Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gardnerville Health & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Screen for Pneumococcal Vaccine Eligibility The facility did not properly assess vaccine status or screen for contraindications before making pneumococcal vaccine decisions for 5 residents. Records for residents with conditions such as CHF, CKD, COPD, diabetes, encephalopathy, and malnutrition did not consistently show eligibility screening, prior vaccine history review, or documentation of whether additional PCV doses were indicated under CDC guidance. In one case, a resident received PCV-20 even though the CDC app indicated no additional pneumococcal vaccine was needed.
Insufficient CNA staffing occurred when the facility did not meet its CNA PPD requirement on multiple days. The facility assessment required 8.75 CNAs per day based on census, but the actual schedule showed fewer CNAs worked on several reviewed days. The Scheduler/CNA confirmed the staffing levels did not meet the facility's minimum CNA PPD requirement.
A CNA accessed the central supply room, where medications were stored in unlocked, partially open cabinets. The MDS Coordinator stated CNAs, maintenance employees, and the Administrator had access to the room, even though they were not authorized to administer meds. In addition, two med carts contained loose tablets and lidocaine patches that were open, exposed, or without secure packaging, and the MDS Coordinator confirmed these items were an infection control and safety issue.
A resident with personal care needs, AFib, anxiety, and cognitive communication deficit was subjected to verbal abuse when a CNA responded in an elevated tone during a care interaction and re-entered the room after being told to leave. The resident reported the CNA yelled, acted in an intimidating manner, and said, “I hope you don’t make me leave,” while another CNA described the tone as inappropriate.
Incomplete Care Plans for Medications, Foley Catheter Care, and Pain The facility failed to develop resident-specific care plans for high-risk meds, Foley catheter care, and pain management for three residents. One resident had orders for spironolactone, methadone, and PRN hydromorphone, but no care plan addressed monitoring for side effects. Another resident had a Foley catheter and an order for routine site cleansing, yet the care plan lacked catheter care interventions and goals. A third resident had chronic pain treated with oxycodone, but the pain care plan contained blank SPECIFY fields and was not individualized.
A resident with emphysema reported a missing lower denture to a CNA, but the grievance was not promptly routed to facility leadership. The Administrator later confirmed the concern had been handled informally, while the grievance form was placed under the DON’s office door when the DON was not in the building, delaying leadership awareness and review of the complaint.
A resident admitted and readmitted with UTI, multidrug-resistant infection, and paraplegia did not have an initial care plan developed for a PICC line. The resident’s care plan lacked documentation for PICC management, and the MDS Coordinator confirmed that no initial care plan had been created.
Failure to ensure competent staff provided PICC care: a resident with a PICC line was receiving IV antibiotics, but the dressing remained dated beyond the required change interval while an LPN documented dressing care as completed. Record review and staff interviews showed the LPN lacked documented IV certification, and the DON was responsible for ensuring staff had the required training and competency before performing PICC maintenance.
Failure to Provide Scheduled Showers and Personal Care: A resident with psychosis, major depressive disorder, and a need for assistance with personal care reported missing scheduled showers and going an extended period without bathing. Records lacked shower documentation for multiple long gaps, and staff confirmed showers were expected twice weekly with documentation in the EHR, but the resident’s bathing schedule was not consistently carried out or recorded.
A resident receiving IV antibiotics through a PICC line had a dressing that remained dated beyond the ordered change interval. Although the IV TAR showed dressing care completed by an LPN, the MDS Coordinator confirmed the dressing had not been changed as documented and that the LPN lacked documented IV certification for PICC care.
Controlled Medication Administration Not Documented: A resident with quadriplegia had an order for oxycodone PRN for pain, but review of the narcotic logbook and MAR showed a dose was given without being accounted for in the controlled drug record. The MDS Coordinator confirmed the remaining oxycodone tablet documented in the logbook was not present in the cart, and the DON was responsible for reviewing the narcotic logbook for accuracy and completeness.
Medication administration errors exceeded the 5% threshold after surveyors observed 29 opportunities and identified 2 errors, for a 6.9% error rate. An RN gave a resident one sennosides tablet instead of the ordered two tablets and administered Zofran without documenting it on the MAR; the RN stated the dose discrepancy was not noticed and the order was not clarified before administration.
Missing Bathing and Catheter Care Documentation: A resident reported not receiving scheduled showers, and the chart lacked bathing entries or verified refusal documentation for extended periods. Three residents with Foley catheters had care plans requiring catheter care every shift, but task records and clinical records lacked evidence that catheter care was provided. Staff stated CNA catheter care should be documented in the EMR, yet the MDS Coordinator could not locate supporting documentation for the residents.
The facility's QAPI committee did not identify that there was no process to screen residents for eligibility for influenza and/or pneumococcal vaccines on admit and annually thereafter. The Administrator confirmed the issue and stated that identifying it could have led to a change in the immunization process by adding targeted questions to the screening document. The QAPI plan stated the committee was responsible for identifying areas needing performance improvement, collecting data, implementing corrective action, and monitoring effectiveness.
The facility failed to ensure required communication training was documented for 8 of 20 sampled employees. A RD, CNAs, an SLP, the IP, an RN, and an LPN lacked evidence of training upon hire, and one RD also lacked annual training documentation. The BOM confirmed the missing records, and the facility policy required communication training during orientation and annually.
The facility failed to ensure QAPI training was completed and documented timely for 5 of 20 sampled employees. A CNA had no documented annual QAPI training for the current year, and four newly hired employees, including CNAs and an LPN, lacked evidence of QAPI training upon hire. The BOM confirmed the missing documentation, and the facility policy required QAPI education during orientation and annually.
The facility failed to ensure timely infection control training for 3 of 20 sampled employees. A CNA had documentation of infection control training but lacked evidence of annual QAPI training, and an LPN and another CNA had no documented evidence of infection control training upon hire. The BOM confirmed the missing documentation, and the facility policy required infection control training during orientation and annually.
Missing Compliance and Ethics Training Documentation: The facility failed to ensure required compliance and ethics training was completed and documented for 3 sampled employees. A DON and 2 CNAs had missing annual training records, and one CNA had no documented initial training. The BOM confirmed the records lacked evidence of training upon hire and annually, despite the facility policy requiring it as part of orientation and on an annual basis.
Missing Behavioral Health Training Documentation: The facility failed to document initial or annual Behavioral Health training for 15 of 20 sampled employees, including the DON, AD, SW, Dietary Manager, CNAs, RN, LPNs, and the Infection Preventionist. Personnel records lacked evidence of training upon hire or annually, and the BOM confirmed the missing documentation while stating orientation and annual training were expected under facility policy.
A resident with multiple comorbidities, including CHF, prior CVA, anxiety, depression, muscle weakness, and impaired mobility and coordination, was subjected to rough incontinence care by a CNA. A PT who entered the room during a brief change observed the CNA roll the small-statured resident onto their side, noted redness on the resident’s buttocks, and saw the CNA roughly wipe the area. The resident cried out in pain, stating that it hurt, but the CNA did not respond or adjust care and continued the brief change. The facility’s investigation concluded the CNA had been rough and dismissive of the resident’s expressed pain, in violation of the facility’s abuse policy.
Two residents with ESBL E. coli UTIs were placed in a shared room under contact precautions, contrary to facility policy and CDC guidelines requiring private room placement for MDRO infections. Despite available private rooms, both residents remained together, and one developed an ESBL UTI after rooming with the other. Staff and documentation confirmed the lapse in infection control practices.
The facility did not follow its own policy and CDC guidelines for infection control, as two residents with ESBL-producing E. coli were placed together in a shared room instead of private rooms, and three residents with wounds or Foley catheters did not have Enhanced Barrier Precautions in place. Staff confirmed the lack of required signage and PPE carts, and acknowledged that the necessary precautions were not implemented.
The facility did not consistently report allegations of abuse, neglect, and serious injury to the State Agency within required time frames. Incidents included verbal and physical abuse by staff, resident-to-resident physical and sexual abuse, and a fall resulting in a hip fracture. Delays in reporting ranged from several days to over a week, contrary to facility policy requiring immediate notification.
A resident with significant neurological diagnoses had their mattress placed on the floor by an LPN without prior device evaluation, physician notification, or obtaining consent from the resident or their representative. This action, which restricted the resident's ability to get up independently, was not communicated to staff or family and was later substantiated as neglect following facility investigation.
A resident with dementia and behavioral disturbances was removed from their room during an episode of agitation and aggression, and left alone in the dining room wearing only a soiled brief and t-shirt. Staff drew back the curtains, exposing the resident to view, and observed from outside the room while the resident continued to display aggressive behaviors. The DON confirmed the resident's dignity was not respected during this incident.
A resident with diabetes and chronic kidney disease was prescribed and administered Eliquis for DVT prophylaxis, but the MDS assessment failed to document the use of this anticoagulant in the appropriate section. The MDS Coordinator confirmed the assessment was inaccurate after reviewing the records.
