Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sierra Basin Post Acute during CMS and state inspections, most recent first.
Failure to Report Alleged Physical Abuse: A resident with a fractured hip and femur reported that a CNA handled the resident roughly and caused concern about worsening the injury. The PT Director notified the DON and WNM, but the allegation was not reported to the required State agencies or the resident’s family, and the CNA remained working in the facility. Interviews confirmed the event was treated as a possible abuse allegation, but required reporting and full investigation steps were not completed.
Inappropriate Diagnosis Supporting Antipsychotic Use: Two residents received antipsychotic medications without an appropriate supporting diagnosis. One resident with dementia was ordered Quetiapine for behaviors, but staff could not identify the targeted behaviors and the DON stated dementia or behaviors alone were not appropriate indications. Another resident with dementia and Alzheimer’s disease was ordered Risperidone for dementia, while the med review listed schizoaffective disorder; the DON and physician confirmed the resident did not have that diagnosis.
Failure to Investigate Allegation of Physical Abuse: A resident with a fractured hip and femur reported that a CNA had been rough during care and made the resident feel unsafe. The PT Director, DON, and WNM acknowledged the allegation, but the investigation was incomplete, with only an unsigned and undated verbal statement from the WNM, no family or State notification, and the CNA still working and caring for residents.
A resident with idiopathic chronic gout was transferred to a hospital after becoming very confused and showing concern for worsening infection. The discharge MDS showed a hospital discharge, but the clinical record had no written bed-hold notification. The RCM said administration handled discharge documentation, and the DON said the direct care nurse and RCM were responsible for educating the resident on the bed-hold policy and documenting it, but no such record could be found.
A resident with muscle weakness and difficulty walking had an initial falls care plan identifying fall risk and baseline interventions, but after two in-facility falls the care plan was not revised. The record showed no new fall-prevention interventions, no changes to existing interventions, and no documented root-cause assessment; an LPN, RCM RN, and DON each confirmed the care plan had not been updated.
A resident with a recent below-knee amputation and ongoing orthopedic wound care missed a scheduled ortho follow-up because the facility’s transportation plan was inaccurate. The appt calendar showed family transport, but the resident said family was unavailable and staff had not confirmed the plan; the RN and Transportation CNA described a breakdown in communication about who would provide transport.
A resident with muscle weakness and difficulty walking experienced two in-facility falls, including one during a transfer to a wheelchair when the brakes were not set and another while using the toilet that caused pain and led to x-rays of the hip and hand. Although post-fall reviews were completed, the resident’s fall care plan was not revised, no new fall-prevention interventions were added, and the DON confirmed the care plan was not updated after the repeated falls.
A treatment/wound cart containing resident meds was observed unlocked in the resident care area with no nursing staff present. The cart held lidocaine cream, triamcinolone (TAC) cream, and nystatin powder. The RCM RN confirmed the cart should not have been left unlocked, and the DON stated staff were expected to lock the cart before walking away. The facility policy required drugs and biologicals to be stored in locked compartments.
Incomplete abuse allegation documentation and resident record: A resident with a fractured femur and prosthetic hip fracture reported that a CNA had been rough during care and feared further injury. The PT director said the allegation was relayed to the DON by text on a personal phone, but the communication was not documented in the resident record or facility files, and the facility could not produce proof of when it was reported, what was said, or what actions were taken. The DON, RCM, and WNM gave differing accounts of the response, and the facility could not provide a completed abuse investigation, abuse report, or updated clinical record.
A staff member failed to perform hand hygiene while assisting residents in the dining room, including after delivering coffee, touching a resident's chair and table, and helping a resident with salad dressing. The staff member acknowledged hand hygiene should have been done between resident contacts and before meal assistance. The IP stated staff should wash hands between touching residents or any surface, and the facility policy required hand hygiene before and after direct resident contact, after contact with nearby objects, and before and after meal assistance.
The facility did not ensure that staff completed elder abuse prevention training before interacting with residents. Eight employees, including the Administrator, Director of Rehabilitation, RN, LPNs, CNA, Dietary Aide, and Housekeeper, began working with residents before completing the required training. This was contrary to the facility's policy, which mandates training upon hire, annually, and as needed.
A facility failed to provide written notification of transfer to a resident and their representative, as required. The resident, with serious health conditions, was transferred to an ER due to breathing difficulties and admitted to a hospital. The facility's Director of Nursing confirmed the removal of the notification requirement from their checklist, and no transfer policy was provided to the surveyor.
A resident was transferred to a hospital without receiving the required written notification of the bed hold policy, as confirmed by the DON. The facility's policy required informing residents and/or their representatives of the bed hold provision upon admission and before hospital transfer, but this was not followed.
