Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 North Las Vegas Care Center during CMS and state inspections, most recent first.
Two residents, one with bipolar disorder and fall history and another with post-stroke hemiplegia, intellectual disabilities, and contractures, were found barricaded in their beds when an Activities Director observed mattresses placed against the beds and held in place by locked Geri-chairs, blocking the only open side. The assigned nurse stated this was done for safety, but the investigation determined the residents were deliberately confined to bed without consent, constituting involuntary seclusion in violation of the facility’s abuse and neglect policy. One resident later reported feeling that this confinement was not appropriate.
A resident with multiple medical and psychiatric diagnoses was subjected to rough handling by a CNA during personal care, including being tugged on while having their brief changed. The incident was reported, investigated, and substantiated as abuse, indicating the facility failed to ensure the resident was protected from abuse as required by policy.
A resident with intact cognition wanted to sit in the gazebo courtyard in the evening when it was cooler, but the doors were locked at 5 PM. Six residents told the resident council they were not allowed into the courtyard after 5 PM, even though it did not cool down until later and the issue had been raised before. The AD confirmed the set hours, and the Administrator said the restriction was due to high temperatures, despite the area having lights, fans, and misters.
A resident with a history of G-tube dislodgement returned from the hospital with an abdominal binder, but the binder use was not included in the baseline care plan. The CNA and LPN were unsure of the binder instructions, and the LPN administered meds through the G-tube without placing the binder. The DON confirmed no clarification order was obtained and the binder was not added to the resident’s baseline care plan.
Care Plan Did Not Include Ordered Oxygen Therapy: A resident with pulmonary hypertension and acute chronic systolic heart failure had an order for continuous oxygen via NC with oxygen saturation monitoring and weekly tubing changes, but the comprehensive care plan was not revised to include oxygen therapy or related interventions. An RN, the Unit Manager, and the DON all confirmed the resident’s oxygen use should have been included in the care plan, and the Unit Manager stated the plan had not been updated after the new order was initiated.
An LPN administered routine morning medications to two residents well after the scheduled time, with one resident receiving meds at 9:26 AM and another at 10:02 AM despite an 8:00 AM schedule. Staff stated the medication assignments were heavy and that delays occurred because of resident care demands and a CNA call-off. In a separate event, an LPN crushed seven medications together and gave them through a resident’s G-tube during an enteral feeding, instead of preparing and administering each medication separately as required by facility practice.
A resident with severe cognitive impairment and a contracted hand was observed with long fingernails and dirt buildup under the nails, along with dirty, foul-smelling skin on the contracted hand. Staff interviews confirmed the resident was dependent on staff for all ADLs, that hand and nail care should be provided routinely, and that the contracted hand should be cleaned before a palm guard was placed, yet CNA staff had not been consistently providing the needed nail care and hygiene.
A resident with metabolic encephalopathy, dementia, and a severely contracted right hand had a palm guard/splint observed on the bedside table instead of being worn. CNA and LPN staff were not familiar with the wearing schedule, and an OT stated the device was intended for contracture management as part of the resident’s splint and brace program. The DON said the OT recommendation should have been converted into a nursing order, but it was not.
Medications were left unsecured at the bedside of two residents. One resident with osteomyelitis and vitamin deficiency had a cup with Vitamin C and ferrous sulfate on the bedside table, and another resident with hemiplegia and hemiparesis had an unlabeled cup with white powder later identified as nystatin powder. Staff confirmed the meds should not have been left at bedside and that the residents did not have self-administration assessments.
Food storage and ice machine sanitation were deficient when surveyors found expired and improperly stored items in the kitchen and nourishment areas. An open jug of lime juice past its expiration date, an unlabeled frozen burrito, expired thickened lemon-flavored water, and expired thickened orange juice were observed, along with a pitcher of dark yellow fluid that was not labeled or dated. Surveyors also noted debris buildup on the ice machines in the main dining room and 3 nourishment rooms, and the Dietary Director acknowledged the storage and labeling issues.
Facility assessment policy was not updated to reflect current CMS guidance requiring active involvement of direct care staff and input from residents, resident representatives, and family members. The assessment tool did not document input from CNAs or floor nurses, and the Administrator could not provide evidence showing how direct care staff were involved in determining the staffing plan. The Administrator and DON confirmed the policy had remained unchanged since 2017 despite awareness of updated CMS guidance.