A resident with newly documented mental health diagnoses was admitted without an updated PASARR Level I or referral for Level II evaluation. Staff interviews revealed a lack of knowledge and training regarding PASARR requirements, and no staff member was overseeing the process, resulting in the facility's failure to follow its own policy for screening and referral.
A resident with chronic obstructive pulmonary disease and congestive heart failure was receiving oxygen therapy, but the care plan did not document the use of oxygen or related diagnoses. Staff observed the resident with varying oxygen delivery and noted the resident often removed the nasal cannula, yet the care plan lacked problems, goals, or interventions for oxygen use and monitoring. The DON confirmed these omissions after reviewing the clinical record.
A resident who required substantial staff assistance for bathing and showering did not receive scheduled showers or baths on multiple occasions, with no documentation of refusals or alternative care provided. The resident reported not receiving regular showers and performed their own bed bath, while staff and the DON confirmed the lack of documentation and missed care.
A resident with COPD and heart failure received oxygen at a higher flow rate than ordered, as staff increased the oxygen from 2 LPM to 2.5–3 LPM without a physician's order or titration instructions. The clinical record did not contain authorization for this change, and facility policy required strict adherence to prescriber orders.
A CNA employed for over one year did not have a documented annual performance review as required by facility policy. The DON confirmed that the evaluation was not completed at the one-year anniversary, resulting in a missed opportunity to identify areas for improvement and training needs.
Two residents did not receive their prescribed medications because the medications were out of stock and not available in the facility, resulting in a medication error rate above 5%. In both cases, RNs identified the missing medications, marked them as 'On Order' from the pharmacy, but did not document physician notification or alternative orders, and the facility lacked a specific policy on medication administration errors.
A multi-dose vial of Tuberculin PPD was found in the medication storage refrigerator without a cap and with a puncture site, but neither the vial nor its box was labeled with the date it was opened, contrary to facility policy and manufacturer instructions. The Infection Preventionist confirmed the vial was open and not dated.
The facility's Facility Assessment was created and implemented solely by the Interim Executive Director without documented review or approval from the QAA Committee or other required leadership. The assessment lacked an attendance sheet and did not follow established procedures for review and input from necessary facility management.
Surveyors found that a nurse administered PRN Acetaminophen to a resident for pain but did not document the administration in the MAR as required by facility policy. In a separate incident, a resident received wound care for a cranial abrasion without a documented physician order, despite the IP stating verbal approval had been obtained. Both deficiencies involved failures in timely and complete documentation of care provided.
The facility did not develop or implement a required Performance Improvement Project (PIP) within the past year. Leadership, including the IED, DON, and LAN, could not provide documentation or details of any PIP, citing loss of access to electronic records after a former administrator's departure. The QAPI committee was not made aware of failures related to reporting abuse, neglect, or other incidents, and there was no evidence of ongoing evaluation of PIPs as outlined in the facility's QAPI Plan.
A resident with chronic health conditions was not offered a timely pneumococcal vaccination to complete the recommended schedule, despite being eligible and having pending immunizations noted in the record. The required vaccine was not administered, and documentation of consent or refusal was missing, contrary to facility policy and CDC guidelines.
A resident with diabetes and hypertension was identified as eligible for the COVID-19 vaccine, but the facility failed to document administration or declination of the vaccine after screening. The clinical record showed only a pending immunization status, and required consent or declination forms were incomplete, resulting in a lack of evidence that the vaccine was offered or given as per facility policy and CDC guidelines.
A resident with severe dementia and behavioral disturbances was removed from their room during an episode of agitation and placed alone in the dining room, wearing only a soiled brief and t-shirt. Staff closed the door, isolating the resident from others and observing through windows, while the resident continued to display aggressive behaviors. Facility documentation and staff interviews confirmed the resident was involuntarily secluded, contrary to policy and resident rights.
A facility failed to ensure an agency CNA completed required elder abuse prevention training upon hire. The CNA was involved in an incident where a resident, exhibiting signs of psychosis, was left in a public area wearing only a t-shirt and soiled brief, visible to others. The CNA's personnel record lacked documentation of abuse training, in violation of facility policy.
A long-term care facility failed to remove expired COVID-19 test kits from a medication room and cart, despite weekly audits by the DON. Additionally, a resident's Oxycodone tablets went missing after an LPN left the medication cart keys unattended, allowing unauthorized access. The facility's policies on medication storage and access were not followed, leading to these deficiencies.
The facility failed to maintain cleanliness of an ice machine, did not discard expired heavy cream, and a staff member neglected hand hygiene protocols during food preparation. The ice machine had a white, flaky substance despite recent maintenance, and expired heavy cream was found in the refrigerator. A staff member entered the trayline without washing hands or changing gloves, contrary to facility policy.
The facility failed to ensure proper infection control practices, including hand hygiene by an Activities Director, who did not sanitize hands between resident contacts. A glucometer was improperly sanitized by an LPN using an incorrect cleaning method. Additionally, unsanitary laundry practices were observed, with a fan blowing air from the dirty to the clean side of the laundry room, and a blanket placed on a floor cleaner to dry. The IP and DON did not oversee these practices, as they were managed by a contracted agency.
A resident was administered Amitriptyline and Buspirone for anxiety without obtaining informed consent as required by facility policy. The medications were given for several days before the necessary consents were signed, contrary to the policy that mandates consents be completed within 48 hours of admission.
The facility failed to ensure accurate MDS assessments for two residents. One resident's MDS inaccurately documented bed rails as restraints, despite confirmation from the resident and staff that they were used for mobility. Another resident's MDS did not reflect a DVT diagnosis, although the resident was receiving anticoagulant treatment for it. The MDS Coordinator acknowledged these discrepancies.
The facility failed to develop care plans for two residents with specific conditions. A resident with DVT did not have a care plan despite receiving anticoagulant therapy, and another resident receiving Trazodone for insomnia lacked a care plan for this condition. The DON confirmed that care plans should be created upon admission and updated within 48-72 hours, highlighting a lapse in protocol adherence.
A resident with Parkinsonism and dementia was confirmed to have a DVT and prescribed Eliquis, but the care plan for DVT was not added until 11 months later. The MDS Coordinator backdated the care plan, which was deemed unprofessional conduct by the DON, as per the Nevada Nurse Practice Act.
The facility failed to ensure that two LPNs were trained and certified in CPR, as required by the facility's policy. The personnel records for these LPNs lacked evidence of current CPR certifications. The BOM, responsible for personnel record review, was unsure about the CPR training policy, including certification requirements and frequency.
A resident received acetaminophen outside of physician-prescribed parameters, with pain levels recorded higher than the ordered range. The LPN confirmed the discrepancy, and the DON acknowledged the failure to follow physician orders, as per the facility's medication administration policy.
A resident was administered Trazodone for insomnia without having a corresponding diagnosis. Despite receiving the medication daily, both an LPN and the DON confirmed the absence of an insomnia diagnosis. The facility's policy required a physician's justification for the use of psychotropic drugs, which was not provided in this instance.
Failure to Screen Residents for Pneumococcal Vaccine Eligibility
Penalty
Summary
The facility failed to ensure 5 of 5 residents reviewed for immunizations were properly assessed for pneumococcal vaccine eligibility before vaccine decisions were made. The report states the facility did not assess immunization status, determine whether additional pneumococcal doses were indicated under current CDC recommendations, or identify contraindications or precautions before making vaccine determinations. The deficiency involved Residents #15, #5, #59, #46, and #1, and was cited as Substandard Quality of Care. Resident #15 was admitted with diagnoses including acute respiratory failure with hypoxia, type II diabetes mellitus without complications, chronic kidney disease stage 3B, and acute diastolic congestive heart failure, and later had pneumonia added as a diagnosis. The resident had a standing vaccine consent form that did not document screening for eligibility. The Nevada Immunization Record showed one dose of PCV-20 had been given before admission, and the CDC PneumoRecs VaxAdvisor indicated the resident’s pneumococcal vaccines were up to date and no additional pneumococcal vaccine was needed. However, the facility Immunization Report did not document screening for eligibility, did not document the prior PCV-20 dose, and did not document that no additional dose was necessary. Resident #5 had diagnoses including encephalopathy, type 2 diabetes mellitus with other specified complications, COPD, pulmonary embolism, and fragile X chromosome, and the representative signed a standing vaccine consent form that did not document screening for eligibility. The resident’s immunization record showed prior influenza and pneumococcal vaccines, and the CDC app indicated the resident was eligible for one dose of either PCV-20 or PCV-21 based on age and time since the last pneumococcal vaccine. Resident #59, Resident #46, and Resident #1 also had vaccine consent or immunization documentation that did not show screening for eligibility, and the facility records for these residents did not consistently document vaccine refusal dates, prior vaccine history, or whether pneumococcal vaccination was indicated or not indicated based on CDC guidance. For Resident #46, the record showed prior PCV-13 and PCV-20 doses, the CDC app indicated no additional pneumococcal vaccine was necessary, yet the facility later administered PCV-20 when the CDC recommendation indicated another dose was not needed.
