Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ponderosa Villa during CMS and state inspections, most recent first.
Nurse aides did not complete required annual training hours, including dementia care training. Record review showed one aide completed 7.5 hours, another completed 9.5 hours, and a third completed no ongoing training hours, and none of the training completed by the first two aides included dementia care. The Administrator confirmed the aides had not met the required annual training amount.
A facility failed to keep care plans comprehensive for 3 residents. One resident with dementia and anxiety had repeated behaviors such as yelling, agitation, repeated call light use, and nighttime distress, but the care plan did not address those needs. Another resident with a right BKA wanted a prosthesis and had daily-life limitations, yet the care plan only noted the amputation without goals or interventions. A third resident with MDD had antidepressant therapy and depression documented, but the care plan had no related diagnosis or interventions.
Failure to Issue Required NOMNCs: Two residents receiving Medicare Part A skilled services were discharged before benefit days were exhausted, but the facility did not provide the required NOMNC, Form CMS-10123. The BOM confirmed both residents should have received the notice.
A resident with a right below-the-knee amputation had physician documentation and admission records showing the diagnosis, and the resident confirmed being unable to walk because of it. However, quarterly MDS assessments did not include the amputation as an active dx, and the DON confirmed it was omitted despite affecting daily activities.
The facility failed to ensure proper hand hygiene during laundry delivery and wound care. A laundry aide did not perform hand hygiene between resident rooms, and an LPN did not change gloves or perform hand hygiene during wound care, contrary to facility policies.
The facility did not ensure that four nurse aides completed the required 12 hours of ongoing training, including dementia care and abuse prevention. Record reviews showed that the aides had not met these requirements over the past year, with varying hours of completed training. The Office Manager confirmed the deficiency, which could potentially impact all 24 residents.
The facility failed to provide adequate bowel management for three residents, resulting in prolonged periods without bowel movements and a lack of documented interventions. Despite having a constipation management policy and physician orders for laxatives, the facility did not consistently administer medications or document interventions for residents experiencing constipation. The Director of Nursing confirmed these deficiencies during interviews.
The facility failed to maintain safe water temperatures in the bathroom sinks of three residents, with temperatures recorded significantly above the 120 degrees Fahrenheit limit. Observations confirmed the elevated temperatures, and the facility's Administrator and Maintenance Director acknowledged the deficiency.
The facility did not provide a resident with the required quarterly statements for their trust account. Despite having a policy that mandates the availability of individual financial records through quarterly statements, the facility's Office Manager admitted to not providing these statements. The Administrator was aware of this deficiency.
A resident with a history of heart failure experienced significant weight loss due to the facility's failure to provide adequate dietitian services and implement nutritional interventions. Despite being at nutritional risk, the resident was not consistently offered meals or snacks, and staff did not assist during meals, leading to low food intake. The Registered Dietician was not informed of the resident's condition, contributing to the ongoing weight loss.
Nurse Aide Annual Training Deficiency
Penalty
Summary
The facility failed to ensure 3 of 5 sampled Nurse Aides completed the required 12 hours of ongoing annual training, including 4 hours of dementia care training, based on their dates of hire. Record review showed NA-A was hired on 6/7/2024 and completed 7.5 hours of ongoing training between 6/7/2024 and 6/7/2025, with none related to dementia care. NA-B was hired on 4/19/2024 and completed 9.5 hours of ongoing training between 4/19/2024 and 4/19/2025, with none related to dementia care. NA-C was hired on 9/22/2023 and completed no ongoing training hours between 9/22/2024 and 9/22/2025. During an interview on 1/13/26 at 7:50 AM, the Administrator confirmed that NA-A, NA-B, and NA-C had not completed the required amount of ongoing annual training hours.