During a fire drill, the facility's fire alarm system failed to sound in the front part of the building, including the therapy gym and dining areas, despite emergency strobe lights activating. Staff members, including a COTA and the Dietary Director, confirmed they did not hear the alarm, although they saw the strobe lights. The Maintenance Director was unaware of the issue, and the Director of Rehabilitation noted that five residents were in the therapy gym at the time.
A resident admitted for PT rehabilitation did not receive the prescribed frequency of PT sessions due to staffing issues after the facility switched PT service providers. The resident, who was recovering from a fracture, was supposed to receive PT five times a week, but received fewer sessions due to the PT Director's leave of absence and difficulties in finding coverage.
Failure to Report Alleged Physical Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident physical abuse for one sampled resident. Resident #24 was admitted with diagnoses including a left femur fracture, fracture around an internal prosthetic left hip joint, and chronic obstructive pulmonary disease. On 03/09/2026, the resident stated that a CNA had handled the resident roughly and expressed concern that the CNA could worsen the existing hip fracture. The resident also requested that the PTA remove the CNA from the resident’s care because of the rough handling. A PT Treatment Encounter Note dated 03/08/2026 documented that Resident #24 asked to speak with a supervisor and reported that a CNA had been rough with the resident. The RN/WNM was notified. The PT Director later confirmed that rough treatment could be considered abuse and recalled notifying the DON by text message on the personal cell phones of both parties. The DON directed the PT Director to notify the WNM and educate the resident on how to file a grievance, and the PT Director then notified the WNM of the allegation. During interviews, the RCM stated the allegation was not known to her until 03/11/2026 and that the CNA involved was still working and providing care to residents. The CNA stated the resident had refused care and that the CNA later notified the WNM, but the CNA was not aware of any allegation of rough treatment until 03/11/2026. The DON confirmed the allegation was not reported to the resident’s family or the required State agencies, and the WNM stated the CNA should have been removed from the resident’s area and that statements from all parties should have been collected, but this was not completed. Facility policies required abuse allegations to be reported immediately and investigated, and the Administrator confirmed the allegation was not reported to the required State agencies.
Inappropriate Diagnosis Supporting Antipsychotic Use
Penalty
Summary
The facility failed to ensure that 2 of 18 sampled residents had an appropriate diagnosis to support the use of an antipsychotic medication. Resident #6 was admitted with a diagnosis of unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. The record showed an order for Quetiapine Fumarate 50 mg at bedtime for behaviors, and a progress note later documented the medication as being given for dementia. A medication regimen review stated the resident received the antipsychotic for behaviors and noted that the physician used an alternate diagnosis, unspecified, while behavioral symptoms presented a danger to the resident or others. During interviews, the CNA reported no hallucinations, delusions, yelling out, or physically or verbally aggressive behavior, and the LPN reported only occasional hallucination-like behavior and no aggressive behavior. The DON reviewed the record and stated behaviors and dementia were not appropriate indications for an antipsychotic medication. Resident #14 was admitted with diagnoses including dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety, and Alzheimer's disease. The resident had an order for Risperidone 0.25 mg twice daily for a diagnosis of dementia. A medication regimen review documented the resident was receiving Risperdal and stated the physician selected schizoaffective disorder as the diagnosis for the resident's use of Risperidone. The DON stated Risperidone is an antipsychotic and would not be used solely for dementia, and the facility could not determine where the physician obtained the schizoaffective disorder diagnosis or the clinical rationale for the order. The physician later confirmed Risperidone was prescribed for dementia and confirmed Resident #14 did not have a diagnosis of schizoaffective disorder.
Failure to Investigate Allegation of Physical Abuse
Penalty
Summary
The facility failed to investigate an allegation of staff-to-resident physical abuse involving a resident with a left femur fracture, a fracture around an internal prosthetic left hip joint, and COPD. On 03/08/2026, the resident told the PTA that a CNA had been rough during care and requested to speak with a supervisor. The resident also expressed concern that the CNA’s handling could worsen the existing hip injury and said the resident felt unsafe because the CNA continued entering the room to care for the roommate. The PT Director confirmed being notified of the allegation and stated that rough handling could be considered abuse. The PT Director reported notifying the DON by text message and then informing the WNM. The DON directed the PT Director to notify the WNM and educate the resident on how to file a grievance. The DON later stated the only statement collected was a verbal statement from the WNM, and that the statement was not signed or dated. The DON also confirmed there was no notification to the resident’s family or to the required State agencies. The WNM stated the resident felt the CNA was rough and transferred the resident too quickly, and the WNM acknowledged the CNA should have been removed from the resident’s area. The WNM also stated that an allegation of physical abuse required temporary suspension of the alleged perpetrator until the investigation was concluded, but that this had not been completed. The RCM stated the CNA was still working in the facility and providing care to residents, and the CNA said the allegation was not brought to the CNA’s attention until 03/11/2026. Facility policy required all allegations of abuse to be thoroughly investigated, with written, signed, and dated witness statements obtained and findings documented and reported.
