Cycle 1
Health 2025-11-07 · Fire 2025-11-07
3 health deficiencies
Top issue: Administration (1 deficiency)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
North Las Vegas, NV
Mission Pines Nursing And Rehab Center
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
2860 E. Cheyenne Avenue, North Las Vegas, NV
(702) 644-7777
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
240
Certified beds
Average residents
177
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1999-05-24
CMS approved date
Coverage
Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.38
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.72
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.27
All reported nurse hours · state 4.34 · national 3.89
Licensed hours
1.10
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
2.94
Weekend nurse staffing · state 3.85 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.85 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
3.89
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 46% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data. |
| Medicare spending per beneficiary | Not Available |
1.02
|
This provider is not required to submit SNF QRP data. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · This provider is not required to submit SNF QRP data. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data. |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
Quality measures
Resident outcomes and process scores
| 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 · Adjusted 1.9 · Observed 1.5 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.5
0.7 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
91.5%
7.2 pts better
|
93.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 97.7% · Q3 98.8% · Q4 99.4% · 4Q avg 98.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.8% |
89.6%
8.2 pts better
|
95.5%
2.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
2.3%
About the same
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.7% · Q3 1.7% · Q4 2.8% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.7% |
4.9%
0.8 pts worse
|
11.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 6.6% · Q3 6.3% · Q4 4.5% · 4Q avg 5.7% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
5.6%
2.2 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 2.3% · Q3 1.8% · Q4 2.8% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 54.3% |
22.2%
32.1 pts worse
|
19.6%
34.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 49.1% · Q2 51.4% · Q3 60.0% · Q4 56.7% · 4Q avg 54.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.7% |
18.5%
10.2 pts worse
|
16.7%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 29.2% · Q3 31.6% · Q4 26.5% · 4Q avg 28.7% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.1% |
19.1%
3 pts better
|
16.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 15.2% · Q3 22.5% · Q4 19.5% · 4Q avg 16.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.0% |
14.2%
3.8 pts worse
|
14.9%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 11.9% · Q3 23.8% · Q4 26.2% · 4Q avg 18.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.1% |
1.8%
1.7 pts better
|
1.0%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.6% · Q4 0.0% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
1.8%
0.2 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 3.4% · Q3 0.6% · Q4 1.1% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.2% |
16.5%
3.7 pts worse
|
19.8%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 23.2% · Q3 19.1% · Q4 22.4% · 4Q avg 20.2% |
| Percentage of long-stay residents with pressure ulcers | 1.5% |
5.5%
4 pts better
|
5.1%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.7% · Q3 2.6% · Q4 0.7% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 72.0% |
84.1%
12.1 pts worse
|
81.7%
9.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 70.8% · 4Q avg 72.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.8% |
9.8%
7 pts better
|
12.0%
9.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.8% · Observed 3.3% · Expected 13.3% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.7% |
23.4%
2.7 pts better
|
23.9%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 16.7% · Expected 19.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-08 · Fire 2024-11-08
8 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Cycle 3
Health 2023-10-13 · Fire 2023-10-13
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
13 fire-safety deficiencies
Top issue: Miscellaneous (5 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-11-07
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2025-12-05
E · Potential for more than minimal harm
2025-11-07
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2025-12-05
E · Potential for more than minimal harm
2025-11-07
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-12-05
E · Potential for more than minimal harm
2025-11-07
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-12-05
E · Potential for more than minimal harm
2025-11-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-12-05
D · Potential for more than minimal harm
2025-11-07
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-12-05
D · Potential for more than minimal harm
2025-11-07
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-12-05
D · Potential for more than minimal harm
2025-11-07
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-12-05
D · Potential for more than minimal harm
2025-11-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-05
D · Potential for more than minimal harm
2025-11-07
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-12-05
D · Potential for more than minimal harm
2025-11-07
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-12-05
D · Potential for more than minimal harm
2025-11-07
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-12-05
E · Potential for more than minimal harm
2024-11-08
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-11-08
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-11-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-08
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-08
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-08
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-12-10
E · Potential for more than minimal harm
2023-10-13
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-10-13
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-10-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-10-13
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-10-13
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-10-13
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-11-02
E · Potential for more than minimal harm
2023-10-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-17
D · Potential for more than minimal harm
2023-10-13
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-24
D · Potential for more than minimal harm
2023-10-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-11-02
D · Potential for more than minimal harm
2023-10-13
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2023-11-02
D · Potential for more than minimal harm
2023-10-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-13
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-11-03
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-05
D · Potential for more than minimal harm
2025-11-07
F761 · Pharmacy Service Deficiencies
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 2025-12-05
D · Potential for more than minimal harm
2025-11-07
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-12-03
E · Potential for more than minimal harm
2024-11-08
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-11-08
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-11-08
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-11-08
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-11-08
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-11-08
F761 · Pharmacy Service Deficiencies
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 2024-12-02
D · Potential for more than minimal harm
2024-11-08
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-11-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-02
F · Potential for more than minimal harm
2023-10-13
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-11-03
F · Potential for more than minimal harm
2023-10-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-13
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-10-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-13
F690 · Quality of Life and Care Deficiencies
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 2023-11-03
D · Potential for more than minimal harm
2023-10-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-13
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-13
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-13
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-07-19
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2023-08-04
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
College Park Rehabilitation Center
North Las Vegas, NV
4-star overall rating with 3-star inspections with $7,443 in total fines with 12 recent health deficiencies with 21 fire-safety deficiencies in the latest cycle
#2
North Las Vegas Care Center
North Las Vegas, NV
2-star overall rating with 2-star inspections with $9,311 in total fines with 13 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Horizon Health And Rehabilitation Center
Las Vegas, NV
2-star overall rating with 2-star inspections with 14 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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