Coronado Ridge Skilled Nursing & Rehabilitation Ce
2855 W. Horizon Ridge Parkway, Henderson, NV 89052 · For profit - Limited Liability company · 121 certified beds · (702) 805-5050 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- a high number of inspection citations overall (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 19.7% | 12.6% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.8% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.4% | 1.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 3.0% | 5.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.4% | 2.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 15.8% | 13.5% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 22.8% | 22.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 89.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.0% | 5.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 14.5% | 15.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 0.9% | 17.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 1.8% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 94.0% | 80.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 25.5% | 23.2% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 12.3% | 9.6% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.47 | 1.85 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.18 | 1.45 | 1.80 | better |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
55.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 284 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 49.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 69 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.85 therapist hours per resident per day in 2026Q1 — more than 95% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 70% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 55.5%CMS range 48.5–60.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.5%CMS range 7.9–13.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 49.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 44.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 49.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 96.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 90.4% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 70.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.7% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.2%CMS range 3.6–9.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.30 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 121 beds and averages 110.7 residents a day — about 91% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.22 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.40 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.99 hrs/resident/day on weekends vs 4.80 on weekdays — 17% thinner on weekends. RN hours go from 1.23 to 1.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 45% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
20 citations, most serious first. The 10 most serious are shown; the remaining 10 are one tap away and print in full.
- Potential for harm · D2025-09-03 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to provide documented evidence of the actions taken and follow-up made after the facility was notified of a reported positive case of Legionella (a bacteria which caused Legionnaires' disease by spreading through contaminated water mist, not water itself, which people inhale) for a resident who was discharged from the facility on 08/02/2025 and tested Legionella Polymerase Chain Reaction positive (PCR test was a laboratory technique used to detect and amplify specific genetic sequences, such as those from viruses or bacteria) at a hospital on [DATE] for 1 of 9 sampled residents (Resident 1). The deficient practice had the potential to prevent early detection and possible transmission of infection among the residents.Findings include:Resident 1 (R1) was admitted on [DATE] and discharged on 08/02/2025, with diagnoses including cerebral edema, urinary tract infection, Escherichia Coli (E. Coli), and dependence on supplemental Oxygen. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-15 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure a baseline care plan was initiated and completed for a resident who was admitted with a peripheral intravenous (IV) access for 1 of 24 sampled residents (Resident 3). The deficient practice had the potential to place residents at risk for not receiving IV access care.Findings include: R3 was admitted on [DATE] and readmitted on [DATE], with diagnoses including end stage renal disease (ESRD).On 08/12/2025 at 11:23 AM, R3 had a purple-colored single lumen peripheral IV catheter in the right inner forearm. The admission assessment dated [DATE], revealed R3 was admitted on the evening of 08/10/2025 with an IV line with site location and purpose unspecified.The medical record lacked documented evidence that a baseline care plan was initiated and completed for R3's peripheral IV line.On 08/13/2025 at 1:51 PM, the Director of Nursing (DON) indicated the admission nurse must document the presence of an IV access for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-15 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure 1) a clarification order was obtained for a resident's peripheral intravenous (IV) line for a newly admitted resident with no IV medication orders for 1 of 24 sampled residents (Resident 3); 2) a physician's order was followed regarding rotating sites for a peripheral IV line for 1 of 24 sampled residents (Resident 155) and 3) the facility policy was followed regarding removal of peripheral IV lines for 2 of 24 sampled residents (Residents 3 and 155). The deficient practice had the potential to place the residents at risk for phlebitis (site infection).Findings include: 1) Resident 3 (R3) was admitted on [DATE] and readmitted on [DATE], with diagnoses including end stage