Missing Facility-Specific QAPI Plan: The facility failed to locate a facility-specific QAPI plan, and the Administrator stated the facility was using the QAPI policy until the plan could be found. Review of the QAPI committee guidelines showed the policy did not identify the requirement to develop a facility-specific QAPI plan to guide organizational and facility performance improvement efforts.
Laundry Dryer Not Kept Sanitary: A non-operational dryer in the clean laundry area had visible dust and lint inside, on the exterior, and between machines. The DON, maintenance staff, laundry staff, and IP all acknowledged the buildup, and the broken dryer had remained in place for years while clean linens and clothes were processed and stored in the same area.
A resident with Parkinson's Disease and a history of transient ischemic attack did not receive timely doses of prescribed antibiotics for cellulitis due to a delay in pharmacy delivery. Despite the medications being available in the facility's Omnicell system, they were not administered, and the physician was not informed of the delay, contrary to facility policy.
A resident with severe pain was not provided with the appropriate pain medication due to a failure to use the available Omnicell system. Despite the resident's request for Norco, the LPN administered Tylenol, which was ineffective, and failed to document the pain level accurately. The Director of Nursing confirmed that the facility's policy required using the Omnicell for immediate medication needs, which was not followed, leading to inadequate pain control.
The facility failed to conduct PASARR Level 2 evaluations for four residents who exhibited new behavioral changes or diagnoses, including anxiety, depression, and aggressive behaviors. Despite documented psychiatric evaluations and nursing progress notes indicating significant mental health issues, the necessary evaluations were not completed, as confirmed by the Director of Nursing.
A resident receiving Vancomycin for bacterial pneumonia experienced a lapse in care when a night nurse failed to notify the physician of a high trough level before administering a dose. The following morning, an LPN held the next dose without verifying the trough level or obtaining a physician's order. This deficiency in communication and documentation placed the resident at risk for ineffective therapy and side effects.
A facility failed to ensure proper colostomy care for a resident, as there were no documented physician orders for the care and management of the colostomy. The CNA provided basic cleaning, but specific orders were absent, and the LPN generally changed the appliance if needed. Interviews with staff confirmed the lack of care orders, which contradicted the facility's policy requiring physician orders to clarify care type and frequency. This deficiency had the potential to introduce infection and negatively impact the resident's health.
A facility failed to ensure proper G-tube care for a resident, leading to a deficiency. The resident was found with a tube feeding pump off but still attached, and a reddish-brown stain on the gown and gauze dressing. The LPN did not assess the G-tube site, relying on a night nurse's report. Further examination revealed hyper granulation and bleeding, with no care orders in place since admission. This lack of proper assessment and monitoring placed the resident at risk for complications.
A facility reported a medication error rate of 9.38%, exceeding the acceptable threshold. Two residents received Metformin outside the prescribed timeframe, as it was administered more than an hour after meals. Additionally, a missed dose of Risperdal occurred due to unavailability, and the LPN failed to notify the physician or check the medication dispensing system for alternatives.
The facility failed to document influenza and pneumococcal vaccinations for two residents, one with chronic pancreatitis and blindness, and another with diabetes and neurocognitive disorder. The Infection Preventionist confirmed the absence of vaccination records in the EHR, despite facility policy requiring such documentation.
The facility failed to document the COVID-19 vaccination status for two residents, one with chronic pancreatitis and blindness, and another with diabetes and a neurocognitive disorder. Their EHRs lacked data on vaccinations, and the Infection Preventionist confirmed the absence of records in the physician's orders and MAR. Facility policy mandates documentation of vaccination status upon admission and annually.
