8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
16 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Las Vegas, NV
1-star overall rating with 1-star inspections with abuse icon flag with $53,360 in total fines with 8 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
5538 W Duncan Dr, Las Vegas, NV
(702) 645-2606
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
144
Certified beds
Average residents
139
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Evergreen Healthcare Group
Operator or chain grouping
Approved since
1969-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.50
Registered nurse staffing
LPN hours / resident day
1.04
Licensed practical nurse staffing
Aide hours / resident day
2.23
Nurse aide staffing
Weekend hours
3.38
Weekend nurse staffing
RN turnover
59%
Annual RN turnover
Total nurse turnover
47%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.8
0.1 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.5
0.4 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 71.8% |
91.5%
19.7 pts worse
|
93.4%
21.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 81.0% |
89.6%
8.6 pts worse
|
95.5%
14.5 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
2.3%
0.3 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.9%
4.9 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 15.6% |
5.6%
10 pts worse
|
5.4%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 42.4% |
22.2%
20.2 pts worse
|
19.6%
22.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 32.3% |
18.5%
13.8 pts worse
|
16.7%
15.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 19.3% |
19.1%
0.2 pts worse
|
16.3%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.4% |
14.2%
2.2 pts worse
|
14.9%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.8%
1.1 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.8%
1.2 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.5% |
16.5%
7 pts worse
|
19.8%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
5.5%
2.5 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 55.2% |
84.1%
28.9 pts worse
|
81.7%
26.5 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.6% |
9.8%
2.8 pts worse
|
12.0%
0.6 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.2% |
1.6%
2.6 pts worse
|
1.6%
2.6 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 70.5% |
80.7%
10.2 pts worse
|
79.7%
9.2 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.3% |
23.4%
3.9 pts worse
|
23.9%
3.4 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Resident Rights (3 deficiencies)
16 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Top issue: Quality of Life and Care (8 deficiencies)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Top issue: Quality of Life and Care (12 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-10-19
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-19
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-10-19
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2023-10-19
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2023-10-19
Fire Safety
Develop a communication plan.
Corrected 2023-10-19
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-10-19
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-10-19
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-10-19
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-10-19
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-10-19
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-10-19
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-19
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-10-19
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-19
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-19
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-09-09
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-09-09
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-09-09
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-09
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-09-09
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2022-09-09
Fire Safety
Establish emergency prep training and testing.
Corrected 2022-09-09
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-09-09
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-09-09
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-09-09
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-09
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-09-09
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-01-06
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2020-01-10
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2020-01-20
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-01-08
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2020-01-13
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2020-01-06
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2020-01-08
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2020-01-17
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-02
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2026-01-02
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-08-22
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-08-22
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-08-23
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-07-28
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-28
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-08-23
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-02-13
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-12-31
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-31
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-07-01
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-07-01
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-02-08
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-09-28
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-28
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-09-28
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-09-28
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-09-28
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2023-09-28
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-09-28
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-28
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-09-28
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-09-28
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-28
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-09-28
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-09-28
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-09-28
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-09-28
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-09-28
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-23
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-23
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-26
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-26
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-06-26
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-26
Health
Ensure 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.
Corrected 2022-07-27
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-07-27
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-07-27
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-07-27
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-07-27
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-07-27
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-07-27
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-07-27
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-07-27
Health
Provide 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.
Corrected 2022-07-27
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-07-27
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-07-27
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-07-27
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2022-07-27
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-07-27
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-07-27
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-07-27
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-07-27
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2022-07-27
Penalties and ownership
Fine · fine $53,360
Fine
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Security Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Nearby options
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