Insufficient CNA Staffing
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents as identified in its facility assessment for 6 of 25 reviewed days. The facility assessment revised 08/26/2025 documented a required daily CNA staffing level of 105.04 hours per day, equal to 8.75 CNAs per day. Review of the June 2026 staffing schedules showed that on 06/01/2026, 06/06/2026, 06/08/2026, 06/13/2026, 06/14/2026, and 06/20/2026, the number of CNAs worked was below the facility's minimum CNA PPD requirement. On 06/25/2026 at 11:14 AM, the Scheduler/CNA stated staffing needs were determined by the PPD requirements based on census to ensure adequate staffing. The Scheduler/CNA reported the facility's average census was 55 residents, with an average of five to six CNAs during AM shifts and three to four CNAs during PM shifts, and explained that sufficient staffing was necessary to meet resident needs, showers, care tasks, and safety. The Scheduler/CNA confirmed that the CNA staffing on the six identified dates did not meet the facility's minimum CNA PPD requirement set by the facility.
Unlocked Medication Storage and Improper Cart Organization
Penalty
Summary
The facility failed to ensure medications were accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication. On 06/24/2026, a CNA entered the central supply room using a keypad code and stated the room stored briefs, personal care supplies, and medical items including bandages, catheters, and alcohol. The CNA confirmed medications were stored in the room and said CNAs and nurses could access it. Two large metal cabinets in the room were observed unlocked and partially open with various medications stored inside. The MDS Coordinator stated nurses, CNAs, the Administrator, and maintenance employees had access to the central supply room, and confirmed the cabinets contained medications and were left unlocked because of the lock on the supply room door. The facility also failed to keep two medication storage carts clean and organized when contaminated or improperly stored medications were not immediately removed from stock. During inspection of the 100-hall medication cart, a loose white oblong tablet was found at the bottom of a drawer. During inspection of the 500-hall medication cart, a loose white tablet, a loose yellow tablet, a lidocaine patch lying on a plastic tray without packaging, and another lidocaine patch with an open package and exposed patch were observed in drawers. The MDS Coordinator confirmed the loose tablet was removed from the drawer and stated the opened items could be an infection control issue, that loose tablets were a safety issue because they were no longer labeled, and that they could be contaminated or tampered with. The facility policy stated medication storage should be kept clean, organized, and free of clutter, and contaminated or deteriorated medications and those in containers without secure closures were to be immediately removed from stock and disposed of.
Resident was subjected to verbal abuse by CNA
Penalty
Summary
The facility failed to ensure a resident remained free from verbal abuse when a CNA used an elevated tone and re-entered the resident’s room after being told to leave. Resident #23 was admitted and later readmitted with diagnoses including need for assistance with personal care, atrial fibrillation, anxiety disorder, and cognitive communication deficit. During the encounter, the resident pressed the call light for help with changing, and CNA1 told the resident they would return shortly. The resident then yelled that CNA1 always turned off the call light and never returned. CNA1 responded in an elevated tone, which was described as inappropriate, and the resident later reported that CNA1 yelled and behaved in an intimidating manner. The resident also stated that CNA1 returned and said, “I hope you don’t make me leave,” and reported not feeling good when CNA1 yelled and became upset. Another CNA entered the room and instructed CNA1 to leave, and CNA2 later described the tone used by CNA1 as not appropriate.
Incomplete Care Plans for Medications, Foley Catheter Care, and Pain
Penalty
Summary
The facility failed to develop complete care plans for three sampled residents related to medication monitoring, indwelling catheter care, and pain management. The report states that the care plans did not include resident-specific interventions and goals for high-risk medications, catheter care, or pain, despite the residents having documented conditions and orders requiring ongoing monitoring and individualized care planning. Resident #38 was admitted with diagnoses including Alzheimer's disease, urinary tract infection, and a stage III sacral pressure ulcer. Physician orders included spironolactone 25 mg daily with instructions to hold for systolic blood pressure less than 90 and monitor for dehydration, methadone 2.5 mg three times daily for chronic pain, and PRN hydromorphone 1 mg every six hours for pain. The comprehensive care plan did not include a care plan for methadone, hydromorphone, or spironolactone, and the MDS Coordinator confirmed this omission and stated the medications should have been care planned so staff would know to monitor for side effects. Resident #5 had diagnoses including osteomyelitis of the vertebra and sacrococcygeal region, diabetes mellitus type 2 with neuropathy, and a stage 4 sacral pressure ulcer, and had a Foley catheter in place with an order for daily and evening cleansing of the Foley site for skin impairment management. The care plan included enhanced barrier precautions related to the catheter but lacked a plan for Foley catheter care interventions and goals. Resident #18 had multiple sclerosis and recurrent moderate major depressive disorder, reported pain in the back, left leg, and shoulder, and stated oxycodone 30 mg every three hours kept the pain tolerable. Although the care plan addressed pain, it contained blank placeholders such as SPECIFY for comfort level, aggravating factors, alleviating factors, and monitoring frequency, and the MDS Coordinator confirmed the plan was not resident-specific.
Delayed Handling of Missing Denture Grievance
Penalty
Summary
The facility failed to make prompt efforts to resolve a grievance when Resident #40 reported a missing lower denture and the grievance form was not given to facility leadership in a timely manner. Resident #40 was admitted with a diagnosis of emphysema, unspecified. On 06/22/2026, the resident told a CNA in the dining room on the 500 unit that the lower denture could not be located and was unsure whether it had been left in a pocket when clothing went to laundry or left on a meal tray. The CNA said the concern would be reported. Later that day, the resident stated the lower denture had recently been replaced and the missing lower denture was lost, while denying difficulty chewing or swallowing. On 06/25/2026, the Administrator stated grievances were handled by the Administrator and were typically discussed at the next day’s standup meeting, but the Administrator was not aware of a grievance related to the missing dentures because the dentures were thought to have been found. The Administrator later received a grievance form dated 06/22/2026 documenting that the resident’s bottom dentures were missing and that the CNA searched pockets, the bathroom, and other areas without finding them. The Administrator explained the Activities Director had filled out the grievance form and placed it under the DON’s office door while the DON was not present in the building all week, and confirmed staff were expected to notify the Administrator and/or DON of grievances right away. The facility policy stated grievances were to be resolved immediately when possible or routed within 24 hours to the grievance official and/or social services/designee.
Missing Initial Care Plan for PICC Line
Penalty
Summary
The facility failed to develop an initial care plan for a PICC line for Resident #59, who was admitted and later readmitted with diagnoses including urinary tract infections, resistance to multiple antimicrobial drugs, and paraplegia. The resident’s care plan, initiated on 11/17/2025 and revised on 06/11/2026, did not include documented evidence of a care plan for the PICC line. On 06/29/2026 at 10:40 AM, the MDS Coordinator stated that a care plan would be required for a PICC line and confirmed that an initial care plan had not been created for the resident. The RAI 3.0 manual states that the resident’s plan of care is used to provide services to attain or maintain the resident’s highest practicable physical, mental, and psychosocial wellbeing and is revised based on changing goals, preferences, needs, and current interventions.
Failure to Ensure Competent Staff for PICC Care
Penalty
Summary
The facility failed to ensure staff were trained and deemed competent before being assigned to provide PICC care for one resident. Resident #59 was admitted and readmitted with diagnoses including resistance to multiple antimicrobial drugs, urinary tract infection, and neuromuscular dysfunction of the bladder, and was receiving IV antibiotics through a PICC line. The resident had a PICC dressing dated 06/14/2026, and the physician’s order and IV TAR required PICC site maintenance with dressing changes and line flushing according to specified intervals and technique. The TAR documented PICC dressing care as completed by an LPN on 06/16/2026 and 06/23/2026, and central line flushes were documented by multiple LPNs on several dates. However, on 06/24/2026, the MDS Coordinator stated the dressing should have been changed every seven days or sooner if soiled or dislodged, and later confirmed the bandage remained dated 06/14/2026 and should have been changed by 06/21/2026. The MDS Coordinator also stated it was not appropriate for the TAR to document completed dressing changes when the dressing date did not correspond. The record review and staff interviews further showed the facility did not have documented IV certification for LPN1, even though that nurse documented PICC dressing changes as completed. The MDS Coordinator stated an LPN must be IV-certified to perform PICC flushes and that the DON was responsible for ensuring staff had appropriate certifications and competencies before being assigned PICC care. The facility’s own procedure, the LPN job description, Nevada Administrative Code, and CDC guidance all addressed training, competency, and maintenance requirements for vascular access devices.
