Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Sage Creek Post-acute during CMS and state inspections, most recent first.
A resident with dementia, COPD, and rhabdomyolysis had an order for SCDs to both lower extremities while in bed, but staff documented the treatment as provided even when the SCD machine was not turned on and later found stored in a bedside chair. Another resident with hyponatremia and AKI had a 1,000 mL fluid restriction, yet a water pitcher and cup were left in the room and the resident was served fluids that exceeded the dietary restriction noted on the tray ticket.
Failure to communicate shortness of breath before hemodialysis. A resident with ESRD and dependence on HD had an episode of low O2 saturation, diminished breath sounds, and congestion before leaving for treatment, but the nursing HD communication form left the recent-change section blank. The hemodialysis clinic later sent the resident to the hospital for congestion, confusion, altered mental status, and shortness of breath.
A resident with metabolic encephalopathy, metabolic acidosis, rhabdomyolysis, and neuropathy had a peripheral IV catheter in the left forearm without documented physician orders for insertion, monitoring, or discontinuation. The IV dressing was unlabeled, and an LPN confirmed there were no orders for the catheter’s care or removal; the DON later acknowledged the catheter should have been discontinued when no longer in use.
A facility failed to provide nephrostomy care as ordered for a resident with bilateral nephrostomy tubes, risking complications. The resident's care was not documented on several shifts, contrary to physician orders and facility policy. The Assistant Regional Director of Clinical Services confirmed the lack of documentation and explained the necessary care procedures, which include ensuring proper drainage and checking for complications.
A facility failed to label an IV medication bag for a resident, as observed when an LPN prepared Ciprofloxacin but an unlabeled Metronidazole bag was found. The ARDCS confirmed the night nurse should have labeled it. Another resident's record lacked documentation for IV line insertion or removal, despite orders for IV medications. The RN couldn't recall the IV access details, and the ARDCS noted missing documentation, violating facility policies.
The facility failed to implement daily wound care orders for two residents, risking further skin breakdown and infections. One resident with rhabdomyolysis and sepsis had multiple wound care orders not documented as completed, while another with muscle weakness and end-stage renal disease also missed regular treatments. Interviews confirmed the lack of documentation and acknowledged the treatments were not performed as ordered.
A resident with a fractured shoulder was not consistently provided with a sling as ordered, leading to a deficiency in care. Despite a physician's order for the sling to be worn at all times, observations and interviews revealed it was not consistently applied, and when used, it was not fitting properly. Staff, including an LPN and the Director of Staff Development, confirmed the inconsistency, and the Director of Rehabilitation Services emphasized the importance of the sling in preventing further injury.
A facility failed to implement fall interventions for a high-risk resident with a history of falls and a shoulder fracture. Despite a care plan requiring the bed to be in a low position, observations showed the bed was often at waist level. Staff interviews revealed inconsistencies in monitoring and applying fall precautions, leading to a deficiency in ensuring the resident's safety.
A resident with an indwelling catheter and UTI history did not receive proper perineal care as per facility procedure. A CNA was observed performing catheter care but failed to wash the resident's perineal area, which is essential to prevent infections. The Infection Preventionist confirmed the CNA's omission, which did not align with the facility's policy aimed at preventing catheter-associated complications.
The facility failed to manage pain effectively for two residents. One resident did not receive pain medication according to prescribed parameters, leading to unmanaged pain. Another resident did not receive pain medication prior to wound care, resulting in severe pain during the procedure. Facility policies on pain management and medication administration were not followed, contributing to these deficiencies.
A resident with chronic pain and opioid dependence was administered Norco outside the prescribed parameters, receiving the medication for pain levels below the ordered threshold. Despite a care plan and facility policy requiring verification of medication administration, the resident received Norco for pain levels as low as 3 and 5, contrary to physician orders.
The facility failed to conduct timely nutritional assessments and weight monitoring for residents, leading to potential delays in nutritional interventions. A resident did not have a baseline weight or weekly weights recorded, resulting in a significant weight loss. Another resident experienced a 7.8% weight loss without a timely nutritional assessment, and a third resident had a 13.3% weight loss with no documented assessment or updated food preferences.