renal disease (ESRD).On 08/12/2025 at 11:23 AM, R3 had a purple-colored single lumen peripheral IV catheter in the right inner forearm. The admission assessment dated [DATE], revealed R3 was admitted on the evening of 08/10/2025 with an IV line with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, document review and record review the facility failed to ensure a resident who required oxygen therapy was not connected to an empty oxygen tank and to obtain a physician's order for oxygen for 1 of 24 sampled residents (Resident 157). This deficient practice had the potential to lead to serious complications, including hypoxia, respiratory failure, and damage to vital organs. Findings include: Resident 157 (R157) was admitted on [DATE] with a diagnosis of chronic respiratory failure with hypoxia, acute kidney failure, unspecified, chronic obstructive pulmonary disease, unspecified and pneumonia, unspecified organism.On 08/12/2025 at 10:35 AM, R157 was connected to a nasal canula, and an oxygen tank attached to the wheelchair, and the tank was empty and off.On 08/12/2025 at 10:45 AM, a Registered Nurse (RN) indicated the resident was on two liters of oxygen continuously due to a diagnosis of chronic respiratory failure and chronic obstructive pulmonary disease. The RN verified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-15 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure 1) a physician order was obtained for moderate to severe pain medication, 2) the resident's pain was routinely monitored and 3) pharmacological and non-pharmacological pain interventions were offered and/or provided for a resident who was assessed to be at risk for pain for 1 of 24 sampled residents (Resident 154). The deficient practice had the potential to negatively impact residents' overall wellbeing.Findings include: Resident 154 (R154) was admitted on [DATE], with diagnoses including fracture of lower end of left radius (one of two bones in the forearm), left ulna styloid process (a small bony projection located at the end of the ulna bone in the forearm), left orbital floor (a thin bone which forms the floor of the eye socket), unspecified phalanx (bones in fingers or toes) of left middle finger and maxillary fracture (upper jaw bone).1) On 08/12/2025 at 11:17 AM, R154 laid in bed with left arm wrapped in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-15 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, document review, and interview, the facility failed to ensure a Physician Order for Life-Sustaining Treatment (POLST) form was witnessed and signed by two staff members, to validate a verbal consent for a do not resuscitate (DNR) status received from a resident's family member for 1 of 24 sampled residents (Resident 7). The deficient practice had the potential to result in a resident not receiving care consistent with their resuscitation preferences.Findings include: Resident 7 (R7) was admitted [DATE], readmitted [DATE], with diagnosis including unspecified mononeuropathy, chronic respiratory failure with hypoxia, and type 2 diabetes mellitus with diabetic neuropathy.A Care Plan dated 06/06/2025, documented R7 had a POLST-DNR and the code status would be reviewed on a quarterly basis and as needed. R7's electronic medical record documented a code status of do not resuscitate. A POLST form dated 06/02/2025, documented do not resuscitate (allow natural death). The words verbal consent were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-16 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and document review, the facility failed to ensure the resident's pain medication was administered as ordered and appropriately managed for 1 of 5 sampled residents (Resident 1), and the pain was timely assessed for 1 of 5 sampled residents (Resident 3). This deficient practice had the potential to result in unmanaged pain, delayed relief, and decreased quality of life for the affected residents. Findings include: A facility policy titled Pain-Clinical Protocol revised October 2022, documented the nursing staff would assess each individual for pain upon admission to the facility, whenever there was a significant change of condition, and when there was an onset of new pain or worsening of existing pain. Resident 1 (R1) R1 was admitted on [DATE], readmitted on [DATE], and discharged on 12/17/2024, with diagnoses including fracture of the first lumbar vertebra, long-term use of opiates, and complex regional pain syndrome. A care plan initiated on 11/13/2024 documented R1 was at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-02 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure informed consent was obtained prior to administration of psychotropic medications for 1 of 4 sampled residents (Resident 1). The deficient practice potentially deprived the resident and/or resident representative of the right to be informed of the medications' risks, benefits and potential side effects. Findings include: Resident 1 (R1) R1 was admitted on [DATE], with diagnoses including puncture wound of right lower leg and fracture of upper and lower end of right fibula (a lower leg bone) and Alzheimer's disease. R1's medical record contained a legal document which revealed R1 had appointed a family member to be R1's legal representative or power of attorney (POA). A physician's order dated 09/02/2024, documented to give Buspirone (anti-anxiety) hydrochloride five milligrams (mg) by mouth two times a day for anxiety as evidenced by verbalization of feeling anxious and being uncooperative. The medical record lacked documented…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-09 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to develop a baseline care plan for a soft collar device, an ACE wrap dressing (an elastic compression bandage typically wrapped around a sprain or strain) and CAM (controlled ankle movement) boot device for 2 of 22 sampled residents (Residents 244 and 250). The deficient practice placed the residents at risk for discomfort, skin integrity issues to affected areas and complications to surgical sites. Findings include: Resident 244 (R244) R244 was admitted on [DATE], with diagnoses including cervical disc disorder with myelopathy and status post cervical spine (C3 to C5 - neck region) decompression with anterior and posterior fusion. On 08/06/2024 at 8:42 AM, R244 laid awake in bed with a family member at bedside. A white foam collar with areas of discoloration was observed around the resident's neck. R244 indicated undergoing neck surgery more than a month ago and was admitted to this facility with the soft collar device.