Failure to Provide Scheduled Showers and Personal Care
Penalty
Summary
The facility failed to ensure timely bathing, hygiene, and personal care for one resident who was unable to perform these activities independently. Resident #44 was admitted with diagnoses including need for assistance with personal care, psychosis, and major depressive disorder. On 06/22/2026, the resident stated scheduled showers on Sundays and Wednesdays were not happening, reported going 23 days without a shower, and said the last shower received was on 06/21/2026. The resident also stated feeling dirty and crappy because routine bathing was not being provided. Record review showed Resident #44’s Documentation Survey Report V2 for May 2026 lacked documentation of a shower provided or declined for two extended periods, from 05/03/2026 to 05/13/2026 and from 05/17/2026 to 05/27/2026. The care plan documented that the resident needed assistance with personal care and preferred showering two days per week with one staff assist. Staff interviews confirmed residents were scheduled for showers twice weekly, that staff were responsible for offering showers or alternatives if declined, and that shower documentation was expected in the EHR. The Infection Preventionist confirmed that if a shower was not documented, it did not occur, and acknowledged the lack of shower documentation for Resident #44.
PICC Dressing Changes Not Performed per Order
Penalty
Summary
The facility failed to ensure PICC line dressing changes were performed according to physician orders for Resident #59, who was admitted and readmitted with diagnoses including resistance to multiple antimicrobial drugs, urinary tract infection, and neuromuscular dysfunction of the bladder. On 06/22/2026, the resident stated they had been in the facility since 2025 and had recently been transferred to the hospital for a severe urinary tract infection with blood in the urine, and also reported having an indwelling catheter. Observation showed a PICC line dressing dated 06/14/2026 while the resident was receiving IV antibiotics through the PICC line. The physician order dated 06/11/2026 directed PICC site maintenance with transparent and gauze dressing changes 24 hours post-insertion, then every seven days and as needed, with upper arm circumference measurements and gauze dressing changes every 48 hours until 06/24/2026 if gauze was present. The June 2026 IV TAR documented dressing care as completed by LPN1 on 06/16/2026 and 06/23/2026, but on 06/24/2026 the MDS Coordinator confirmed the bandage remained dated 06/14/2026 and should have been changed by 06/21/2026. The MDS Coordinator also stated it was not appropriate for the TAR to document completed dressing changes when the dressing date did not correspond, and later confirmed LPN1 lacked documented IV certification while documenting dressing changes as completed even though the dressing appeared unchanged.
Controlled Medication Administration Not Documented
Penalty
Summary
The facility failed to ensure that administration of a controlled medication was documented in the controlled drug record for Resident #31. Resident #31 was admitted with quadriplegia, C1-C4 incomplete, and had an order for oxycodone HCl 10 mg by mouth every six hours as needed for pain management. During review of the controlled drug logbook in the 100-hall medication storage cart, page 11 showed one tablet remaining of oxycodone IR 10 mg, but there were no corresponding bubble packs of oxycodone in the narcotics drawer of the medication cart. The MDS Coordinator searched the cart and confirmed the tablet documented in the logbook was not present. The MDS Coordinator also reviewed the May 2026 MAR and stated that a dose of oxycodone administered in the morning on 05/06/2026 was not accounted for in the logbook as required. The MDS Coordinator stated the DON was responsible for reviewing the narcotic logbook to ensure documentation was accurate and complete. The facility policy stated controlled medications were subject to special handling, storage, disposal, and record keeping, and that current controlled medication accountability records were to be kept in the MAR or narcotic book.
Medication Administration Errors Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure medications were administered with an error rate of less than 5%. Surveyors observed 29 medication administration opportunities and identified 2 errors, resulting in a 6.9% medication error rate. The report states this practice had the potential to result in residents receiving medications in a manner inconsistent with physician orders and professional standards, placing them at risk for ineffective treatment, adverse drug reactions, and compromised health outcomes. For Resident #4, who was admitted with hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, the June 2026 MAR documented sennosides 8.6 mg daily for constipation with instructions to give two tablets, and Zofran 4 mg every four hours as needed for nausea. During the morning medication pass, the RN prepared and later administered only one tablet of sennosides even though the MAR directed two tablets. The RN stated the dose was given based on the mg listed and that the discrepancy was not noticed, and acknowledged the order should have been clarified before administration. The RN also administered Zofran after the resident requested it, but the medication was not documented on the MAR, and the MAR lacked evidence that ondansetron had been administered on the prior day when the RN recalled giving it after the Pyxis was restarted.
Missing Bathing and Catheter Care Documentation
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a sampled resident when bathing documentation was missing and refusal documentation could not be verified. Resident #44, who was admitted with diagnoses including need for assistance with personal care, psychosis, and major depressive disorder, stated that scheduled showers on Sundays and Wednesdays were not occurring and reported going 23 days without a shower. The resident said the last shower received was on 06/21/2026 and described feeling dirty and crappy because of the lack of bathing. The resident’s documentation for May 2026 lacked entries showing a shower was provided or declined for two extended periods, and the care plan documented a need for assistance with personal care and a preference for showering two days per week with one staff assist. The facility also failed to document catheter care for residents with indwelling urinary catheters. Resident #59 had diagnoses including resistance to multiple antimicrobial drugs, UTI, and neuromuscular dysfunction of the bladder, and had an indwelling Foley catheter with a care plan requiring catheter care every shift. The resident’s task record lacked a scheduled catheter care task, and the clinical record lacked evidence that catheter care had been provided. Staff interviews indicated CNAs were responsible for catheter care and cleaning, nurses were responsible for catheter changes, and catheter care was expected every shift, but the MDS Coordinator could not locate documentation verifying that care had been completed. Resident #5 also had an indwelling Foley catheter and diagnoses including osteomyelitis of the vertebra, diabetes mellitus type 2 with neuropathy, and a stage 4 sacral pressure ulcer. A physician order directed daily and evening shift Foley site care for skin impairment management, but the task record lacked a catheter care task and the clinical record lacked evidence of catheter care. The care plan included enhanced barrier precautions related to the catheter but did not include a plan for Foley catheter care interventions and goals. Resident #18, who had multiple sclerosis and major depressive disorder, also had a Foley catheter and a current UTI. The care plan required catheter care every shift and included interventions for infection and UTI, but the task record lacked a catheter care task and the clinical record lacked evidence that catheter care had been provided. Staff interviews confirmed catheter care was expected to be documented in the EMR, but no documented evidence could be produced for these residents.
QAPI Committee Failed to Identify Missing Immunization Screening Process
Penalty
Summary
The facility's QAPI committee failed to identify that the facility lacked a process to ensure residents were screened for eligibility to receive influenza and/or pneumococcal vaccines upon admission and annually thereafter. During interview, the Administrator confirmed on 06/29/2026 at 3:03 PM that the QAPI committee had not identified this concern and stated they were not sure how the committee could have identified it. The Administrator also stated that identifying the concern could have led to a change in the immunization process by adding a document with targeted questions. The facility policy titled QAPI Plan, updated and approved 02/06/2026, stated that QAPI was a dynamic process used to identify areas for improvement and drive quality of care and services, and that the QAPI committee was responsible for identifying areas requiring performance improvement, collecting data, developing and implementing corrective action, and creating monitors to determine whether changes were effective and sustained.
Missing Communication Training Documentation for Multiple Employees
Penalty
Summary
The facility failed to ensure initial and annual communication training was completed timely for 8 of 20 sampled employees. Personnel record review showed Employee #4, a Registered Dietician hired on 12/08/2025, had documentation of Communication Training completed on 05/13/2025 but lacked annual training for 2026. Employee #10, a CNA hired on 01/16/2026, Employee #11, a Speech Pathologist hired on 02/03/2026, Employee #12, the Infection Preventionist hired on 03/11/2026, Employee #13, an RN hired on 01/13/2026, Employee #15, an LPN hired on 01/26/2026, Employee #16, a CNA hired on 04/23/2026, and Employee #17, a CNA hired on 11/28/2025, all lacked documented evidence of Communication Training completed upon hire. On 06/29/2026 at 8:43 AM, the Business Office Manager stated there was orientation training upon hire and annual training thereafter, and that agency staff do not go directly through the facility for orientation training. The Business Office Manager confirmed the personnel records for Employee #4, #10, #11, #12, #13, #15, #16, and #17 lacked documented evidence of Communication training completed upon hire and annually. The facility policy titled, Nursing Personnel Education and Training, published 11/2016, stated education for new employees and contract staff is provided as part of orientation and scheduled annually, including Communication Training.
Missing QAPI Training Documentation for Multiple Employees
Penalty
Summary
The facility failed to ensure initial Quality Assurance and Performance Improvement (QAPI) training was completed timely for 5 of 20 sampled employees. Employee #9, a CNA hired on 08/05/2020, had documentation showing QAPI training completed on 09/16/2024, but the personnel record lacked documented evidence of annual QAPI training completed in 2025. Employee #10, a CNA hired on 01/16/2026, Employee #15, an LPN hired on 01/26/2026, Employee #16, a CNA hired on 04/23/2026, and Employee #17, a CNA hired on 11/28/2025, all had personnel records that lacked documented evidence of QAPI training completed upon hire. On 06/29/2026 at 8:43 AM, the Business Office Manager stated there was orientation training upon hire and annual training thereafter, and that agency staff do not go directly through the facility for orientation training. The Business Office Manager confirmed that Employee #9, #10, #15, #16, and #17's personnel records lacked documented evidence of QAPI training completed upon hire and annually. The facility policy titled, Nursing Personnel Education and Training, published 11/2016, stated that education for new employees and contract staff is provided as part of orientation and scheduled annually, including the Quality Assurance Program.