Involuntary Seclusion of Two Residents by Barricading Beds
Penalty
Summary
The deficiency involves the involuntary seclusion and confinement of two residents to their beds by staff using physical barriers. One resident had bipolar disorder and a history of falling, and the other had hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, intellectual disabilities, and contractures. Facility reports documented that during early-morning rounds, the Activities Director observed that both residents’ beds, which were permitted to be placed against a wall with one open side, had the open side blocked by a mattress propped up and held in place by a locked Geri-chair, effectively barricading the residents in bed. When questioned, the nurse assigned to the hallway stated this was done for safety. The investigation determined that the residents were deliberately barricaded in bed, resulting in their confinement without consent. One of the residents later recalled the incident and stated that being confined to bed in this manner felt inappropriate at the time. Staff interviews confirmed awareness of the facility’s abuse policy and protocols for reporting allegations, and staff acknowledged that the incident involved involuntary seclusion of the two residents. The facility’s written policy on abuse, neglect, exploitation, mistreatment, and involuntary seclusion prohibited such practices and required thorough investigation of all allegations, including identification and removal of alleged perpetrators, identification of victims, and documentation of where and when the incident occurred and interview summaries.
Failure to Protect Resident from Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from abuse when a certified nursing assistant (CNA) was reported to have been rough while changing the resident's brief, including tugging on the resident. The incident involved a resident with a history of cervical spine fusion, cocaine abuse with cocaine-induced psychotic disorder with hallucinations, depression, and pain. The resident reported the incident, and the CNA was removed from the resident's care for the remainder of the shift due to incompatibility between the resident and the CNA. The CNA resigned from the facility after the allegation was reported. An investigation was conducted, and the facility substantiated the allegation of abuse. The facility's policy prohibits all forms of abuse, neglect, and mistreatment, and requires immediate reporting and investigation of such incidents. The deficiency was identified through interviews, record review, and document review, which confirmed that the resident was not kept safe from abuse as required.
Courtyard Access Restricted Before Residents Wanted Evening Use
Penalty
Summary
The facility failed to ensure residents could make choices about aspects of life in the facility that were significant to them, specifically access to the outdoor courtyard and gazebo in the evening. The courtyard had a posted schedule stating it was open daily from 7:30 AM to 5:00 PM, and maintenance staff locked the doors at 5:00 PM. Resident 46, who was re-admitted with generalized abdominal pain and secondary thrombocytopenia and had a BIMS score of 15 indicating intact cognition, stated they wanted to sit outside under the gazebo in the evening when it was cooler, but the facility would not let them because the doors were locked. During the resident council meeting, six residents reported they were not permitted to go into the courtyard after 5:00 PM, even though they said it did not begin to cool down until around 6:00 PM. They also stated the issue had been raised in prior resident council meetings and that no rationale had been provided for the 5:00 PM closure. The Activity Director confirmed the courtyard was open from 7:30 AM to 5:00 PM and that maintenance locked the doors at 5:00 PM. The Administrator stated the reason for the locked doors was the high temperatures in the city, and acknowledged there was no reason the doors had to be locked since the weather started to cool around 8 PM and the area had lights, fans, and misters.
Baseline Care Plan Missing for Abdominal Binder Use After G-Tube Dislodgement
Penalty
Summary
The facility failed to develop a baseline care plan for the use of an abdominal binder for a resident with a history of gastrostomy tube (G-tube) dislodgement. The resident was admitted and later readmitted with diagnoses including metabolic encephalopathy, unspecified dementia, and G-tube status. The facility’s policy stated that a baseline care plan would be developed and implemented within 48 hours of admission and include information necessary to properly care for the resident. On observation, the resident was non-verbal, had a tube feeding pump in the room, and two abdominal binders were present on a table. The CNA stated not knowing the orders for the abdominal binder, and the LPN was not certain about the instructions for the binders. The LPN administered medication through the G-tube and left the room without placing the abdominal binder on the resident. The record showed the resident had been transferred to the hospital for G-tube replacement after dislodgement, and the hospital record documented PEG tube replacement. The medical record lacked evidence that the abdominal binder use was included in the resident’s baseline care plan, and the DON confirmed that the admitting nurse did not include the binder in the baseline care plan or obtain a clarification order for its use.