Incomplete Care Plans for Behavioral, Functional, and Mental Health Needs
Penalty
Summary
The facility failed to ensure that the care plan was comprehensive for 3 of 12 sampled residents. For Resident 2, the record showed diagnoses including hyponatremia, dementia, anxiety, and hypertension, and physician orders for buspirone, citalopram, and quetiapine related to anxiety, sadness, negative statements to self, and extreme anxiety. Progress notes documented repeated behaviors including verbal conflict with another resident, increased evening anxiety, repeated call light use, yelling, agitation, nervousness after supper, confusion, anger toward staff, and statements that the resident felt miserable or nervous. Interviews with the RN and DON confirmed the resident had dementia and obsessive-compulsive disorder, frequently yelled out at night, argued with a roommate, required frequent redirection and reassurance, preferred a bed near the window, wanted the divider curtain open, and had comfort routines, but the care plan did not include these behaviors, goals, or interventions related to anxiety or dementia. For Resident 4, the admission record and prior medical documentation showed a history of right below-the-knee amputation. The resident told the surveyor they were unable to walk because of the amputation and wanted a prosthesis so they could walk again, but had not received one. The care plan only included a brief statement in the activity involvement problem section that the resident had an amputation of part of the right leg, with no goals or interventions related to the amputation. The DON confirmed the resident had repeatedly expressed a desire for a prosthesis, had been reassessed and found not to be a candidate because of limited physical strength and fragile skin, and that the amputation affected daily life and should have been included in the care plan for staff reference. For Resident 18, the admission record showed a diagnosis of Major Depressive Disorder, the quarterly MDS documented depression and antidepressant use, and the physician ordered sertraline for major depressive disorder. The undated care plan contained no evidence of the resident’s MDD diagnosis or any interventions related to that diagnosis. The DON confirmed there were no care plan goals or interventions related to the resident’s MDD.
Failure to Issue Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to issue the Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, for 2 residents who were receiving Medicare Part A skilled services. Record review showed that Resident 10 began Medicare Part A skilled services on 8/2/25, had a last covered day of Part A services on 10/16/25, and was discharged from Part A services before benefit days were exhausted; the facility-completed SNF Beneficiary Notification Review indicated that a NOMNC was not provided even though it should have been. Record review also showed that Resident 33 began Medicare Part A skilled services on 10/27/25, had a last covered day of Part A services on 11/12/25, and was discharged from Part A services before benefit days were exhausted; the same review document indicated that a NOMNC was not provided even though it should have been. The Business Office Manager confirmed on 1/13/26 at 8:30 AM that both residents did not receive the NOMNC and should have.
Inaccurate MDS Coding of Active Diagnosis
Penalty
Summary
The facility failed to accurately code an active diagnosis on the MDS for one resident. Record review showed the resident was admitted with a diagnosis of acquired absence of the right leg below the knee, and physician documentation in the record also identified a history of a below-the-knee amputation of the right leg. An interview with the resident confirmed the right lower leg had been amputated and that the resident was unable to walk because of it. Despite this documented history and the resident's current condition, quarterly MDS assessments contained no evidence of an active diagnosis related to the below-the-knee amputation. The DON confirmed that the resident's amputation was not included in the active diagnoses on the MDS even though it affected the resident's daily activities.
Inadequate Hand Hygiene During Laundry Delivery and Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene practices during laundry delivery, affecting multiple residents. Observations revealed that a laundry aide did not perform hand hygiene between resident rooms while delivering laundry, despite having received education on hand hygiene protocols. The facility's policy on monitoring compliance with infection control included hand hygiene practices, but the performance improvement plan did not cover the laundry delivery process. The Director of Nursing confirmed that staff were expected to perform hand sanitization between resident rooms, including during laundry delivery. Additionally, the facility did not adhere to its wound care policy, which required hand hygiene and glove changes between handling soiled and new dressings. An LPN was observed performing wound care on a resident without changing gloves or performing hand hygiene between removing a soiled dressing and applying a new one. The facility's wound care policy, last revised in 2010, clearly outlined the need for hand hygiene and glove changes, but these steps were not followed during the observed procedure.
Deficiency in Nurse Aide Training
Penalty
Summary
The facility failed to ensure that four sampled nurse aides received the required 12 hours of ongoing training, including training on dementia care and abuse prevention, as mandated by licensure reference 175 NAC 12-006.04(B)(ii)(1). This deficiency was identified through record reviews and an interview, which revealed that the nurse aides had not met the training requirements over the prior 12 months. Specifically, Medication Aide (MA)-B had only completed 5.25 training hours with no training on abuse or dementia, Nurse Aide (NA)-E had completed 6.75 training hours, NA-A had no training on abuse, and NA-C had completed 8.5 training hours. The Office Manager confirmed these findings, acknowledging that the nurse aides did not meet the annual training requirements, which had the potential to affect all residents in the facility, with a census of 24.
