General Information: EL JEN CONVALESCENT HOSPITAL AND RETIREMENT CENTER
Nursing home name EL JEN CONVALESCENT HOSPITAL AND RETIREMENT CENTER
Address5538 W DUNCAN DR
LAS VEGAS, NV 89130
Phone number (702) 645-2606
Located within a hospital No
Type of ownership For profit - Corporation
Owner operates multiple homesNo
Accept Medicare or Medicaid Medicare and Medicaid
Continue Care Retirement CommunityNo
Resident and family councils Resident
Certified number of beds 144
Total number of residents 125
Perc of occupied beds 86
Sprinkler status Yes
Number of Facility Reported Incidents0
Number of Substantiated Complaints4
Number of Fines0
Total Amount of Fines$0
Total Number of Penalties0
Total Number of Penalties0
Ratings Summary: EL JEN CONVALESCENT HOSPITAL AND RETIREMENT CENTER
Overall rating 3
3
Nursing Home Staffing 4
4
Registered Nurses only 4
4
Health Inspections 2
2
Quality Measures 3
3
Nursing Home Staffing Info: EL JEN CONVALESCENT HOSPITAL AND RETIREMENT CENTER
National AverageNevada AverageEL JEN CONVALESCENT HOSPITAL AND RETIREMENT CENTER
Overall staff rating NA NA 4
4
Registered Nurses only rating NANA 4
4
Total Number of Residents NA NA 125
Total Number of Nurse Staff Hours per Resident per Day 4.11 hours 4.4 hours 3.73 hours
Total Number of Licensed Nurse Staff Hours per Resident per Day 1.64 hours 1.99 hours 1.44 hours
Registered Nurses Hours per Residents per Day 0.81 hours 1.15 hours 0.8 hours
Licensed Practical or Vacation Nurses Hours per Resident per Day 0.83 hours 0.84 hours 0.64 hours
Certified Nursing Assistants Hours per Residents per Day 2.47 hours 2.41 hours 2.28 hours
Physical Therapy Staffing Hours per Resident Per Day 0.1 hours 0.17 hours 0.04 hours
Health Survey: EL JEN CONVALESCENT HOSPITAL AND RETIREMENT CENTER
Heath Survey Summary on 2014-03-18
Total Number of Health Deficiencies 15
Scope and Severity of most Severe Health Deficiency Isolated/Actual harm
Heath Survey Summary on 2013-05-24
Total Number of Health Deficiencies 12
Scope and Severity of most Severe Health Deficiency Pattern/Minimal harm or potential for actual harm
Heath Survey Summary on 2012-06-08
Total Number of Health Deficiencies 8
Scope and Severity of most Severe Health Deficiency Pattern/Minimal harm or potential for actual harm
Health Survey Details: EL JEN CONVALESCENT HOSPITAL AND RETIREMENT CENTER
Inspection Results: 03/18/2014
Corrected Deficiency Scope and Severity
Ensure that residents are fully informed and understand their health status, care and treatments. Isolated/Minimal harm or potential for actual harm
Keep residents' personal and medical records private and confidential. Isolated/Minimal harm or potential for actual harm
Keep each resident free from physical restraints, unless needed for medical treatment. Pattern/Minimal harm or potential for actual harm
Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated/Minimal harm or potential for actual harm
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated/Minimal harm or potential for actual harm
Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated/Minimal harm or potential for actual harm
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated/Minimal harm or potential for actual harm
Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated/Minimal harm or potential for actual harm
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated/Minimal harm or potential for actual harm
Ensure residents maintain acceptable nutritional status. Isolated/Actual harm
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated/Minimal harm or potential for actual harm
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated/Minimal harm or potential for actual harm
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated/Minimal harm or potential for actual harm
Have a program that investigates, controls and keeps infection from spreading. Isolated/Minimal harm or potential for actual harm
Choose a doctor to serve as the medical director to create resident care policies and coordinate medical care in the facility. Pattern/Minimal harm or potential for actual harm
Inspection Results: 05/24/2013
Corrected Deficiency Scope and Severity
07/31/2013 Provide activities to meet the interests and needs of each resident. Isolated/Minimal harm or potential for actual harm
07/31/2013 Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. Isolated/Minimal harm or potential for actual harm
07/31/2013 Provide housekeeping and maintenance services. Isolated/Minimal harm or potential for actual harm
07/31/2013 Keep each resident free from physical restraints, unless needed for medical treatment. Isolated/Minimal harm or potential for actual harm
07/31/2013 Keep residents' personal and medical records private and confidential. Isolated/Minimal harm or potential for actual harm
07/31/2013 Ensure services provided by the nursing facility meet professional standards of quality. Isolated/Minimal harm or potential for actual harm
07/31/2013 Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated/Minimal harm or potential for actual harm
07/31/2013 Ensure that residents are safe from serious medication errors. Isolated/Minimal harm or potential for actual harm
07/31/2013 Store, cook, and serve food in a safe and clean way. Isolated/Minimal harm or potential for actual harm
07/31/2013 Have a program that investigates, controls and keeps infection from spreading. Pattern/Minimal harm or potential for actual harm
07/31/2013 Train all employees on what to do in an emergency, and carry out unannounced staff drills. Isolated/Minimal harm or potential for actual harm
07/31/2013 Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated/Minimal harm or potential for actual harm
Inspection Results: 06/08/2012
Corrected Deficiency Scope and Severity
07/24/2012 Keep residents' personal and medical records private and confidential. Isolated/Minimal harm or potential for actual harm
07/24/2012 Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated/Minimal harm or potential for actual harm
07/24/2012 Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated/Minimal harm or potential for actual harm
07/24/2012 Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated/Minimal harm or potential for actual harm
07/24/2012 Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Pattern/Minimal harm or potential for actual harm
07/24/2012 Store, cook, and serve food in a safe and clean way. Isolated/Minimal harm or potential for actual harm
07/24/2012 Have a program that investigates, controls and keeps infection from spreading. Isolated/Minimal harm or potential for actual harm
07/24/2012 Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern/Minimal harm or potential for actual harm