Missing Infection Control Training Documentation for 3 Employees
Penalty
Summary
The facility failed to ensure timely initial and annual infection control training for 3 of 20 sampled employees. Employee #9, a CNA hired on 08/05/2020, had documentation showing infection control training completed on 09/23/2024, but the personnel record lacked documented evidence of annual QAPI training completed in 2025. Employee #15, an LPN hired on 01/26/2026, had no documented evidence of infection control training completed upon hire. Employee #16, a CNA hired on 04/23/2026, also had no documented evidence of infection control training completed upon hire. During an interview on 06/29/2026, the BOM stated that orientation training occurs upon hire and annual training occurs thereafter, and confirmed that the personnel records for Employees #9, #15, and #16 lacked documented evidence of infection control training completed upon hire and annually. The facility policy titled Nursing Personnel Education and Training, published 11/2016, stated that education for new employees and contract staff is provided as part of orientation and scheduled annually, including infection control training.
Missing Compliance and Ethics Training Documentation
Penalty
Summary
The facility failed to ensure initial and annual compliance and ethics training was completed timely for 3 of 20 sampled employees. Employee #2, hired as the Director of Nursing on 07/29/2024, had compliance and ethics training documented on 04/01/2025, but the personnel record lacked annual training for 2026. Employee #9, hired as a CNA on 08/05/2020, had compliance and ethics training documented on 05/02/2025, but the personnel record lacked annual training for 2026. Employee #16, hired as a CNA on 04/23/2026, had no documented evidence of initial compliance and ethics training in the personnel record. On 06/29/2026 at 8:43 AM, the BOM stated there was orientation training upon hire and annual training thereafter, and that agency staff do not go directly through the facility for orientation training. The BOM confirmed the personnel records for Employees #2, #9, and #16 lacked documented evidence of compliance and ethics training completed upon hire and annually. The facility policy, Nursing Personnel Education and Training, published 11/2016, stated that education for new employees and contract staff is provided as part of orientation and scheduled annually, including Compliance and Ethics Training.
Missing Behavioral Health Training Documentation
Penalty
Summary
Behavioral Health training was not completed timely for 15 of 20 sampled employees, based on interview, personnel record review, and document review. The facility failed to ensure initial training was documented for Employee #1, #12, #13, #14, #15, #16, and #17, and failed to ensure annual training was documented for Employee #2, #3, #5, #6, #7, #8, #9, and #10. The affected employees included the Administrator, DON, Activities Director, Social Worker, Dietary Manager, CNAs, Infection Preventionist, RN, and LPNs. The personnel records reviewed lacked documented evidence of Behavioral Health training completed upon hire or annually, depending on the employee. On 06/29/2026 at 8:43 AM, the BOM stated there was orientation training upon hire and annual training thereafter, and that agency staff do not go directly through the facility for orientation training. The BOM confirmed that the listed employees' records did not contain documentation showing Behavioral Health training was completed upon hire and annually, and the facility policy titled, Nursing Personnel Education and Training, published 11/2016, stated that education for new employees and contract staff as part of orientation and scheduled annually includes Behavioral Health training.
Failure to Protect Resident From Rough and Painful Incontinence Care by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a CNA during incontinence care. The resident had multiple medical conditions, including acute chronic systolic congestive heart failure, cerebral infarction due to embolism of the right middle cerebral artery, anxiety disorder, depression, muscle weakness, difficulty walking, bilateral localized swelling, and lack of coordination. During a brief change in the resident’s room, a Physical Therapist entered after knocking and announcing therapy and observed the CNA roll the small-statured resident onto their side. Upon removal of the brief, the therapist noted the resident’s bottom appeared red. The Physical Therapist then observed the CNA roughly wipe the resident’s bottom, after which the resident verbalized, “ow, that hurt.” The CNA did not respond to the resident’s expression of pain and continued changing the brief without acknowledging or addressing the resident’s discomfort. The facility’s investigation, as described by the Administrator, determined that the CNA had been rough with the resident during the brief change and was dismissive of the resident’s verbal call out when the resident felt pain. This conduct was contrary to the facility’s abuse policy, which states that each resident has the right to be free from abuse, including physical abuse or mistreatment, and that the facility would implement processes to ensure residents are not subject to abuse by staff.
Failure to Isolate Residents with MDRO UTI According to Infection Control Policy
Penalty
Summary
The facility failed to ensure appropriate care and infection control practices for residents with multidrug-resistant organism (MDRO) urinary tract infections (UTIs), specifically Extended-Spectrum Beta-Lactamase (ESBL) producing E. coli. Two residents, both diagnosed with ESBL E. coli UTIs, were placed in a shared room despite facility policy and CDC guidelines recommending private room placement for residents with MDROs. Clinical records and staff interviews confirmed that both residents were on contact precautions, yet continued to share a room for an extended period, even though the facility had available private rooms. One resident, with a history of chronic respiratory failure and chronic kidney disease, tested positive for ESBL E. coli in the urine and was treated with IV antibiotics. This resident was not placed in a private room upon return from the hospital, as required by infection control policy, but instead continued to share a room with another resident. The second resident, with multiple psychiatric and neurological diagnoses, subsequently developed an ESBL E. coli UTI after sharing the room with the first resident. This resident reported being in isolation for approximately one month, which exacerbated existing anxiety. Facility documentation, including infection line listings and staff schedules, confirmed that the two residents shared a room during the period of infection and that staffing levels were sometimes below the facility's stated minimum. The Infection Preventionist and DON acknowledged that the resident with the initial ESBL infection should have been placed in a private room, and that the failure to do so was not in accordance with facility policy or CDC recommendations. The deficiency was further supported by the presence of empty beds in the facility at the time, indicating that private room placement was feasible.
Failure to Implement Transmission-Based and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Transmission-Based Precautions (TBP) and Enhanced Barrier Precautions (EBP) according to its own policy and CDC recommendations for several residents. Specifically, two residents with confirmed ESBL-producing E. coli infections in their urine were placed in the same shared room, despite facility policy and CDC guidelines indicating that such residents should be placed in private rooms to prevent the spread of multidrug-resistant organisms (MDROs). Documentation showed that one resident tested positive for ESBL E. coli after sharing a room with another resident who had the same organism, and both were kept on contact precautions in a shared room. Staff interviews confirmed that the residents were not separated, and the Infection Preventionist and DON acknowledged that a private room should have been used. Additionally, the facility did not implement EBP for three residents who met the criteria for these precautions. These residents had conditions such as open wounds and indwelling Foley catheters, which, according to facility policy and CDC guidance, require EBP regardless of confirmed MDRO status. Observations during facility tours revealed that there was no EBP signage or PPE carts outside the rooms of these residents, and staff confirmed that EBP was not in place for them. The DON and IP verified that these residents should have been under EBP but were not. The facility's own infection control policies, as well as CDC guidelines, were not followed in these cases. The policies specified the need for private rooms for residents with certain infections and the use of EBP for residents with specific medical devices or wounds. Despite having available private rooms, the facility did not adhere to these protocols, and staff schedules indicated periods of minimal staffing, which may have contributed to the lapses in infection control practices.
Failure to Timely Report Allegations of Abuse, Neglect, and Serious Injury
Penalty
Summary
The facility failed to ensure timely reporting of allegations of abuse, neglect, and serious bodily injury to the State Agency (SA) as required by both facility policy and federal regulations. In seven out of ten Facility Reported Incidents (FRIs) reviewed, initial reports were submitted to the SA outside the mandated time frames. Specific incidents included allegations of verbal abuse by a Certified Nursing Assistant, resident-to-resident physical and sexual abuse, neglect resulting in a fall with a hip fracture, and employee-to-resident physical and verbal abuse. Documentation showed delays ranging from several days to over a week between the occurrence of the incidents and the submission of initial reports to the SA. Facility policy required immediate reporting, but interviews with facility leadership confirmed that the process was not consistently followed. The incidents involved various forms of abuse and neglect, including physical altercations between residents, inappropriate sexual contact, and a fall resulting in serious injury. Progress notes and interviews indicated that staff did not always report incidents to facility leadership immediately, and leadership did not always report to the SA within the required two-hour or 24-hour windows, depending on the severity of the allegation.
