Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

EL JEN SKILLED CARE

LAS VEGAS, NV · 144 certified beds · Last Life Safety survey August 31, 2023

CMS Certification Number 295008 · first certified October 1969

Ownership

Operated by EVERGREEN HEALTHCARE GROUP · For profit - Limited Liability company

Ownership changed March 16, 2022 (change of ownership)from ELJEN MEDICAL HOSPITAL

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within NV

36 citations — more than 77% of the 66 certified nursing homes in NV. Compared within NV rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 16 citations; the earlier surveys in the window averaged 10. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (August 2024 to September 2024), and past the point by which nine in ten NV facilities have been surveyed. This facility’s last Life Safety survey was August 2023. Facilities in NV are typically surveyed 11–13 months after the last one (median 12), measured over 117 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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5 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

11 of the 36 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 36 Life Safety citations above. The Physical Environment Index

F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

How that compares

Citations on file over three years

Compared with the median facility in NV, and nationally. Surveyors differ markedly between states, so the NV figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	36
Median facility in NV	26
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
November 1, 2019	8
June 21, 2022	12
August 31, 2023	16

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0353	Inspect, test, and maintain automatic sprinkler systems.	3	2023-08-31
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	2	2023-08-31
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	2	2023-08-31
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	2	2023-08-31
K-0222	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.	2	2023-08-31
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	2	2022-06-21
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	2	2023-08-31
K-0363	Install corridor and hallway doors that block smoke.	1	2022-06-21

What the citations cover

Citations by CMS category

Emergency Preparedness Deficiencies 11
Gas, Vacuum, and Electrical Systems Deficiencies 8
Smoke Deficiencies 7
Egress Deficiencies 5
Other 5

Citations by CMS category
Category	Citations
Emergency Preparedness Deficiencies	11
Gas, Vacuum, and Electrical Systems Deficiencies	8
Smoke Deficiencies	7
Egress Deficiencies	5
Miscellaneous Deficiencies	3
Services Deficiencies	2

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

August 31, 2023 — 16 citations

Citations issued on August 31, 2023
Tag	What the surveyor checks	Status
E-0006	Conduct risk assessment and an All-Hazards approach.	Deficient, Provider has date of correction (October 19, 2023)
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (October 19, 2023)
E-0020	Establish policies and procedures including evacuation.	Deficient, Provider has date of correction (October 19, 2023)
E-0024	Establish policies and procedures for volunteers.	Deficient, Provider has date of correction (October 19, 2023)
E-0029	Develop a communication plan.	Deficient, Provider has date of correction (October 19, 2023)
E-0037	Establish staff and initial training requirements.	Deficient, Provider has date of correction (October 19, 2023)
K-0222	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.	Deficient, Provider has date of correction (October 19, 2023)
K-0232	Have corridors or aisles that are unobstructed and are at least 8 feet in width.	Deficient, Provider has date of correction (October 19, 2023)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (October 19, 2023)
K-0341	Install a fire alarm system that can be heard throughout the facility.	Deficient, Provider has date of correction (October 19, 2023)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (October 19, 2023)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (October 19, 2023)
K-0711	Provide a written emergency evacuation plan.	Deficient, Provider has date of correction (October 19, 2023)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (October 19, 2023)
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	Deficient, Provider has date of correction (October 19, 2023)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (October 19, 2023)

June 21, 2022 — 12 citations

Citations issued on June 21, 2022
Tag	What the surveyor checks	Status
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	Deficient, Provider has date of correction (September 9, 2022)
E-0036	Establish emergency prep training and testing.	Deficient, Provider has date of correction (September 9, 2022)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (September 9, 2022)
E-0041	Implement emergency and standby power systems.	Deficient, Provider has date of correction (September 9, 2022)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (September 9, 2022)
K-0222	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.	Deficient, Provider has date of correction (September 9, 2022)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (September 9, 2022)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (September 9, 2022)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (September 9, 2022)
K-0912	Have power receptacles that are properly grounded.	Deficient, Provider has date of correction (September 9, 2022)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (September 9, 2022)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (September 9, 2022)

November 1, 2019 — 8 citations

Citations issued on November 1, 2019
Tag	What the surveyor checks	Status
E-0026	Establish roles under a Waiver declared by secretary.	Deficient, Provider has date of correction (January 20, 2020)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (January 8, 2020)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (January 6, 2020)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (January 10, 2020)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (January 13, 2020)
K-0911	Meet requirements for the installation and maintenance of electrical systems.	Deficient, Provider has date of correction (January 6, 2020)
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	Deficient, Provider has date of correction (January 17, 2020)
K-0921	Ensure that testing and maintenance of electrical equipment is performed.	Deficient, Provider has date of correction (January 8, 2020)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.