Missing Written Bed-Hold Notice After Hospital Transfer
Penalty
Summary
The facility failed to ensure that Resident #78 was provided written notice of the facility bed-hold policy when the resident was transferred to a hospital. Resident #78 was admitted with a primary diagnosis of idiopathic chronic gout, multiple sites, without tophus, and later had a physician progress note documenting that the resident was seen in bed, very confused, with a strong urine odor present. A urinalysis was ordered and medications were adjusted due to concern for worsening confusion, and the provider planned to send the resident to acute care for concern of worsening infection. Resident #78's discharge MDS documented a discharge to a short-term general hospital with a discharge date of 02/18/2026. The clinical record lacked documented evidence of a bed-hold notification. During interviews, the RCM stated administration would be responsible for completed discharge documentation, and the DON stated the direct care nurse present during transfer and the RCM were responsible for educating the resident on the facility's bed-hold policy, including written documentation. The DON also stated the facility could not locate a bed-hold notification in the resident's record or medical records office and explained the facility previously collected verbal consents, which may explain the missing documentation.
Care Plan Not Updated After Repeated Falls
Penalty
Summary
The facility failed to revise the comprehensive person-centered care plan for Resident #34 after the resident experienced two falls in the facility. Resident #34 was admitted and later readmitted with diagnoses including muscle weakness and difficulty walking, and the initial falls care plan dated 12/19/2025 identified the resident as being at risk for falls with baseline fall-prevention interventions. The resident sustained falls on 12/24/2025 and 01/08/2026, which represented a change in condition requiring reassessment and revision of the care plan. The clinical record lacked documented evidence that the care plan was revised after either fall, and no new fall-prevention interventions or modifications to existing interventions were added. During interviews on 03/11/2026, the LPN, RCM RN, and DON each confirmed the care plan had not been updated after the resident’s falls and that no documented root-cause assessment was included.
Missed orthopedic appointment due to transportation miscommunication
Penalty
Summary
The facility failed to ensure Resident #55 received transportation assistance for an orthopedic follow-up appointment in accordance with the resident’s needs and the documented transportation plan. Resident #55 was admitted and later readmitted with diagnoses including acquired absence of the right leg below the knee and orthopedic aftercare following surgical amputation. Provider consultation forms documented orthopedic follow-up care for range of motion, splint care, suture removal, and dressing changes, with ongoing weekly follow-up recommended because of the resident’s recent surgery and wound care needs. For the scheduled orthopedic appointment, the appointment calendar documented that the resident had an appointment with no transport. The resident later stated the facility lacked accurate communication about transportation and recalled asking about the plan on the day of the appointment, only to be told a communication slip indicated family would assist. The resident stated family was not available and the appointment was missed. The RN stated staff relied on the appointment calendar and believed family would provide transport, while the Transportation CNA stated the resident should have been collaborated with before the appointment and that the calendar should have reflected the transportation plan; the CNA also stated the resident required facility transportation assistance but the calendar showed family transport.
Failure to Update Fall Care Plan After Repeated Falls
Penalty
Summary
The facility failed to ensure supervision and assistive devices were provided to prevent accidents when it did not revise the comprehensive person-centered care plan after a resident experienced two falls. Resident #34 was admitted with diagnoses including muscle weakness and difficulty walking, and on 03/09/2026 reported two in-facility falls: one occurred during a transfer to a wheelchair when the wheelchair brakes were not set, and the second occurred while attempting to use the toilet. After the second fall, the resident reported pain and required x-rays of the hip and hand. The resident’s clinical record showed falls on 12/24/2025 and 01/08/2026, with post-fall reviews completed after each event. However, the initial fall care plan dated 12/19/2025 remained unchanged, and no new fall-prevention interventions or modifications were added after either fall. The record lacked documented evidence that the care plan was revised following the resident’s repeated falls, and the DON confirmed the care plan had not been updated to include the facility falls, revised interventions, or a documented root-cause assessment.
Unlocked Treatment Cart Containing Medications
Penalty
Summary
The facility failed to ensure a treatment/wound cart containing resident medications was secured. On 03/12/2026 at 11:36 AM, surveyors observed the treatment/wound cart unlocked in the resident care area with no nursing staff present. Inside drawers one and two of the cart were one tube of lidocaine cream, one tube of triamcinolone (TAC) cream, and three bottles of nystatin powder. At 11:40 AM, the RCM RN confirmed the cart had been left unlocked and stated it should not be left unlocked, explaining it was important to keep the cart locked so residents and visitors could not get into it and to keep everyone safe. At 1:59 PM, the DON stated the expectation was for staff to ensure the treatment cart was locked before walking away. The facility policy titled Storage of Medications stated drugs and biologicals were to be stored in locked compartments and that only authorized persons had access to locked medications.