Mattress Used as Restraint Without Evaluation or Consent
Penalty
Summary
A deficiency occurred when a resident with metabolic encephalopathy and idiopathic normal pressure hydrocephalus had their mattress placed directly on the floor by an LPN without prior evaluation or consent. The LPN removed the resident's bed frame and placed the mattress on the floor without notifying other staff, the physician, or the resident's family. This action was witnessed by a CNA and later reported after the resident had been discharged. The facility's investigation substantiated the allegation of neglect, noting that the mattress on the floor acted as a restraint, as the resident was unable to get up unassisted, whereas previously the resident had been able to get out of bed independently. Facility policy required a device evaluation and consent from the resident or their representative before implementing any device that could act as a restraint. The policy also mandated physician notification and an order specifying the type, reason, and duration of use for any restraint. In this case, none of these steps were followed prior to the intervention, and the resident and their family were not informed of the risks and benefits associated with the change. The lack of a barrier between the mattress and the floor and the absence of required notifications and evaluations led to the substantiated finding of neglect.
Resident Left in Soiled Brief and T-Shirt in Dining Room During Behavioral Episode
Penalty
Summary
A resident with diagnoses including severe unspecified dementia with behavioral disturbances, anxiety disorder, cognitive communication deficit, seizures, and difficulty walking experienced a behavioral episode while being assisted with a brief change. The resident became verbally agitated, exhibited signs of psychosis, and began yelling and making accusations against staff. During the episode, the resident grabbed and injured a CNA, attempted to strike staff with a call light, and threw items in the room. In response, staff, including an LPN and CNA, removed the resident from the room and transferred the resident to the dining room as a behavioral intervention. The resident was left in the dining room wearing only a soiled brief and a t-shirt, with the curtains drawn back, exposing the resident to view. Staff left the resident alone in the dining room, closed the door, and observed the resident through the windows. While in the dining room, the resident continued to display aggressive behaviors, including attempting to remove the television from the wall, swinging the television cord at staff, and throwing the remote control. The LPN attempted to calm the resident by offering food, drink, and medication, with the resident eventually accepting medication and calming down. Throughout the incident, the resident remained in a soiled brief and t-shirt in a common area, with the curtains open, which was confirmed by the DON as disrespectful to the resident's dignity. Facility documentation and staff interviews confirmed that the resident was secluded in the dining room and not treated with respect and dignity during the behavioral episode.
Inaccurate MDS Assessment for Anticoagulant Use
Penalty
Summary
The facility failed to ensure the accuracy of a Minimum Data Set (MDS) 3.0 assessment for one resident. The resident, who had a diagnosis of type one diabetes mellitus with diabetic chronic kidney disease, was prescribed and administered Eliquis, an anticoagulant, for deep vein thrombosis (DVT) prophylaxis. Review of the resident's Medication Administration Record (MAR) confirmed that the medication was given consistently throughout the month. However, the MDS assessment completed for the resident did not indicate that the resident was receiving an anticoagulant in Section N, which is designated for documenting high-risk medications. The MDS Coordinator acknowledged that the assessment was inaccurate after reviewing the documentation and confirmed that the omission occurred despite the resident's ongoing anticoagulant therapy.
Failure to Implement PASARR Screening and Referral Process
Penalty
Summary
The facility failed to ensure that there was a process in place to identify and refer residents for Preadmission Screening and Resident Review (PASARR) Level II, and did not initiate a PASARR Level I submission for one of thirteen sampled residents. Specifically, a resident was admitted with diagnoses including unspecified psychosis and depression, but the PASARR Level I on file was completed years prior and did not reflect the current mental health diagnoses. The resident's active diagnoses, including psychosis and cognitive symptoms, were documented after admission, but there was no evidence that a new or updated PASARR Level I or a referral for Level II evaluation was initiated. Interviews with facility staff revealed a lack of understanding and training regarding PASARR processes. The Licensed Social Worker stated they had no responsibilities related to PASARR, and the Admissions Director admitted to not knowing what PASARR was or the required timeframes for completion. The Administrator confirmed that no staff member was overseeing PASARR procedures and acknowledged that the process was not being followed. The facility's policy required validation and tracking of PASARR Level I and referral for Level II when indicated, but this was not implemented for the resident in question.
Failure to Include Oxygen Therapy and Related Diagnoses in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a complete care plan was developed and implemented for a resident with chronic obstructive pulmonary disease, chronic systolic (congestive) heart failure, and asthma. The resident was observed receiving oxygen via nasal cannula, with the oxygen concentrator set at varying rates, and staff reported the resident often removed the cannula at night, requiring adjustments to oxygen delivery. Despite a physician's order for continuous oxygen at 2 liters per minute, the resident's care plan did not include documentation related to oxygen use or the associated diagnoses. Interviews and record reviews confirmed that the care plan lacked problems, goals, or interventions addressing the resident's need for oxygen therapy and monitoring for respiratory symptoms. The DON acknowledged that the care plan should have included these elements and confirmed their absence prior to a later update. This omission meant that staff may not have been fully aware of the resident's needs regarding oxygen administration and monitoring.
Failure to Provide Scheduled Showers or Baths for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who required substantial to maximal assistance with activities of daily living, specifically bathing and showering, did not receive scheduled showers or baths as required. The resident, who had diagnoses including intervertebral disc degeneration, muscle weakness, and atrial fibrillation, reported not receiving regular showers and resorted to giving themselves a bed bath. The resident expressed feeling itchy and bad about themselves due to the lack of regular scheduled showers. The resident's care plan and Minimum Data Set (MDS) indicated a need for staff assistance with bathing and showering. A review of the resident's medical records for a three-month period revealed multiple dates where there was no documented evidence that a shower, bath, or bed bath was provided as scheduled. There was also no documentation indicating the resident refused care or that alternative arrangements were made to compensate for missed showers or baths. Staff interviews confirmed that showers were scheduled twice weekly and that refusals or completed showers were to be documented in both paper and electronic records. The Director of Nursing confirmed the absence of documentation for the missed dates and acknowledged that there was no evidence the resident had refused or was unavailable for care on those occasions.
Oxygen Administration Not in Accordance with Physician Order
Penalty
Summary
The facility failed to ensure that oxygen was administered according to a physician's order for one resident with chronic obstructive pulmonary disease and chronic systolic heart failure. The resident was observed receiving oxygen via nasal cannula at a rate of 2.5 to 3 liters per minute, despite a physician's order specifying continuous oxygen at 2 liters per minute. Staff reported that the resident often removed the nasal cannula at night, and in response, staff increased the oxygen flow rate without obtaining a new physician's order or titration instructions. Review of the clinical record confirmed there was no order to increase or titrate the oxygen flow rate based on oxygen saturation readings. The facility's policy required medications, including oxygen, to be administered strictly according to prescriber orders, and any changes or clarifications were to be documented. The Director of Nursing confirmed that staff increased the oxygen flow rate without proper authorization or documentation, and the clinical record lacked any order supporting this change.
Annual CNA Performance Review Not Completed
Penalty
Summary
The facility failed to complete an annual performance review for a Certified Nursing Assistant (CNA) who had been employed for more than one year. Review of personnel records showed that the CNA, hired on 08/31/2023, did not have documentation of a performance review for 2024. During an interview, the Director of Nursing confirmed responsibility for conducting CNA performance evaluations and acknowledged that the required review had not been completed at the one-year mark. Facility policy requires employee reviews every 12 months to identify areas for improvement and necessary competencies.
Medication Error Rate Exceeds Acceptable Threshold Due to Missed Doses
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with a calculated error rate of 7.69% based on 26 observed opportunities and two errors. The errors involved two residents who did not receive their prescribed medications due to the medications being out of stock. In both cases, the registered nurses identified that the medications were not available in the medication cart and attempted to locate them in the medication storage room and automated dispensing system. When the medications were not found, the nurses indicated they would contact the pharmacy, but the medications were not administered as ordered. One resident, with a history of cerebral infarction, intracardiac thrombosis, and ventricular tachycardia, did not receive a scheduled dose of Pradaxa because it was not available in the facility. The nurse documented the medication as 'On Order' from the pharmacy but did not provide documentation of physician notification or alternative orders. Another resident, with diagnoses including obstructive and reflux uropathy and post-surgical aftercare, did not receive a scheduled dose of Finasteride for similar reasons, with the medication also marked as 'On Order' and no documentation of physician notification or alternative instructions. The Director of Nursing confirmed that there was no facility policy specifically addressing medication administration errors and that staff were expected to follow the rights of medication administration. The DON also acknowledged that there was no documentation of physician notification or pharmacy contact for the missed doses. Facility policy required medications to be administered as prescribed and for any withheld or missed doses to be documented with an explanatory note, which was not done in these cases.
Multi-Dose Vial of Tuberculin PPD Not Dated Upon Opening
Penalty
Summary
Surveyors observed that a multi-dose vial of Tuberculin Purified Protein Derivative (PPD) was stored in the medication storage refrigerator without a cap and with a visible puncture site in the rubber stopper. Neither the vial nor its manufacturer box was labeled with the date the vial was opened, despite manufacturer instructions to discard the vial within 30 days of opening. The Infection Preventionist confirmed that the vial was open and lacked an open date, acknowledging that it would need to be destroyed. Facility policy required that the date opened and the initials of the first person to use the vial be recorded on all multi-dose vials, but this was not followed in this instance.