Failure to Follow SCD and Fluid Restriction Orders
Penalty
Summary
The facility failed to ensure a sequential compression device (SCD) was accurately documented, applied, and in use as ordered for a resident with unspecified dementia, COPD, and rhabdomyolysis. A physician order dated 04/12/2026 directed SCD use to both lower extremities while in bed every shift, and a physician progress note the same day documented DVT precautions and placement of SCDs. During observations on 04/28/2026 and 04/29/2026, the resident was lying in bed with an SCD machine hanging on the foot board, but the machine was not turned on. The resident’s MAR for 04/2026 documented that the SCD was applied as ordered daily at 6:30 AM. However, on 04/29/2026, an LPN stated she was unaware whether the SCD was currently applied and acknowledged documenting it as applied at 6:30 AM. The LPN later confirmed the machine was not turned on and explained staff should round frequently to ensure it was on and functioning. On 04/30/2026, no SCD machine was observed in the room; the RN later found the pump in a plastic bag in the bedside chair under a blanket and acknowledged the treatment had been documented as provided without first confirming the machine was available, turned on, and functioning. The facility also failed to follow a physician-ordered fluid restriction for a resident admitted with hyponatremia and acute kidney injury. A 04/20/2026 order specified a total daily fluid restriction of 1,000 mL, with limits for dietary fluids and nursing-provided fluids. On 04/29/2026, a water pitcher containing about 500 mL was observed on the bedside table, along with an empty cup. On 04/30/2026, a pitcher and cup of water were again observed in the room, and an RN confirmed the observation, stating pitchers should not be placed in the room for residents on fluid restriction because they allow unrestricted access to fluids. Later that day, the resident was served soup, cranberry juice, and ice cream totaling about 16 oz, while the dietary ticket indicated only 4 oz of fluid restriction; a CNA confirmed the resident was on fluid restriction and acknowledged the fluids served did not match the dietary ticket.
Failure to Communicate Shortness of Breath Before Hemodialysis
Penalty
Summary
The facility failed to communicate a resident’s episode of shortness of breath to the hemodialysis clinic before the resident left for treatment. Resident 28 was admitted and readmitted with diagnoses including unspecified encephalopathy, anemia, end stage renal disease, and dependence on renal hemodialysis. The care plan documented the resident required hemodialysis and was to be free of signs or symptoms of complications related to hemodialysis. On 04/20/2026, the resident had a drop in oxygen saturation to 88%, was repositioned and treated by nursing, and improved to 94%. Breath sounds were diminished bilaterally, oxygen at 2 liters via nasal cannula was provided for hemodialysis, and white blood cells were elevated with a chest x-ray to be ordered. Later that morning, the resident complained of congestion and went to the hemodialysis appointment. The nursing hemodialysis communication form completed before departure included resident and access information and vital signs, but the section for general condition and recent changes was left blank and did not document the shortness of breath episode. The hemodialysis clinic later reported the resident was sent to the hospital emergency room for evaluation due to congestion and confusion, and a nurse practitioner documented the resident was sent from the hemodialysis clinic to the acute hospital due to altered mental status and shortness of breath.
Missing Orders and IV Site Documentation
Penalty
Summary
The facility failed to obtain physician orders for the insertion, use, and monitoring of a peripheral IV catheter for Resident 23, who was admitted with diagnoses including metabolic encephalopathy, metabolic acidosis, rhabdomyolysis, and a history of neuropathy. On 04/28/2026 at 9:00 AM, the resident was observed with an IV catheter in the left forearm, and the dressing on the IV site did not have a label showing the insertion date or the date of the last dressing change. The medical record showed a physician order dated 04/24/2026 for dextrose-sodium chloride 5-0.45% IV solution at 70 milliliters per hour for one liter once, and the MAR showed the IV solution was administered as ordered on 04/24/2026. The medical record lacked documented evidence of physician orders for the IV catheter insertion or for required IV site care, including monitoring for bleeding, catheter dislodgement, infiltration, signs of infection, dressing changes, and discontinuation of the IV catheter. On 04/28/2026 at 2:21 PM, an LPN who provided care to the resident confirmed the observation and was unable to explain why the IV catheter remained in place when it was not in use, stating she was unaware of its presence. The LPN reviewed the physician orders and confirmed there were no orders for the catheter's insertion, use, monitoring, or discontinuation. On 04/30/2026, the DON stated nursing staff should have obtained physician orders for the IV catheter insertion and required care and acknowledged that the catheter should have been discontinued when it was no longer in use.
Failure to Provide Nephrostomy Care as Ordered
Penalty
Summary
The facility failed to provide nephrostomy care in accordance with the physician's order and facility policy for one resident. The resident, who was admitted with diagnoses including malignant neoplasm of the bladder and sepsis, had bilateral nephrostomy tubes to allow urine drainage due to a blockage. A physician's order required nephrostomy care every shift, with the option to change the bag as needed. However, the Medication Administration Record (MAR) for September 2024 showed no documented evidence of nephrostomy care being performed on specific shifts over three days. The Assistant Regional Director of Clinical Services confirmed the lack of documentation for nephrostomy care on the specified dates and explained that such care includes emptying the bag, ensuring proper drainage, checking for kinks, and identifying complications. The facility's policy, revised in October 2010, outlined similar procedures and emphasized the importance of following physician orders to prevent complications. The failure to document and perform the required nephrostomy care placed the resident at risk for complications related to the nephrostomy tubes.