Care Plan Did Not Include Ordered Oxygen Therapy
Penalty
Summary
The facility failed to revise the comprehensive care plan to identify the need for oxygen therapy and to include interventions for managing oxygen use for Resident 41. Resident 41 was admitted with diagnoses including pulmonary hypertension and acute chronic systolic heart failure. A physician order dated 05/24/2025 and updated on 06/17/2025 directed oxygen at 2 liters per minute via nasal cannula, with oxygen saturation monitoring every shift and weekly changes of oxygen tubing and humidification systems. On 08/26/2025, the resident was observed receiving oxygen at 2.5 liters per minute via nasal cannula, and the oxygen tubing in use was not labeled or dated. The Medication and Treatment Administration Record documented that the oxygen tubing was changed weekly as ordered, and a progress note dated 05/24/2025 acknowledged the physician order for oxygen. The comprehensive care plan did not identify oxygen use or include interventions for oxygen therapy management. On 08/27/2025, an RN confirmed that any resident on continuous oxygen therapy would have oxygen therapy included in the care plan. On 08/28/2025, the Unit Manager confirmed the care plan had not been revised to include oxygen therapy and stated that oxygen care plans were usually only indicated when there was a concern or compliance issue. The Unit Manager acknowledged that nursing staff could update the care plan and that it should have been revised to include new or changed orders. On 08/29/2025, the DON confirmed that any resident receiving oxygen should have it included in the comprehensive care plan and that Resident 41 did not have a revised care plan to include the oxygen therapy initiated after the initial comprehensive care plan was completed.
Late Medication Administration and Improper Enteral Medication Preparation
Penalty
Summary
The facility failed to ensure professional standards of practice were followed for timely medication administration and for correct preparation and administration of medications given through an enteral route for three sampled residents. One resident with hemiplegia and hemiparesis following cerebral infarction and gastrostomy status had routine morning medications, including aspirin, gabapentin, metoprolol tartrate, and a multivitamin with iron, scheduled for 8:00 AM but documented and observed as administered at 9:26 AM. Another resident with cellulitis of the left lower limb and quadriplegia had multiple routine morning medications, including acetaminophen, naproxen sodium, allopurinol, baclofen, buspirone, ciprofloxacin, and others, scheduled for 8:00 AM but documented and observed as administered at 10:02 AM. During the morning medication pass, an LPN confirmed that the medications for these two residents were scheduled for 8:00 AM but were given beyond the one-hour allowable window. The LPN stated that the assignment included 28 residents, two enteral feedings, blood sugars, and vital signs for 13 residents because a CNA did not provide vital signs, and that 23 residents still had not received morning medications. Another LPN stated being assigned 29 residents and acknowledged that medications for the last six residents were late. The 300-Hall Unit Manager stated that two medication nurses were each assigned 28 to 29 residents, that a CNA call-off left some vital signs unobtained, and that it was difficult if not impossible to administer medications timely with that workload. A third resident with metabolic encephalopathy, unspecified dementia, and gastrostomy status was observed receiving enteral medications in an incorrect manner. An LPN crushed seven medications together in one pouch, interrupted the resident’s enteral feeding, and administered the crushed medications through the G-tube using a piston syringe with water flushes before resuming the feeding. The LPN acknowledged that crushing the medications together was not in accordance with facility policy and stated that each medication should have been crushed in individual pouches and given one at a time with water flushes in between. The Unit Manager and DON stated that multiple medications should not be crushed together and that the facility’s standard of nursing practice required individual crushing and administration with flushes between medications.
Failure to Provide Nail Care and Hand Hygiene for a Dependent Resident
Penalty
Summary
The facility failed to provide nail care and hygiene for a dependent resident with severely contracted hands. Resident 12 was admitted and readmitted with diagnoses including metabolic encephalopathy, unspecified dementia, and G-tube status. The resident’s quarterly MDS showed severely impaired cognition and dependence on staff for hygiene. On observation, the resident’s right and left fingernails were long, about one-fourth inch past the nail bed, and the right hand was severely contracted. Brown matter was observed under the left fingernails, and the Wound Care Nurse confirmed the long nails and dirt buildup. Staff interviews and further observation showed the resident’s contracted right hand was dirty, had dead skin and moisture, and had a foul odor. The OT identified the white splint as a palm guard for the resident’s contracted right hand and stated restorative nurse aides were expected to place it in the right hand as part of contracture management, starting with cleaning the hand first. The OT also stated the amount of dirt in the right hand and under the left fingernails could not have accumulated overnight, indicating CNAs were not routinely assisting with nail care and hand hygiene. The Unit Manager confirmed the resident was non-verbal, dependent on staff for all ADLs, and that hand and nail care should be provided once every shift and as needed, while CNA staff acknowledged the resident’s nails were long and dirty and that they were responsible for trimming and cleaning them.