Facility Assessment Lacked Required Review and Approval
Penalty
Summary
The facility failed to ensure that the Facility Assessment (FA) was properly reviewed, updated, and approved by the required facility leadership and management, including the Quality Assessment and Assurance (QAA) Committee. The FA dated 03/25/2025, which was presented by the Interim Executive Director (IED), did not include documented evidence of review or approval by the QAA Committee, nor did it have an attendance sheet indicating participation from the necessary leadership members. The IED confirmed that the FA was created and implemented solely by themselves without input or review from other required members of facility leadership or management. Additionally, the facility did not have a policy or procedure in place regarding the review, updating, or implementation of the FA, nor did it specify the required attendees for such processes. The previous FA, dated 08/29/2024, did include an attendance sheet with various facility leaders, but the IED stated that this version was considered null and void. The lack of proper review and approval processes for the FA was acknowledged by the IED, who admitted that the 03/25/2025 FA did not meet federal regulations and requirements.
Failure to Timely Document PRN Medication and Wound Care Orders
Penalty
Summary
A deficiency was identified when a registered nurse administered two tablets of Acetaminophen 325 mg to a resident who complained of back pain, but failed to document the administration in the resident's Medication Administration Record (MAR) at the time of administration. The nurse confirmed the omission during a review of the MAR, acknowledging that the medication had been given but not recorded. Facility policy required immediate documentation of medication administration, including PRN medications, specifying the need to record the date, time, dose, symptoms, results, and the signature or initials of the administering staff. Another deficiency occurred when a resident returned from the emergency room with a cranial abrasion and had a dressing applied to the head. The Infection Preventionist (IP) and an LPN evaluated and treated the abrasion, with the IP applying Xeroform and wrapping the resident's head. However, the clinical record for this resident lacked a physician's order for the wound care that was provided. The IP later confirmed that, although verbal approval from the physician had been obtained, the order was not documented in the resident's record as required by facility policy. Both deficiencies were confirmed through observation, interview, and record review. The facility's policies on medication administration and skin integrity required timely and complete documentation of all care provided, including obtaining and recording physician orders for treatments and documenting all medication administrations in the MAR.
Failure to Develop and Implement Required Performance Improvement Project
Penalty
Summary
The facility failed to develop and implement at least one Performance Improvement Project (PIP) within the past year, as required. During interviews, the Interim Executive Director (IED), Director of Nursing (DON), and Lead Administrator of Nevada (LAN) confirmed that while monthly Quality Assurance Performance Improvement (QAPI) committee meetings were held, they were unable to provide documentation or describe any PIP completed in the last year. The LAN explained that the facility's electronic system for documenting PIPs became inaccessible after the former Administrator left, leaving the QAA committee without access to necessary records. The IED, who had only recently assumed the role, was unable to confirm the existence of any current PIPs or locate related documentation. Additionally, the QAPI committee had not been informed of the facility's failure to follow policies and regulations regarding the reporting of abuse, neglect, mistreatment, misappropriation of property, and exploitation. The facility's QAPI Plan indicated that PIPs should be evaluated on an ongoing basis by the QAA committee, but there was no evidence that this process had occurred in the past year.
Failure to Offer and Document Timely Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that a resident was offered a timely pneumococcal vaccination to complete the recommended vaccine schedule. The resident, who had a history of type two diabetes mellitus with circulatory complications and chronic diastolic (congestive) heart failure, had previously received the PPSV23 vaccine on three occasions. However, there was no documentation in the clinical record or immunization audit report indicating that the resident had received any of the other recommended pneumococcal vaccines, such as PCV13, PCV15, or PCV20. The resident's record listed these vaccines as pending, and a multi-vaccine consent form indicated eligibility but lacked a signature for consent or declination. Interviews with the Infection Preventionist (IP) revealed that the facility determined vaccine eligibility based on consent, vaccination history, and CDC recommendations. The IP confirmed that the resident had not received the PCV vaccines and that pending immunization status indicated the resident was due and had given consent. The facility's policy required vaccination upon admission and as per CDC guidelines, with documentation of administration, refusal, or non-vaccination in the electronic health record. Despite these procedures, the required pneumococcal vaccine was not administered, and proper documentation of consent or refusal was not present.
Failure to Document and Administer COVID-19 Vaccine to Eligible Resident
Penalty
Summary
The facility failed to ensure that one of five sampled residents received or declined an updated or booster dose of the COVID-19 vaccine after being screened for eligibility. The resident, who had diagnoses including type two diabetes mellitus without complications and hypertension, was admitted to the facility and identified as eligible for the COVID-19 vaccine. However, the Immunization Audit Report only documented a status of pending immunization, and the Resident Multi-Vaccine Consent Form lacked a signature indicating consent or declination. There was no documented evidence in the clinical record that the vaccine was administered or declined. Interviews with the Infection Preventionist (IP) confirmed that the resident's record did not contain documentation of previous COVID-19 vaccination and that the vaccine had not been administered. The facility's policy required that residents be offered recommended COVID-19 vaccinations upon admission and as eligible, with documentation of acceptance or declination. Despite these requirements and CDC recommendations, the necessary documentation and administration or declination of the vaccine for this resident were not completed.
Resident Subjected to Involuntary Seclusion During Behavioral Episode
Penalty
Summary
A deficiency occurred when a resident with severe dementia, anxiety disorder, cognitive communication deficit, and other medical conditions was subjected to involuntary seclusion. During an episode of behavioral disturbance, the resident became verbally agitated, exhibited signs of psychosis, and physically aggressive behaviors, including grabbing and scratching a CNA and attempting to strike staff with a call light. In response, staff removed the resident from their room and transferred them to the community dining room while the resident was only wearing a soiled brief and a t-shirt. Once in the dining room, staff closed the door, isolating the resident from others, and observed the resident through the windows with the curtains drawn back. The resident continued to display agitated behaviors, such as attempting to rip the television from the wall, swinging the television cord at staff, and throwing objects. Staff offered food, drink, and medication, with the resident eventually accepting medication and calming down. The resident was then returned to their room. Facility documentation and interviews confirmed that the resident was left alone in the dining room with the door closed, separated from other residents, and exposed to view while in a state of distress and undress. The facility's own policies and resident rights documents define involuntary seclusion as the separation or isolation of a resident against their will, which occurred in this incident. The DON acknowledged that the situation was handled poorly and that the resident was isolated from the community during the episode.
Failure to Provide Timely Elder Abuse Training to Agency CNA Involved in Resident Incident
Penalty
Summary
The facility failed to ensure that an agency contracted Certified Nursing Assistant (CNA), identified as Employee #24, completed initial elder abuse prevention training upon hire. Employee #24 was hired on 11/08/2024 and terminated on 03/05/2025, but their personnel record lacked documented evidence of elder abuse training completion at any point during employment. Facility policy required all staff, including agency staff, to complete abuse training upon hire and annually thereafter. An incident occurred in which Employee #24 was involved with a resident who became verbally agitated and exhibited signs of psychosis during assistance with a brief change. The CNA removed the resident from their room and transferred them to the community dining room while the resident was wearing only a t-shirt and a soiled brief. The resident was left in the dining room with the curtains drawn back, visible to others, while staff observed from outside the room. As a result of this incident, three employees were terminated for policy violations. The lack of required abuse prevention training for Employee #24 was confirmed by both the Director of Nursing and the Administrator.
Expired Supplies and Missing Narcotics in LTC Facility
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals, leading to expired COVID-19 testing supplies being present in the medication room and on a medication cart. During an inspection, it was observed that the medication storage room contained a box of COVID-19 test kits that had expired, and the same was found in the medication cart for the 200 hall. The Resident Care Manager and the LPN confirmed the expiration of these supplies. Although the Director of Nursing (DON) claimed to conduct weekly audits to remove expired items, the expired test kits were not removed because the expiration date had been extended, as per the Administrator's documentation. However, the Administrator later confirmed that the test kits were indeed expired. Additionally, the facility failed to store narcotic medications appropriately, resulting in the loss of a resident's narcotic pain medication. Resident #188, who was admitted with diagnoses requiring pain management, had a physician order for Oxycodone. However, 38 tablets of the medication went missing from the medication cart. The LPN responsible for the cart reported the missing medication to the DON and admitted to leaving the keys on top of the cart, which could have allowed unauthorized access. The facility was unable to determine who accessed the medication, and the missing Oxycodone was not recovered. The facility's policy stated that only authorized personnel should have access to controlled medications, and the medication nurse should maintain possession of the keys, which was not adhered to in this case.