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-09 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure documentation of application of an ordered Thrombo-Embolus deterrent (TED) stocking (stockings that help prevent blood clots and swelling in the legs) was completed for 1 of 22 sampled residents (Resident 3). The failure had the potential to adequately assess the resident's efficacy of treatment, determine resident's need for further intervention, and compliance with the physician's order. Findings include: Resident 3 (R3) R3 was admitted on [DATE], with diagnoses including heart failure and essential hypertension. On 08/06/2024 at 12:44 PM, R3 was observed sitting up in the wheelchair next to the foot of the bed. Noted R3 had edema (swelling) at both legs, skin was reddish and shiny. R3's lower pants elastic bands were making indentation markings onto the skin. R3 was observed with no TED stockings in place. R3's comprehensive care plan had a focus problem identified for: - Activities of daily living (ADL)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 10 citations
- Potential for harm · D2024-08-09 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure care and management orders were obtained, transcribed, and carried out for a soft collar device, an ACE wrap (an elastic compression bandage typically wrapped around a sprain or strain) and a boot device for 2 of 22 sampled residents (Residents 244 and 250) and a post-operative appointment was scheduled timely for 1 of 22 sampled residents (Resident 250). The deficient practice placed the residents at a potential risk for discomfort, skin integrity issues to the affected areas and complications to surgical sites. Findings include: Resident 244 (R244) R244 was admitted on [DATE], with diagnoses including cervical disc disorder with myelopathy and status post cervical spine (C3 to C5 - neck region) decompression with anterior and posterior fusion. On 08/06/2024 at 8:42 AM, R244 laid awake in bed with a family member at bedside. A white foam collar with areas of discoloration was observed around the resident's neck.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-09 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure psychoactive medication side effects monitoring was documented for 1 of 22 sampled residents (Resident 3). The failure to document side effects of psychoactive drugs had a potential to facilitate dose adjustments if needed and the efficacy of the medication for the resident. Findings include: Resident 3 (R3) R3 was admitted on [DATE], with diagnoses of anxiety disorder and schizophrenia. R3 physicians' orders documented the following orders: - 07/12/2019, Monitor for Adverse Side Effects (S/E): Anticholinergic (dry mouth, urinary retention, blurred vision); orthostatic hypotension (arrhythmias); sedation, confusion, hallucinations, and agitation- every shift. - 08/02/2019, Antidepressant Drug S/E Monitor: Dry mouth, blurred vision, tachycardia, urinary retention, constipation, confusion, delirium, hallucinations, flushing, increased blood pressure, postural hypotension, sedation, fatigue, dizziness, ataxia, insomnia, headache,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-09 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility to ensure medications were secured for 1 of 6 medication carts and 1 of 22 Residents (Resident 15). The deficient practice could have jeopardized the safety of both staff and residents, as unsecured medication carts increase the risk of unauthorized access to potent medications, medication errors, theft, or misuse, posing serious health hazards and compromising the overall well-being of individuals within the facility. Findings include: On 08/07/2024 at 2:55 PM, a nurse was standing by the medication cart parked next to room [ROOM NUMBER]. The nurse stepped away and left the medication cart unlocked. The nurse was observed to walk towards the nursing station and was not in line of sight of the medication cart. The nurse was away for four minutes with one resident and one facility staff member who had passed by the open cart. Another two nurses had approached the cart and had used the hand sanitizer on top of the cart, when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-07-13 · tag F0848 — widespreadProvide a neutral and fair arbitration process and agree to arbitrator and venue.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to ensure the Arbitration Agreement provided for the selection of a neutral arbitrator agreed upon by both parties; and for the selection of a venue that is convenient to both parties. The deficient practice had the potential to obstruct each resident's ability to make a well-informed decision about signing the arbitration agreement. Findings include: On 07/13/2023, the facility Resident-Facility Arbitration Agreement, undated, indicated by signing the contract, the resident agreed to have all claims decided by arbitration and the resident was giving up the right to jury or court trial. There were lines provided for the resident to initial and sign the agreement. The agreement lacked provisions for the selection of a neutral arbitrator agreed upon by both parties, and for the selection of a venue that was convenient to both parties. On 07/13/23 at 10:31 the Director of Admissions verbalized the facility offered the binding arbitration agreement to each resident. The Director of Admissions confirmed the arbitration agreement…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-13 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — the official record, unedited, may be distressing