Failure to Implement Palm Guard Recommendation for Contractured Hand
Penalty
Summary
The facility failed to ensure therapy recommendations for use of a palm guard were transcribed as an order and implemented for a resident with a severely contracted right hand. The resident was admitted and readmitted with diagnoses including metabolic encephalopathy, unspecified dementia, and G-tube status. On observation, the resident’s right hand was severely contracted, and a white hand splint was seen on the bedside table. A CNA confirmed the resident’s right hand was severely contracted and saw the splint on the table, but was not familiar with the wearing schedule. An LPN also confirmed the splint was on the table and not being worn, and was not familiar with the schedule. An OT explained the white splint was a palm guard intended for the resident’s contracted right hand and stated restorative nursing aides were expected to ensure it was placed in the resident’s hand as part of contracture management. The OT discharge summary documented that the resident was on a splint and brace program and would benefit from RNA services, with the RNA to put on and take off the right palm guard for six hours and as tolerated. The DON stated the OT recommendation should have been converted into a nursing order, but it was not done, and nursing staff entering the room should have clarified the use of the palm guard. The DON also stated the resident was admitted with a severely contracted right hand and that the OT evaluation documented a recommendation for a right palm guard.
Medications Left Unsecured at Residents’ Bedside
Penalty
Summary
The facility failed to ensure medications were secured and not left at residents’ bedside for 2 of 40 sampled residents. Resident 14 was admitted and readmitted with diagnoses including osteomyelitis of the vertebra and sacral region and vitamin deficiency. On 8/26/2025 at 8:48 AM, the resident was observed awake and alert in bed with a medication cup containing two white pills and a red capsule on the bedside table. The resident said they were not certain what the pills were and could not explain why or who left them there. LPN3 later confirmed the medications were on the bedside table and identified them as Vitamin C and ferrous sulfate, stating the night nurse must have left them there and that medications were not to be left at bedside but had to be consumed or refused in the nurse’s presence because the resident did not have a self-administration assessment. Resident 15 was admitted and readmitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction and gastrostomy status. On 08/27/2025 at 9:24 AM, an unlabeled medication cup with white powder was observed on the bedside table, and LPN1 confirmed it appeared to be nystatin powder for the resident’s body rashes and said it should not have been left there by the previous shift. Later that day, the Unit Manager stated medications must not be left at the resident’s bedside for safety reasons. On 08/29/2025, the DON stated medications must be kept in the presence of authorized staff and not left at the bedside, and that the night nurses who left the medications on the bedside tables of Residents 14 and 15 did not follow facility policy for medication storage and administration.
Food Storage and Ice Machine Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure foods were stored according to recommended standards and failed to keep ice machines clean in 3 of 4 ice makers in the facility. During a kitchen tour with the Dietary Director, surveyors found an open jug of lime juice in the walk-in cooler with an expiration date of August 25, 2025, and an unlabeled, undated food item wrapped in aluminum foil in the reach-in freezer. The Dietary Director stated the lime juice should have been discarded after the expiration date and identified the foil-wrapped item as a frozen burrito that should have been labeled and dated. On a follow-up kitchen tour, surveyors found a carton of thickened lemon-flavored water in the reach-in refrigerator that had been opened on 08/22/2025 but had expired on 05/09/2025, and a carton of thickened orange juice from concentrate that had been opened on 04/19/2025 but had expired on 02/13/2025. The Dietary Director stated staff should have checked the dates before stocking the items and affirmed the orange juice should have been discarded after the expiration date. Surveyors also observed debris buildup on the ice machine in the main dining room and on the ice machines in the 100-hall, 200-hall, and 300-hall nourishment rooms, and found a covered pitcher of dark yellow fluid in the refrigerator that was not labeled or dated.
