 167 was not updated after each incident, contrary to the facility's policy, leading to a deficiency in care planning and risk management.
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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) |
|---|---|---|---|---|
| College Park Rehabilitation Center | 0 mi | ★★★★★ | 30 | 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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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.