11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Henderson, NV
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
100 Delmar Gardens Drive, Henderson, NV
(702) 361-6111
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
242
Certified beds
Average residents
198
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Valley West Health
Operator or chain grouping
Approved since
1988-06-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
12 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
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
RN hours / resident day
0.46
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
1.03
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.28
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.77
All reported nurse hours · state 4.34 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
3.53
Weekend nurse staffing · state 3.85 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.85 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
3.66
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Program rank
5,417
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.26
Composite VBP score used to determine payment impact.
Payment multiplier
0.9897
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.20
Baseline 17.00% · Performance 19.95% · Measure score 3.20 · Achievement 3.20 · Improvement 0
Healthcare-associated infections
0
Baseline 6.24% · Performance 8.20% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7.42
Baseline 51.06% · Performance 33.33% · Measure score 7.42 · Achievement 7.42 · Improvement 6.26
Adjusted total nurse staffing
3.88
Baseline 3.93 hours · Performance 4.18 hours · Measure score 3.88 · Achievement 3.88 · Improvement 0.87
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.45% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 116 · Observed rate 6.9% · Lower 95% interval 6.54% |
| Discharge to community | 47.45% |
50.57%
3.1 pts worse
|
No Different than the National Rate · Eligible stays 43 · Observed rate 41.86% · Lower 95% interval 35.28% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 91.04% |
95.27%
4.2 pts worse
|
Numerator 122 · Denominator 134 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 134 |
| Discharge self-care score | 38.64% |
53.69%
15 pts worse
|
Numerator 34 · Denominator 88 |
| Discharge mobility score | 27.27% |
50.94%
23.7 pts worse
|
Numerator 24 · Denominator 88 |
| Pressure ulcers or injuries, new or worsened | 1.49% |
2.29%
0.8 pts better
|
Numerator 2 · Denominator 134 · Adjusted rate 1.31% |
| Healthcare-associated infections requiring hospitalization | 8.2% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 11.67% · Lower 95% interval 4.78% |
| Staff COVID-19 vaccination coverage | 1.9% |
8.2%
6.3 pts worse
|
Numerator 6 · Denominator 316 |
| Staff flu vaccination coverage | 13.44% |
42%
28.6 pts worse
|
Numerator 43 · Denominator 320 |
| Discharge function score | 47.73% |
56.45%
8.7 pts worse
|
Numerator 42 · Denominator 88 |
| Transfer of health information to provider | 82.5% |
95.95%
13.5 pts worse
|
Numerator 33 · Denominator 40 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 6.52% |
25.2%
18.7 pts worse
|
Numerator 6 · Denominator 92 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.8
About the same
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.8 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.5
0.6 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 41.4% |
91.5%
50.1 pts worse
|
93.4%
52 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.8% · Q2 38.1% · Q3 42.0% · Q4 48.6% · 4Q avg 41.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 60.7% |
89.6%
28.9 pts worse
|
95.5%
34.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 60.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
2.3%
0.2 pts worse
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 3.0% · Q3 1.1% · Q4 1.6% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.5% |
4.9%
1.6 pts worse
|
11.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 10.5% · Q3 5.3% · Q4 5.2% · 4Q avg 6.5% |
| Percentage of long-stay residents who lose too much weight | 13.5% |
5.6%
7.9 pts worse
|
5.4%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 16.3% · Q3 10.3% · Q4 12.7% · 4Q avg 13.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.0% |
22.2%
1.8 pts worse
|
19.6%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 23.8% · Q3 23.5% · Q4 22.5% · 4Q avg 24.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.3% |
18.5%
6.8 pts worse
|
16.7%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 25.8% · Q3 27.4% · Q4 22.9% · 4Q avg 25.3% · 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 | 25.9% |
19.1%
6.8 pts worse
|
16.3%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.2% · Q2 37.6% · Q3 18.9% · Q4 12.1% · 4Q avg 25.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.6% |
14.2%
15.4 pts worse
|
14.9%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 44.8% · Q3 33.3% · Q4 16.9% · 4Q avg 29.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.0% |
1.8%
0.2 pts worse
|
1.0%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 3.2% · Q3 2.3% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.8%
0.6 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.6% · Q3 1.8% · Q4 1.1% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.6% |
16.5%
8.1 pts worse
|
19.8%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 28.5% · Q3 24.9% · Q4 21.0% · 4Q avg 24.6% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
5.5%
0.3 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 7.7% · Q3 6.1% · Q4 2.1% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 44.2% |
84.1%
39.9 pts worse
|
81.7%
37.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 53.0% · Q2 29.3% · Q3 39.2% · Q4 56.2% · 4Q avg 44.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.3% |
9.8%
3.5 pts better
|
12.0%
5.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.3% · Observed 6.7% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.6%
0.1 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.4% · Q3 1.2% · Q4 1.3% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 25.7% |
80.7%
55 pts worse
|
79.7%
54 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 25.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.5% |
23.4%
1.1 pts worse
|
23.9%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.5% · Observed 26.0% · Expected 25.3% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (3 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
16 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Fire safety
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-12-17
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-17
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-12-17
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-12-17
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2025-12-17
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-12-17
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-12-17
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-12-17
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-12-17
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-12-17
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-12-17
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-11-07
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-11-07
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-07
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-07
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-11-07
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-11-07
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-11-07
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-07
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-11-07
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-11-07
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-11-07
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-07-11
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-07-11
Fire Safety
Develop a communication plan.
Corrected 2023-07-11
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-07-11
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 2023-07-11
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-07-11
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-11
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-07-11
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-11
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-11
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-07-11
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-07-11
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-07-11
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-07-11
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-07-11
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2023-07-11
Inspection history
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-12-05
Health
Assess the resident when there is a significant change in condition
Corrected 2025-12-05
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 2025-12-05
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-12-05
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-05
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-05
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2025-12-05
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-12-05
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-17
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-05-22
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-06-17
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 2024-11-07
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-11-07
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-07
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-11-07
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-07
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-07
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-11-07
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-11-07
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-11-07
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-07
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-11-07
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-07
Health
Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
Corrected 2023-07-18
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-07-18
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-18
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-18
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 2023-07-18
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-07-18
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-07-18
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-07-18
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-07-18
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 2023-07-18
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Security Interest · Organization
Operational/Managerial Control · Individual
Nearby options
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