Facility Assessment Policy Not Updated to Reflect CMS Guidance
Penalty
Summary
The facility failed to ensure its facility assessment policy was reviewed and updated to reflect new CMS guidance that included active involvement of direct care staff and input from residents, resident representatives, and family members. A review of the facility assessment policy dated 2017 showed it had not been updated to include this guidance, and the facility assessment tool did not document input from direct care staff such as CNAs and floor nurses in the development process. During interview, the Administrator stated the facility assessment was completed at least annually or when there were significant changes to the building and explained that direct care staff provided input during QAPI meetings for the facility assessment. However, the Administrator could not provide documented evidence showing how direct care staff were involved in determining the staffing plan. The Administrator and DON later confirmed the policy had not been updated since 2017 and acknowledged awareness of CMS guidance issued in 2024, but the policy still did not reflect the new guidance.
Missing Facility-Specific QAPI Plan
Penalty
Summary
The facility failed to ensure it had a facility-specific Quality Assurance Performance Improvement (QAPI) plan. During interview on 08/29/2025 at 12:02 PM, the Administrator was unable to locate the QAPI plan and stated the facility was using the QAPI policy until the plan could be found. Document review showed a facility policy titled, Quality Assurance and Performance Improvement Program Committee Guidelines, revised on 09/29/2021, but it did not identify the requirement to develop a facility-specific QAPI plan containing the processes that guide the nursing home's efforts to assure care and services are maintained at acceptable levels of performance and continually improved. The report stated the QAPI plan was used to guide the organizational and facility performance improvement efforts.
Laundry Dryer Not Maintained in Sanitary Condition
Penalty
Summary
The facility failed to maintain the laundry environment in a sanitary condition by allowing a non-operational dryer in the clean area of the laundry room to accumulate dust and lint. During observation, the clean area contained a bank of four commercial dryers, and one dryer was not working and had visible dust and lint inside the drum, on the exterior surfaces, and in the gap between machines. The dryer was located where clean linens and clothes were processed and stored. During interview, the Director of Maintenance described the dryer as moderately dirty with lint and dust buildup on the inside and outside of the machine. The laundry aide stated the dryer had been broken for at least three years and said laundry staff were responsible for wiping down the front of the machine while maintenance handled the sides and back. The Director of Maintenance stated the broken dryer had been in place for five years and that a facility consultant had previously advised leaving it in place because it would not be fixed or replaced. The Infection Preventionist confirmed the dust and lint buildup on the exterior of the machine and identified it as a potential infection control concern because clean linens and clothes were in the same area. The District Manager stated staff were expected to clean the laundry area, including the front and underneath of the dryer, while maintenance was responsible for the sides and back. The Administrator stated the facility was able to maintain washing and drying with the current three working dryers.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to administer medications timely to a resident, which could potentially render the treatment ineffective. The resident, who was admitted with diagnoses including Parkinson's Disease and a history of transient ischemic attack, had physician orders for Doxycycline Hyclate and Amoxicillin-Pot Clavulate to be administered twice daily for cellulitis. However, the medication administration record (MAR) indicated that the resident missed multiple doses over two days due to the facility awaiting delivery from the pharmacy. Despite the medications being available in the facility's Omnicell automated dispensing system, they were not administered as required. The Licensed Practical Nurse Unit Manager confirmed the availability of the medications in the Omnicell, and the Director of Nursing verified that the facility's policy was to use the Omnicell for unavailable medications. Additionally, the physician was not notified about the delay in starting the medications, which was against the facility's policy for medication procurement and administration.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident 4, who was admitted with multiple diagnoses including pain and required specific pain management. On the morning of January 30, 2025, the resident requested Norco, a narcotic pain medication, during the morning medication pass but was informed that the facility had run out of the medication. Instead, the resident was given Tylenol, which was ineffective in managing the pain. The resident expressed a pain level of 9, indicating severe pain, but the Licensed Practical Nurse (LPN3) did not administer the Norco from the Omnicell, an onsite medication dispensing machine, despite its availability. The LPN also failed to document the administration of Tylenol and incorrectly recorded a pain level of 0 in the Medication Administration Review (MAR). The Director of Nursing (DON) confirmed that the facility's policy required the use of the Omnicell for immediate medication needs and emphasized that the nursing staff should have administered Norco from the Omnicell when the resident reported a high pain level. The failure to assess and document the resident's pain level accurately and to administer the appropriate medication as per the physician's order led to inadequate pain control for the resident. The facility's policies on medication procurement and pain management were not followed, resulting in the resident experiencing unmanaged pain until the Norco was eventually administered later in the morning.
