Cycle 1
Health 2025-05-16 · Fire 2025-05-16
9 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Las Vegas, NV
Sage Creek Post-Acute
4-star overall rating with 4-star inspections with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
2350 Ione Road, Las Vegas, NV
(702) 790-3000
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
58
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
2017-10-31
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.07
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
1.45
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.41
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
4.92
All reported nurse hours · state 4.34 · national 3.89
Licensed hours
2.52
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
4.24
Weekend nurse staffing · state 3.85 · national 3.43
Weekend RN hours
0.69
Weekend registered nurse coverage · state 0.85 · national 0.47
Physical therapist
0.22
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.70
CMS adjusted RN staffing hours
Adjusted total hours
3.21
CMS adjusted total nurse staffing hours
Case-mix index
2.10
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,563
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.69
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.28
Baseline 22.65% · Performance 22.21% · Measure score 0.28 · Achievement 0 · Improvement 0.28
Healthcare-associated infections
1.12
Baseline 6.15% · Performance 7.50% · Measure score 1.12 · Achievement 1.12 · Improvement 0
Total nurse turnover
2.45
Baseline 65.00% · Performance 53.66% · Measure score 2.45 · Achievement 2.45 · Improvement 2.32
Adjusted total nurse staffing
0.82
Baseline 3.42 hours · Performance 3.31 hours · Measure score 0.82 · Achievement 0.82 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.32% |
10.72%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 300 · Observed rate 14.67% · Lower 95% interval 10.18% |
| Discharge to community | 54.17% |
50.57%
3.6 pts better
|
No Different than the National Rate · Eligible stays 277 · Observed rate 45.49% · Lower 95% interval 48.33% |
| Medicare spending per beneficiary | 1.27 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 244 · Denominator 244 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 244 |
| Discharge self-care score | 68.75% |
53.69%
15.1 pts better
|
Numerator 44 · Denominator 64 |
| Discharge mobility score | 70.31% |
50.94%
19.4 pts better
|
Numerator 45 · Denominator 64 |
| Pressure ulcers or injuries, new or worsened | 1.64% |
2.29%
0.7 pts better
|
Numerator 4 · Denominator 244 · Adjusted rate 1.25% |
| Healthcare-associated infections requiring hospitalization | 7.5% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 204 · Observed rate 8.82% · Lower 95% interval 4.85% |
| Staff COVID-19 vaccination coverage | 0.66% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 151 |
| Staff flu vaccination coverage | 81.82% |
42%
39.8 pts better
|
Numerator 126 · Denominator 154 |
| Discharge function score | 76.56% |
56.45%
20.1 pts better
|
Numerator 49 · Denominator 64 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 181 · Denominator 181 |
| Transfer of health information to patient | 93.75% |
96.28%
2.5 pts worse
|
Numerator 45 · Denominator 48 |
| Resident COVID-19 vaccinations up to date | 1.64% |
25.2%
23.6 pts worse
|
Numerator 2 · Denominator 122 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.4% |
84.1%
2.7 pts worse
|
81.7%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 93.4% · Q2 87.1% · Q3 75.7% · Q4 69.3% · 4Q avg 81.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.9% |
9.8%
2.1 pts worse
|
12.0%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 12.1% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.6%
0.2 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.2% · Q3 1.1% · Q4 1.7% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 69.5% |
80.7%
11.2 pts worse
|
79.7%
10.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.2% |
23.4%
1.2 pts better
|
23.9%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.2% · Observed 23.5% · Expected 25.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-28 · Fire 2024-06-28
7 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-05-11 · Fire 2023-05-11
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
21 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-16
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-05-27
E · Potential for more than minimal harm
2025-05-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-27
E · Potential for more than minimal harm
2025-05-16
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-27
E · Potential for more than minimal harm
2025-05-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-16
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-05-16
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-05-29
D · Potential for more than minimal harm
2025-05-16
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-05-16
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-05-16
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 2025-05-30
E · Potential for more than minimal harm
2024-06-28
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-07-25
E · Potential for more than minimal harm
2024-06-28
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-07-25
E · Potential for more than minimal harm
2024-06-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-25
E · Potential for more than minimal harm
2024-06-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-07-25
E · Potential for more than minimal harm
2024-06-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-25
E · Potential for more than minimal harm
2024-06-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-25
F · Potential for more than minimal harm
2023-05-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-06-30
F · Potential for more than minimal harm
2023-05-11
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-06-30
F · Potential for more than minimal harm
2023-05-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-11
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-11
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-11
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-11
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-11
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-11
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-11
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-11
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-11
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-11
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-11
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-11
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-11
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 2023-06-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-16
F578 · Resident Rights Deficiencies
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 2025-06-04
D · Potential for more than minimal harm
2025-05-16
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-06-04
D · Potential for more than minimal harm
2025-05-16
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 2025-06-04
D · Potential for more than minimal harm
2025-05-16
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-06-04
D · Potential for more than minimal harm
2025-05-16
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-06-04
D · Potential for more than minimal harm
2025-05-16
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-04
D · Potential for more than minimal harm
2025-05-16
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 2025-06-04
D · Potential for more than minimal harm
2025-03-13
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-03-13
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-03-25
D · Potential for more than minimal harm
2024-09-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-06-28
F688 · Quality of Life and Care Deficiencies
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 2024-07-29
D · Potential for more than minimal harm
2024-06-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-29
D · Potential for more than minimal harm
2024-06-28
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 2024-07-29
D · Potential for more than minimal harm
2024-06-28
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-07-29
D · Potential for more than minimal harm
2024-06-28
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-07-29
D · Potential for more than minimal harm
2024-06-28
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-07-29
D · Potential for more than minimal harm
2023-08-15
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 2023-09-05
D · Potential for more than minimal harm
2023-05-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-05
D · Potential for more than minimal harm
2023-05-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-05
D · Potential for more than minimal harm
2023-05-11
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-06-05
Penalties and ownership
What sits behind the stars
Ownership
Nevada Opco LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Corporate Officer · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Hancock, Mark
Corporate Officer · Individual
Jergensen, Joshua
Corporate Officer · Individual
Jones, Travis
W-2 Managing Employee · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Providence Group Nh, LLC
5% Or Greater Indirect Ownership Interest · Organization
Ramos, Eduardo
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Green Valley Health And Wellness Suites
Henderson, NV
2-star overall rating with 3-star inspections with $12,235 in total fines with 13 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
#2
Advanced Health Care Of Henderson
Las Vegas, NV
5-star overall rating with 5-star inspections with $8,018 in total fines with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Coronado Ridge Skilled Nursing & Rehabilitation Ce
Henderson, NV
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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