Deficiencies in Ice Machine Cleanliness, Food Storage, and Hand Hygiene
Penalty
Summary
The facility failed to maintain cleanliness standards for an ice machine, as observed on June 24, 2024. The ice machine in the kitchen had a hard, white, flaky substance around the outside and inside of the door. Despite a task sheet indicating routine maintenance was completed on June 4, 2024, including door gasket cleaning, the Nutrition Services Supervisor could not locate the contractor's cleaning log or the schedule for the next deep cleaning. The facility's policy required monthly cleanings of the ice machine, which were to be documented, but this was not adhered to. Additionally, the facility did not follow its policy for discarding expired food. On June 24, 2024, a cardboard case containing seven unopened and one opened one-quart cartons of heavy cream with expiration dates of June 16, 2024, was found in the walk-in refrigerator. The Nutrition Services Supervisor confirmed these should have been discarded. Furthermore, during a lunch trayline observation on June 25, 2024, a staff member failed to perform hand hygiene as required. The staff member entered the trayline from the kitchen prep area without washing hands or changing gloves, despite knowing the policy required handwashing and new gloves before handling food. The Nutrition Services Supervisor confirmed the breach in protocol.
Infection Control Deficiencies in Hand Hygiene, Glucometer Use, and Laundry Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by a staff member, specifically the Activities Director (AD), who did not perform hand hygiene between contact with residents and environmental surfaces. The AD was observed touching a resident's hand and bedding, then placing hands on the nurse's station counter, and subsequently greeting another resident without performing hand hygiene. The Infection Preventionist (IP) confirmed that hand hygiene should be completed before and after contact with residents, but had not provided education to the AD on this matter, as the IP only provided infection control education to nursing staff. The Director of Nursing (DON) stated that all staff received training on hand hygiene at the time of hire, yet the AD did not adhere to these practices. The facility also failed to properly sanitize a glucometer between resident uses. A Licensed Practical Nurse (LPN) used the same glucometer for two residents and cleaned it with a 70 percent isopropyl alcohol prep pad instead of the required Sani-Cloth germicidal disposable wipe. The DON confirmed that the glucometer should be cleansed with a Sani-Cloth and remain wet for two minutes, following the manufacturer's instructions to prevent the spread of blood-borne pathogens. The facility's policy and the manufacturer's instructions specified the use of specific disinfectant wipes and procedures, which were not followed by the LPN. Additionally, the facility's laundry practices were found to be unsanitary. A fan was observed blowing air from the dirty side of the laundry room to the clean side, potentially contaminating clean laundry. Industrial floor cleaners were stored on the clean side, and a blanket was placed on a floor cleaner to dry, which was then stored on a wire rack without a solid bottom. The IP and DON did not oversee the infection control practices of the laundry room, as these services were provided by a contracted agency. The facility's policy required soiled laundry to be handled in a manner preventing microbial contamination, which was not adhered to in this instance.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consents were obtained prior to administering two psychotropic medications to a resident. The resident, who was admitted with diagnoses including unspecified dementia, obstructive sleep apnea, and anxiety disorder, was prescribed Amitriptyline and Buspirone for restlessness related to anxiety. These medications were administered from June 18, 2024, through June 24, 2024, without obtaining the necessary informed consents beforehand. The facility's policy required informed consents for psychotropic drugs to be completed within 48 hours of admission. However, the consents for Amitriptyline and Buspirone were only signed and dated on June 24, 2024, after the medications had already been administered. The Director of Nursing confirmed that the medications were given prior to obtaining the informed consent documentation, which was a violation of the facility's policy.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents. For one resident, the MDS assessment inaccurately documented the use of bed rails as restraints. The resident, along with a CNA and an LPN, confirmed that the bed rails were used to assist with mobility and did not restrict movement. The MDS Coordinator also acknowledged that the bed rails were not used as restraints, despite being coded as such in the MDS assessment. The facility's policy stated that bed rails are not considered restraints unless they prevent the resident from getting out of bed. For another resident, the MDS assessment failed to reflect an active diagnosis of Deep Vein Thrombosis (DVT), despite the resident receiving anticoagulant medication for this condition. The resident's clinical record lacked documentation of a DVT diagnosis in the active diagnosis list, although a Nurse Practitioner Progress Note and a physician's order indicated the presence of a DVT. The MDS Coordinator confirmed that the MDS should have been updated to include the DVT diagnosis.
Failure to Develop Care Plans for DVT and Insomnia
Penalty
Summary
The facility failed to develop a care plan for two residents with specific medical conditions. Resident #13, who was admitted with diagnoses including Parkinsonism and unspecified dementia, was confirmed to have a deep vein thrombosis (DVT) on 07/24/2023. Despite receiving anticoagulant therapy with Eliquis as per a physician's order, a care plan addressing the DVT was not initiated until 06/25/2024. The care plan should have included interventions such as leg elevation, monitoring for color changes, and assessing anticoagulant therapy to prevent clot dislodgment. Similarly, Resident #20, admitted with anxiety and cellulitis, was receiving Trazodone for insomnia as per a physician's order dated 03/12/2024. However, the resident's comprehensive care plan did not include a plan for managing insomnia. The Director of Nursing confirmed that care plans should be created upon admission and updated within 48-72 hours as new problems or interventions arise, indicating a lapse in the facility's adherence to this protocol.
Backdating of Care Plan for DVT
Penalty
Summary
The facility failed to meet professional standards for accurate recording as per the Nevada Nurse Practice Act when the Minimum Data Set Coordinator, a Registered Nurse, backdated a resident's care plan for deep vein thrombosis (DVT) by 11 months. The resident, who was admitted with diagnoses including Parkinsonism and unspecified dementia, was confirmed to have a DVT on July 24, 2023, and was prescribed Eliquis, an anticoagulant, on July 26, 2023. However, the resident's Comprehensive Care Plan did not include a care plan for DVT or the anticoagulant until June 25, 2024, despite the medication being administered from June 1, 2024, to June 25, 2024. The MDS Coordinator admitted to adding the care plan for DVT on June 25, 2024, and backdating it to July 24, 2023, based on a progress note. The Director of Nursing confirmed that backdating the care plan was unacceptable and that care plans should be created upon admission and updated within 48-72 hours as new problems or interventions arise. The Director of Nursing provided an audited copy of the Comprehensive Care Plan, which documented that the DVT care plan was indeed created on June 25, 2024. This action was considered unprofessional conduct under the Nevada Nurse Practice Act, which prohibits inaccurate recording or falsifying records.
Deficiency in CPR Certification for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff were trained and certified to perform Cardio-Pulmonary Resuscitation (CPR) in the event of a resident cardiac arrest. This deficiency was identified for two of the five sampled licensed nurses, specifically two Licensed Practical Nurses (LPNs). The personnel records for these LPNs lacked documented evidence of current CPR certifications. During the survey process, the Business Office Manager (BOM) confirmed responsibility for personnel record review but was unsure about the policy for CPR training, including who was required to be certified and how often training was required. The facility's policy on CPR, updated on a specified date, required licensed nurses to have current CPR certification.
Failure to Administer Medication Within Prescribed Parameters
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically regarding the administration of acetaminophen outside of physician-prescribed parameters. Resident #288, who was admitted with diagnoses including encephalopathy, hypothyroidism, and hypertension, had a physician's order for acetaminophen to be administered for pain levels between one and four. However, the medication administration record (MAR) documented that acetaminophen was given on multiple occasions when the resident's pain levels exceeded these parameters, with pain levels recorded as high as ten. The Licensed Practical Nurse (LPN) confirmed that the administration of acetaminophen did not adhere to the physician's order, and the Director of Nursing (DON) acknowledged that the medication was not administered as prescribed. The facility's policy on medication administration, dated January 2021, required that medications be administered as prescribed, and the DON emphasized the importance of following physician orders to ensure medications are given based on resident needs. Despite this, the facility could not confirm whether the medication was necessary, highlighting a failure to adhere to prescribed medication protocols.
Psychotropic Medication Prescribed Without Diagnosis
Penalty
Summary
The facility failed to ensure that a psychotropic medication was prescribed with a diagnosed indication for use for one of the residents. Resident #20 was admitted with diagnoses including anxiety and cellulitis of the left lower limb. However, the resident was receiving Trazodone for insomnia without having a diagnosis of insomnia. A Licensed Practical Nurse confirmed that the resident did not have a diagnosis for insomnia, despite receiving Trazodone daily for this condition. The Director of Nursing also confirmed the absence of an insomnia diagnosis for Resident #20, acknowledging that the resident should have had one. The facility's policy required a physician to provide justification for the continued use of psychotropic drugs, including a diagnosis and description of symptoms, which was not adhered to in this case.
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What surveyors actually found near you
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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 Gardnerville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mountain View Health And Rehabilitation | 13 mi | ★★★★★ | 22 | 0 |
| Barton Hospital D/p Snf | 13.1 mi | ★★★★★ | 14 | 0 |
| Sierra Basin Post Acute | 15.5 mi | ★★★★★ | 13 | 0 |
| Northstar Post Acute | 16 mi | ★★★★★ | 42 | 0 |
| Ormsby Post Acute Rehabilitation | 16.7 mi | — | 34 | 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 October 2026) and official state health department websites.