Failure to Conduct PASARR Level 2 Evaluations for Residents with Behavioral Changes
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASARR) Level 2 evaluation for four residents who exhibited new behavioral changes or diagnoses. This deficiency was identified through observations, interviews, and record reviews. The residents involved were found to have significant behavioral health issues that were not addressed with the necessary PASARR Level 2 evaluations, which are required for residents with newly evident or possible serious mental disorders. Resident 115 was admitted with chronic pancreatitis and blindness, and later exhibited behaviors such as talking to self, refusing medications, and being confrontational with staff. Despite these behaviors and a psychiatric diagnosis of anxiety and major depressive disorder with psychotic symptoms, the facility did not complete a PASARR Level 2 evaluation. Similarly, Resident 81, with a history of schizoaffective disorder and neurocognitive disorders, displayed aggressive and non-compliant behaviors, yet no PASARR Level 2 evaluation was conducted. Resident 139, who had a history of dementia and cerebral infarction, showed aggressive behaviors and required close monitoring, but was not referred for a PASARR Level 2 evaluation. Lastly, Resident 119, with new diagnoses of anxiety and depressive disorders, was also not referred for the necessary evaluation. The Director of Nursing confirmed the oversight and acknowledged the need for PASARR Level 2 evaluations for these residents, as per the facility's policy.
Failure to Communicate High Vancomycin Trough Level
Penalty
Summary
The facility failed to ensure proper communication and documentation regarding a high Vancomycin trough level for a resident being treated for bacterial pneumonia. The resident, who had been admitted with diagnoses including intracranial injury and bacterial pneumonia, was prescribed Vancomycin intravenously every eight hours. On one occasion, the night nurse administered a dose of Vancomycin without notifying the physician of a high trough level that was available prior to the administration. This oversight was due to the nurse's unfamiliarity with the laboratory book and electronic health record (EHR) system. The following morning, an LPN decided to hold the resident's scheduled Vancomycin dose based on a verbal report from the night nurse, without verifying the trough levels in the EHR or contacting the physician for guidance. The medical record lacked evidence of communication with the physician regarding the high trough level, and there was no physician order to hold the medication. The LPN acknowledged the error in not verifying the results or obtaining a physician's order before holding the dose. The Director of Nursing confirmed that Vancomycin requires close monitoring due to its narrow therapeutic index and potential toxicities. The pharmacy guidelines emphasized the importance of laboratory monitoring and timely administration of doses. The failure to communicate the high trough level and the decision to hold the medication without a physician's order placed the resident at risk for ineffective antibiotic therapy and serious side effects.
Deficient Colostomy Care Management
Penalty
Summary
The facility failed to ensure proper care and management of a colostomy for one resident, identified as Resident 69. The resident was unsure when the colostomy barrier wafer was last changed, and the medical record lacked documented evidence of physician orders for colostomy care. Observations and interviews revealed that the Certified Nursing Assistant (CNA) provided basic cleaning care but did not have specific orders to follow. The CNA was responsible for cleaning around the colostomy site and changing the collection bag if needed, while the Licensed Practical Nurse (LPN) would generally change the appliance if necessary. However, there were no documented physician orders specifying the type of care, frequency of cleaning, or appliance changes for the resident. Interviews with facility staff, including the Unit Manager and Director of Nursing (DON), confirmed the absence of care and management orders for the resident's colostomy. The DON stated that a physician order should be obtained upon admission to clarify the type of care needed and the frequency of changing the colostomy appliance. The facility's policy on ostomy care indicated that appliances should stay on for five to seven days unless there is leakage, burning, or pain, in which case they should be changed immediately. The lack of documented orders and adherence to the facility's policy had the potential to introduce infection and negatively impact the resident's health.