Deficiencies in IV Medication Labeling and Documentation
Penalty
Summary
The facility failed to ensure proper labeling of intravenous (IV) medication bags, as observed in the case of a resident who was administered Metronidazole without a label bearing their name. The Licensed Practical Nurse (LPN) was observed preparing to administer Ciprofloxacin to the resident, following the facility's process of affixing a sticker label from the original package onto the IV bag. However, an empty IV bag of Metronidazole was found without a label, which the LPN confirmed. The Assistant Regional Director of Clinical Services (ARDCS) acknowledged that the night nurse should have labeled the IV bag, as per facility practice, to ensure the six rights of medication administration were followed. Another deficiency was noted in the case of a resident who was admitted with a history of malignant neoplasm of the bladder and sepsis. The resident's medical record lacked documentation of a physician's order for the insertion or removal of a peripheral IV line, despite orders for IV medication administration and saline flushes. The Charge Registered Nurse (RN) could not recall if the resident was admitted with an IV access or if it was inserted at the facility. The ARDCS confirmed the absence of documentation for the IV line's insertion or removal, which was against the facility's policy requiring documentation of such procedures. The facility's policies on peripheral IV catheter insertion and removal, dated 2001, require documentation of the provider's order, procedure details, and communication with the physician. The lack of adherence to these policies in the case of the second resident highlights a failure in maintaining proper documentation and following established protocols for IV access management, which could lead to medication errors and complications related to IV access.
Failure to Implement Daily Wound Care Orders
Penalty
Summary
The facility failed to implement daily wound care physician orders for two residents, increasing the risk of further skin breakdown and infections. Resident 1, who was admitted with conditions including rhabdomyolysis and sepsis, had multiple physician orders for wound care that were not documented as completed on specified dates. These orders included treatments for various wounds on the resident's body, such as the application of ace wraps and specific wound dressings. The medical records lacked evidence of these treatments being performed on several occasions, indicating a failure to adhere to the prescribed care regimen. Resident 2, admitted with muscle weakness and end-stage renal disease, also did not receive regular wound care as ordered. The medical records showed missing documentation for wound care on multiple dates, suggesting that the treatments were not completed. Interviews with a wound care LPN and the DON confirmed the absence of documentation and acknowledged that wound care was not performed as ordered. The facility was in the process of replacing a wound nurse during this period, which may have contributed to the oversight. The facility's policy required documentation of wound care, but this was not followed, leading to the identified deficiency.
Inconsistent Application of Sling for Resident with Fractured Shoulder
Penalty
Summary
The facility failed to ensure that a splint was consistently applied to treat a fractured shoulder as ordered for a resident. The resident, who had a history of falling and a nondisplaced fracture of the greater tuberosity of the left humerus, was admitted with a physician's order to wear a sling at all times to immobilize the shoulder. However, observations and interviews revealed that the sling was not consistently applied, and the resident reported that it was not used daily. On multiple occasions, the resident was found without the sling, and staff members, including an LPN and the Director of Staff Development, confirmed the absence of the sling and the inconsistency in its application. Further observations indicated that when the sling was applied, it was not fitting properly and was not the correct type to aid the resident's condition. The Director of Rehabilitation Services confirmed the resident's need for maximum assistance and the importance of the sling in preventing further injury. Despite the facility's policy on maintaining and supervising the use of assistive devices, the staff failed to ensure the proper and consistent application of the sling as ordered, leading to a deficiency in care for the resident.
Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement fall interventions and management for a resident identified as high risk for falls. The resident, who had a history of falling and a nondisplaced fracture of the left humerus, was admitted with a care plan that included keeping the bed in a low position. However, observations revealed that the resident's bed was often at waist level, contrary to the care plan's directives. The resident reported a recent fall at the facility, and staff confirmed the bed was not consistently kept in the lowest position, which was a critical intervention for fall prevention. The facility's fall protocols were not adequately followed, as indicated by the use of a yellow star fall indicator instead of the appropriate red star for high-risk residents. Staff interviews revealed inconsistencies in monitoring and implementing fall precautions, such as hourly checks and the use of fall mats. Despite the resident's high fall risk and recent fall history, the necessary precautions were not consistently applied, leading to a deficiency in ensuring a safe environment for the resident.