Inadequate Bowel Management for Residents
Penalty
Summary
The facility failed to provide adequate bowel management for three residents, as evidenced by record reviews and interviews. The facility's Constipation Management Policy outlined specific interventions to be taken when a resident experiences constipation, including administering prune juice, milk of magnesia, suppositories, and enemas on consecutive days. However, the facility did not adhere to this policy for Residents 12, 17, and 18, resulting in prolonged periods without bowel movements and a lack of documented interventions. Resident 18, who was terminally ill and under hospice care, experienced multiple episodes of constipation lasting several days, with no bowel movements documented for up to 13 days. Despite having physician orders for laxatives and being on a bowel management plan, there were significant gaps in the administration of these medications and documentation of interventions. The Director of Nursing (DON) confirmed the lack of documented bowel movements and interventions during these periods. Similarly, Resident 17, who was dependent on staff for toileting and had multiple medical issues, also experienced extended periods without bowel movements. The resident's care plan included orders for various laxatives, but these were not consistently administered, and there was no documentation of bowel interventions or assessments. Resident 12, who had a diagnosis of constipation and was on a bowel management plan, also went eight days without a documented bowel movement, with no administration of as-needed medications. The DON confirmed the absence of documentation and interventions for these residents.
Excessive Water Temperatures in Resident Bathroom Sinks
Penalty
Summary
The facility failed to ensure that the bathroom sinks of three residents maintained a water temperature of 120 degrees Fahrenheit or less, as required by the facility's policy and state regulations. Observations conducted on November 18, 2024, revealed that the water temperatures in the bathroom sinks of Residents 5, 14, and 21 were significantly higher than the allowable limit, with readings of 140, 136, and 135 degrees Fahrenheit, respectively. A subsequent walkthrough with the Administrator and the Maintenance Director confirmed these elevated temperatures, with readings of 141, 139.4, and 139.6 degrees Fahrenheit in the respective residents' bathroom sinks. During an interview, both the Administrator and the Maintenance Director acknowledged that the water temperatures should not exceed 120 degrees Fahrenheit.
Failure to Provide Quarterly Resident Trust Account Statements
Penalty
Summary
The facility failed to ensure that quarterly statements of Resident Trust Accounts were sent to residents or their representatives as required. This deficiency was identified during an interview with a resident who confirmed they had a resident trust account but were not receiving the necessary quarterly statements. A review of the facility's policy on Resident Personal Funds indicated that individual financial records must be available to residents through quarterly statements and upon request. However, an interview with the Office Manager revealed that the facility did not provide residents with accounting statements on a quarterly basis. The Administrator was aware of this issue, acknowledging that personal fund accounting statements were not being provided to residents.
Failure to Provide Adequate Nutritional Support
Penalty
Summary
The facility failed to provide adequate dietitian services and implement necessary nutritional interventions for a resident identified as being at nutritional risk. The resident, who had a history of heart failure and was previously on Hospice care, experienced significant weight loss over several months. Despite the care plan indicating the need for monitoring food intake and encouraging the resident to eat, the facility did not ensure these interventions were effectively implemented. The resident's weight decreased from 183.8 pounds in December 2023 to 158.8 pounds by November 2024, with no additional dietitian notes or new physician orders addressing the weight loss. Observations revealed that the resident was not consistently offered meals or snacks and received no assistance from staff during meals, resulting in low food intake percentages. The Dietary Manager confirmed that the Registered Dietician was not informed of the resident's weight loss or the cessation of Hospice services, and the resident had not been reviewed by the dietician since April 2024. This lack of communication and follow-up contributed to the resident's continued weight loss and inadequate nutritional support.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Crawford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crest View Care Center | 24 mi | ★★★★★ | 19 | 0 |
| Hemingford Care Center | 30.4 mi | ★★★★★ | 23 | 0 |
| Pioneer Manor Nursing Home | 37.1 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.