Deficiency Text Not Available
- Potential for harm · Dcited before2023-07-13 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — the official record, unedited, may be distressing
Deficiency Text Not Available
- Potential for harm · Dcited before2023-07-13 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure a physician order was obtained and care management was implemented for the use of compression stockings to treat edema for 1 of 32 sampled residents (Resident 4). This deficient practice could possibly result in inadequate treatment, increased complications, and reduced quality of life. Findings include: Resident 4 (R4) R4 was admitted on [DATE] and readmitted on [DATE], with diagnoses including obesity, diabetes mellitus, hypertension, and heart failure. The Brief Interview of Mental Status dated 03/28/2023, documented a score of 14/15, which means R4's cognitive status was intact. R4's medical record lacked documented evidence a physician's order was obtained or transcribed in the Treatment Administration Record for the use of compression stockings. On 07/11/2023 at 11:00 AM, R4 lay in bed, verbally alert, and responsive. Both of R4's legs were edematous (swollen), not elevated. [NAME] compression stockings were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure the correct size of an indwelling urinary catheter (Foley) was followed as ordered or clarified, and Foley care and management were transcribed in the Medication Administration Record (MAR) and implemented for 2 of 32 sampled residents (Residents 289 and 348). These deficient practices could lead to potential urinary tract infections (UTIs), an increased risk of catheter-associated complications, dehydration, blockage, and discomfort or pain for the resident. Findings include: A facility policy titled, Indwelling Catheter Use dated 10/2017, documented an assessment of each resident's continence status upon admission, and care plans addressing resident continence were reviewed and revised. The facility monitors residents with catheters for changes in skin integrity, skin irritation or breakdown, and signs and symptoms of urinary tract infection. The catheter should be changed in accordance with the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-07-13 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure the ordered parameters for the pain medication were followed as ordered for 1 of 32 sampled residents (Resident 8). The deficient practice could potentially result in adverse effects on Resident 8's health and well-being, compromised pain management, increased discomfort, and potential complications. Findings include: Resident 8 (R8) R8 was admitted on [DATE] and readmitted on [DATE], with diagnoses including use of an opiate analgesic, absence of the left foot, absence of the right leg below the knee, and presence of the right artificial hip joint. The Brief Interview of mental status dated 05/08/2023, documented a score of 14/15, which means R8's cognitive status was intact. On 07/11/2023 at 3:19 PM, R8 lay in bed, verbally alert and oriented. R8 had a left foot amputation during recent surgery. R8 indicated had constant pain during the day, but pain medication had been ordered. A Physician order dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-13 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and document review, the facility failed to maintain a level of quaternary ammonia between 200 and 400 parts per million in the 3-compartment sink and ensure the floor sink drain was set up in a manner to prevent water splashing. The deficiency had the potential to adversely affect the ware washing process, resulting in improperly sanitized equipment and utensils that could contaminate food and cause foodborne disease to the residents. Findings include: 07/11/23 8:00 AM, an inspection of the kitchen was performed with the Food Services Manager. The following concerns were identified: The chemical sanitizing quaternary ammonia solution in the 3-compartment sink was tested by the Manager using a testing strip model DQ-40, with an expiration date of January 2024. After 10 seconds of being submerged in the solution, the test strip did not change color, indicating the concentration of the chemical sanitizing solution was zero (0) parts per million (PPM). The Food Services Manager confirmed the observation and explained the concentration of the chemical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to GENERATIONS HEALTHCARE — 27 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 4.1 | ≈ chain avg |
| Health inspection | 4 of 5 | 3.6 | +0.4 vs chain |
| Staffing | 4 of 5 | 3.7 | +0.3 vs chain |
| Quality measures | 4 of 5 | 4.6 | -0.6 vs chain |
The other 26 homes this chain runs (chain average 4.1★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BMO BANK NATIONAL ASSOCIATION | Organization | 5% OR GREATER SECURITY INTEREST | since 10/06/2021 |
| JENSEN, RHETT | Individual | W-2 MANAGING EMPLOYEE | since 11/14/2021 |
| MASTROCOLA, LOIS | Individual | CORPORATE OFFICER | since 04/13/2016 |
| OLDS, THOMAS | Individual | CORPORATE OFFICER | since 04/13/2016 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.7M paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NV
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Nevada Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 295099. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-15, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.