Failure in G-tube Care and Monitoring
Penalty
Summary
The facility failed to ensure proper gastrostomy (G-tube) care for Resident 79, who was admitted with diagnoses including metabolic encephalopathy, gastroparesis, and gastrostomy malfunction. The deficiency was identified when the facility did not enter or carry out G-tube care orders in accordance with protocol. On observation, the resident was found with a tube feeding pump off but still attached, and a reddish-brown stain was noted on the gown and gauze dressing. The Licensed Practical Nurse (LPN) did not assess the G-tube site during the termination of feeding, relying instead on a report from the night nurse, which led to a lack of proper assessment and monitoring of the site. Further examination by the Wound Registered Nurse and the Director of Nursing (DON) revealed hyper granulation and bleeding at the G-tube site, which had not been reported or addressed. The DON confirmed that no care orders were in place for the G-tube site care since the resident's admission, which should have included regular assessment and monitoring. The failure to have care orders and proper assessment placed the resident at risk for complications. The facility's protocol, as per the Lippincott Nursing Procedures, was not followed, which required inspection for signs of infection and other issues.
Medication Administration Errors and Missed Dose
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with a reported rate of 9.38% during a medication administration pass. This deficiency involved two residents, one of whom was unsampled. The errors were primarily related to the administration of Metformin, an antidiabetic medication, which was not given in accordance with the physician's orders. The orders specified that Metformin should be administered with meals to ensure proper absorption and efficacy. However, the medication was given more than an hour after breakfast, which was outside the prescribed timeframe. For Resident 58, the LPN administered Metformin at 8:21 AM, despite the breakfast being finished about an hour earlier. Similarly, for Resident 61, Metformin was administered at 8:37 AM, also more than an hour after breakfast. The LPN admitted to combining the 7:00 AM and 8:00 AM medication passes to save time, which led to the late administration of Metformin. The Unit Manager and DON confirmed that the medication was not administered as per the physician's orders, and the facility's policy required medications to be given within one hour of the scheduled time. Additionally, there was a missed dose of Risperdal for Resident 61 due to the medication being unavailable. The LPN did not reorder the medication in time and failed to notify the physician about the missed dose. The Unit Manager indicated that the LPN should have checked the medication dispensing system for an alternative supply or contacted the physician for guidance. The DON confirmed that the missed dose was not handled properly, as the facility's policy required immediate action to obtain unavailable medications and to report missed doses to the physician.
Failure to Document Vaccinations for Residents
Penalty
Summary
The facility failed to provide documented evidence of influenza and pneumococcal vaccinations for two of five sampled residents, which could potentially prevent ensuring residents have had the necessary vaccines to fight off diseases. Resident 115, who was admitted with chronic pancreatitis and blindness, had no data available in their Electronic Healthcare Records (EHR) under Preventive Health Care; Vaccinations, Tests & Results. Similarly, Resident 81, admitted with diagnoses including diabetes and neurocognitive disorder, also had no vaccination data available in their EHR. On September 11, 2024, the Infection Preventionist (IP) confirmed that the vaccine records section for these residents was blank after reviewing the EHR, physician's orders, and medication administration record (MAR). The facility's policy, dated May 15, 2023, requires documentation of all vaccines given, historical, or offered but refused, in the residents' EHR.
Failure to Document COVID-19 Vaccination for Residents
Penalty
Summary
The facility failed to provide documented evidence that the COVID-19 vaccine was offered or administered to two of the five sampled residents, identified as Resident 115 and Resident 81. Resident 115 was admitted with diagnoses including chronic pancreatitis and blindness, while Resident 81 had diagnoses significant for diabetes and a neurocognitive disorder. Upon review of their Electronic Healthcare Records (EHR), it was found that there was no data available under the Preventive Health Care section for vaccinations, tests, and results for both residents. On September 11, 2024, the Infection Preventionist (IP) confirmed that the vaccine records section for these residents was blank. The IP checked the physician's orders and the medication administration record (MAR) for any documentation of the COVID-19 vaccine but found no results. The IP indicated that all vaccines, whether given, historical, or offered but refused, should be documented in the residents' EHR. The facility's policy on Standing Orders for Immunizations requires the evaluation of residents' vaccination status upon admission and annually, with documentation of the date, time, and injection site or declination in the medical record.
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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 | 0.6 mi | ★★★★★ | 30 | 0 |
| Mission Pines Nursing And Rehab Center | 0.6 mi | ★★★★★ | 15 | 0 |
| Gaye Haven Intermediate Care Facility | 2.8 mi | — | 0 | 0 |
| Horizon Health And Rehabilitation Center | 4.3 mi | ★★★★★ | 1 | 0 |
| Saint Joseph Transitional Rehabilitation Center | 5.6 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.