Failure to Provide Proper Perineal Care for Resident with Catheter
Penalty
Summary
The facility failed to provide appropriate perineal care for a resident with an indwelling catheter and a history of urinary tract infections (UTIs). The resident, who was admitted with diagnoses including Alzheimer's disease, chronic kidney disease stage four, and a UTI, was observed on a specific date with a kinked urinary catheter tubing, which was causing urine obstruction. A Certified Nursing Assistant (CNA) was observed performing catheter care but failed to wash the resident's perineal area, which is a crucial step in preventing infections. The CNA acknowledged the omission of perineal care, which is part of the facility's procedure for catheter care. The Infection Preventionist confirmed that the CNA did not follow the facility's policy, which includes washing the urethral meatus to prevent catheter-associated complications such as UTIs. The resident had previously been transferred to the hospital for UTI treatment and returned with antibiotic therapy, indicating a heightened risk for recurrent infections due to the deficient practice.
Failure in Pain Management for Two Residents
Penalty
Summary
The facility failed to manage pain effectively for two residents, leading to unmanaged and prolonged pain. Resident 12, who had diagnoses including urinary tract infection and immunodeficiencies, was not administered pain medication according to the ordered parameters. Despite having a care plan that included administering medication as ordered, the resident frequently experienced pain levels outside the prescribed range for the medications Norco and Tylenol. Observations and interviews revealed that the resident was in frequent pain, and the staff did not adhere to the physician's orders, administering medication at inappropriate pain levels. Resident 20, with diagnoses including a stage 4 pressure ulcer and chronic pain, did not receive pain medication prior to wound care treatment, resulting in severe pain during the procedure. The resident was observed grimacing and groaning in pain while being turned for wound care, and the pain medication was only requested after the procedure had begun. The Wound Care Treatment Nurse assumed the medication had been administered post-therapy, but it was confirmed that the medication should have been given at least an hour before the wound care to ensure comfort. The facility's policies on pain assessment and management, as well as medication administration, were not followed, contributing to the deficiencies. Staff interviews confirmed the failure to adhere to prescribed pain management protocols, which were intended to alleviate pain based on clinical conditions and treatment goals. The attending physician emphasized the importance of following prescribed parameters for effective pain management, which was not done in these cases.
Resident Administered Unnecessary Pain Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically pain medication. Resident 60, who was admitted with diagnoses including metabolic encephalopathy, opioid dependence, and chronic pain, was administered Norco (Hydrocodone-Acetaminophen) outside the physician-ordered parameters. The care plan for the resident, initiated on May 27, 2024, included interventions to assess pain every shift and offer nonpharmacological interventions. However, the Medication Administration Record for June 2024 showed that Norco was administered on multiple occasions when the resident's pain level was below the prescribed threshold of 7-10. The facility's policy on administering medications, revised in April 2019, requires staff to verify the right resident, medication, dosage, time, and method before administration. Despite this policy, the resident received Norco for pain levels as low as 3 and 5, contrary to the physician's orders. On June 27, 2024, the Medical Director emphasized the importance of adhering to prescribed parameters for effective pain management, indicating that staff should not have administered opioids unless the pain level was moderate to severe, as ordered.
Failure to Conduct Timely Nutritional Assessments and Weight Monitoring
Penalty
Summary
The facility failed to ensure proper weight management and nutritional assessments for several residents, leading to potential delays in implementing necessary nutritional interventions. Resident 168 was admitted and readmitted with significant medical conditions, including amputations, but the facility did not obtain a baseline weight upon admission or conduct weekly weight checks as required. The Registered Dietitian (RD) confirmed that the weight was not obtained until 19 days after admission, resulting in a documented weight loss of 16 pounds. The RD acknowledged the importance of obtaining a baseline weight and weekly weights to monitor changes and prevent delayed interventions. Resident 20 experienced a significant weight loss of 7.8% over a short period, yet the facility did not conduct a nutritional assessment following this change. The RD noted the weight loss but did not report a change of condition or reassess the resident, citing the resident's overweight status as a reason for not being concerned. The RD confirmed that a nutritional assessment was not completed until over a month later, which could have impacted the resident's health status. Resident 16 also experienced a significant weight loss of 13.3% within a month, but the facility failed to complete a nutritional assessment when the weight change was identified. The RD and dietary manager did not document the resident's food preferences and dislikes, which could have contributed to the resident's poor meal consumption. The RD confirmed that a nutritional assessment was not initiated or completed despite the significant weight change, and the dietary manager's revisits were not documented in the resident's 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 Las Vegas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Green Valley Health And Wellness Suites | 1.9 mi | ★★★★★ | 24 | 0 |
| Advanced Health Care Of Henderson | 2 mi | ★★★★★ | 0 | 0 |
| Coronado Ridge Skilled Nursing & Rehabilitation Ce | 2.8 mi | ★★★★★ | 20 | 0 |
| Oasis Nursing & Rehab Of Green Valley | 2.9 mi | ★★★★★ | 20 | 0 |
| Advanced Health Care Of Las Vegas | 5.1 mi | ★★★★★ | 10 | 0 |
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