Fire Safety Survey: EL JEN CONVALESCENT HOSPITAL AND RETIREMENT CENTER
Fire Safety Survey Summary on 2014-03-14
Total Number of Fire SafetyDeficiencies 7
Scope and Severity of most Severe Health Deficiency Pattern/Minimal harm or potential for actual harm
Fire Safety Survey Summary on 2013-05-22
Total Number of Fire SafetyDeficiencies 2
Scope and Severity of most Severe Health Deficiency Isolated/Minimal harm or potential for actual harm
Fire Safety Survey Summary on 2012-06-07
Total Number of Fire SafetyDeficiencies 7
Scope and Severity of most Severe Health Deficiency Pattern/Minimal harm or potential for actual harm
Fire Safety Survey: EL JEN CONVALESCENT HOSPITAL AND RETIREMENT CENTER
Fire Safety Survey Results: 03/14/2014
Corrected Deficiency Severity
Corridor and hallway doors that block smoke. Isolated/Minimal harm or potential for actual harm
Smoke barrier doors that can resist smoke for at least 20 minutes. Isolated/Minimal harm or potential for actual harm
Automatic sprinkler systems that have been maintained in working order. Pattern/Minimal harm or potential for actual harm
Posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Isolated/Minimal harm or potential for actual harm
Restrictions on the use of highly flammable decorations. Isolated/Minimal harm or potential for actual harm
Proper construction of ducts through walls designed to prevent smoke passage. Isolated/Minimal harm or potential for actual harm
Properly installed electrical wiring and equipment. Pattern/Minimal harm or potential for actual harm
Fire Safety Survey Results: 05/22/2013
Corrected Deficiency Severity
05/22/2013 Properly installed electrical wiring and equipment. Isolated/Minimal harm or potential for actual harm
05/22/2013 Emergency lighting that can last at least 1 1/2 hours. Isolated/Minimal harm or potential for actual harm
Fire Safety Survey Results: 06/07/2012
Corrected Deficiency Severity
06/23/2012 Exits that are accessible at all times. Isolated/Minimal harm or potential for actual harm
06/23/2012 Smoke barrier doors that can resist smoke for at least 20 minutes. Pattern/Minimal harm or potential for actual harm
06/23/2012 Corridor and hallway doors that block smoke. Pattern/Potential for minimal harm
06/23/2012 Emergency lighting that can last at least 1 1/2 hours. Pattern/Potential for minimal harm
06/23/2012 Record of quarterly fire drills for each shift under varying conditions. Widespread/Potential for minimal harm
06/23/2012 Posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Widespread/Potential for minimal harm
06/23/2012 Properly installed electrical wiring and equipment. Pattern/Minimal harm or potential for actual harm

Resident Complaints: EL JEN CONVALESCENT HOSPITAL AND RETIREMENT CENTER
Date Complaint Substantiated: 11/15/2012
CorrectedCategoryDeficiencySeverity
02/04/2013Keep accurate, complete and organized clinical records on each resident that meet professional standards. E
12/25/2012Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. G
02/04/2013Provide necessary care and services to maintain or improve the highest well being of each resident . H
12/25/2012Ensure services provided by the nursing facility meet professional standards of quality. D
12/25/2012Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. E
12/25/20121) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. D
12/25/2012Keep each resident free from physical restraints, unless needed for medical treatment. D
12/25/2012Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. D

Quality Measures: EL JEN CONVALESCENT HOSPITAL AND RETIREMENT CENTER
Quality Measures National Average Nevada Average EL JEN CONVALESCENT HOSPITAL AND RETIREMENT CENTER
Overall quality rating NA NA 3
3
Long-Stay Residents
Percent of Long Stay Residents Whose Need for Help with ADLs has Increased 15.4% 16.1% 22.5%
Percent of Long Stay Residents Who Self Report Moderate to Severe Pain 8.3% 10.1% 4.0%
Percent of High Risk Long Stay Residents With Pressure Ulcers 6.1% 7.0% 10.1%
Percent of Long Stay Residents Who Lose Too Much Weight 7.2% 5.8% 14.1%
Percent of Low Risk Long Stay Residents Who Lose Control of Their Bowel or Bladder 43.9% 50.1% 52.2%
Percent of Long Stay Residents with a Catheter Inserted and Left in Their Bladder 3.2% 4.6% 2.6%
Percent of Long Stay Residents With a Urinary Tract Infection 6.2% 6.7% 8.6%
Percent of Long Stay Residents Who Have Depressive Symptoms 6.3% 4.0% 0.3%
Percent of Long Stay Residents Who Were Physically Restrained 1.4% 1.1% 2.3%
Percent of Long Stay Residents Experiencing One or More Falls with Major Injury 3.2% 2.3% 0.9%
Percent of Long Stay Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine 92.7% 89.3% 99.7%
Percent of Long Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine 94.3% 90.5% 99.7%
Percent of Long Stay Residents Who Received an Antipsychotic Medication 20.7% 20.6% 25.7%
Short-Stay Residents
Percent of Short Stay Residents Who Self Report Moderate to Severe Pain 19.2% 21.8% 12.7%
Percent of Short Stay Residents With Pressure Ulcers That Are New or Worsened 1.2% 1.2% 4.9%
Percent of Short Stay Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine 83.4% 81.6% 93.6%
Percent of Short Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine 82.4% 82.8% 95.2%
Percent of Short Stay Residents Who Newly Received an Antipsychotic Medication 2.6% 3.2% 3.4%

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