Incomplete abuse allegation documentation and resident record
Penalty
Summary
The facility failed to ensure Resident #24’s medical record was complete and readily accessible after the resident reported that a CNA had handled the resident roughly during care. Resident #24 was admitted with diagnoses including fracture of the left femur, fracture around an internal prosthetic left hip joint, and COPD. On 03/08/2026, a Physical Therapy Treatment Encounter Note documented that the resident requested to speak with a supervisor and said a CNA had been rough with the resident; an RN/WNM was notified. The resident later stated the CNA had handled the resident roughly and the resident was concerned about further injury to the existing hip fracture. The PT Director stated the allegation was communicated to the DON by text message on the PT Director’s personal cell phone, but that communication was not documented in the resident record or maintained in facility files. The PT Director was unwilling to provide the text correspondence, and the facility could not produce documentation showing when the allegation was reported to the DON, what was communicated, or what actions were taken in response. The DON stated the WNM was asked to obtain a statement from the resident, but the only statement collected was a verbal statement from the WNM, which was not signed or dated. The RCM stated the PT Director notified the RCM of the allegation on 03/11/2026 and that the RCM had been previously unaware. The RCM also stated the CNA involved was still working in the facility and providing care to residents, and the RCM was unable to review the allegation with the CNA. The WNM stated the CNA should have been removed from the resident’s area and that an allegation of physical abuse required temporary suspension of the alleged perpetrator until the investigation was concluded. The facility was unable to provide a completed abuse investigation, abuse report, or updated clinical record reflecting any changes made to the resident’s care.
Failure to Perform Hand Hygiene During Resident Meal Assistance
Penalty
Summary
The facility failed to ensure a staff member performed hand hygiene while assisting residents in the dining room during 4 of 4 observed opportunities. On 03/09/2026 at 12:14 PM, the staff member delivered coffee to a resident, touched the back of a resident's chair, touched the table in front of a resident and then touched the resident's chair, and assisted a resident with opening a container of salad dressing and poured the dressing over the resident's salad without performing hand hygiene between resident contacts or before assisting with the meal. The staff member confirmed hand hygiene had not been performed in between touching residents or before assisting with the resident's salad dressing and stated the staff member should have washed their hands or performed hand hygiene between resident contact. On 03/12/2026 at 1:33 PM, the Infection Preventionist stated staff should have performed hand hygiene or washed their hands in between touching residents or anytime a staff member touched a surface. The facility policy titled Handwashing/Hand Hygiene, revised 08/2019, stated hand hygiene is the primary means to prevent the spread of infections and should be performed before and after direct contact with residents, after contact with objects in the immediate vicinity of residents, and before and after assisting a resident with meals.
Failure to Train Staff on Elder Abuse Prevention Before Resident Interaction
Penalty
Summary
The facility failed to ensure that staff were trained on the prevention of elder abuse before engaging with residents, as evidenced by the personnel records of 8 out of 20 sampled employees. These employees, including the Administrator, Director of Rehabilitation, Registered Nurse, Licensed Practical Nurses, Certified Nursing Assistant, Dietary Aide, and Housekeeper, did not complete their required elder abuse training until after they had already started working with residents. The training was supposed to be completed upon hire, annually, and as needed, but the records show that the training was delayed for all these employees. The facility's policy, titled 'Abuse Neglect, Exploitation and Misappropriation Prevention Program,' revised in April 2021, mandates that staff orientation and training include topics such as abuse prevention, identification, and reporting of abuse. However, the Administrator confirmed that the initial elder abuse training for the mentioned employees was not completed before they began their duties with residents, indicating a lapse in adherence to the facility's policy and training requirements.
Failure to Provide Written Notification of Transfer
Penalty
Summary
The facility failed to provide written notification of transfer or discharge to a resident and their representative, which is a requirement for ensuring that residents and their representatives are informed of the reasons for such actions. This deficiency was identified during a review of the clinical records and interviews with facility staff. The resident in question was admitted to the facility with serious health conditions, including hypertensive heart disease with heart failure and acute respiratory failure. On a specific date, the resident was transferred to an emergency room due to difficulty breathing and acute hypoxia, and subsequently admitted to a hospital. The clinical records for the resident did not contain any documented evidence that written notification of the transfer or discharge was provided to the resident or their representative. During an interview, the Director of Nursing confirmed that the facility had removed the requirement for notification of transfer to a hospital from their transfer checklist. Additionally, the facility was unable to provide a policy related to facility transfers when requested by the surveyor, further indicating a lapse in following proper procedures for resident transfers.
Failure to Notify Resident of Bed Hold Policy
Penalty
Summary
The facility failed to provide a bed hold policy notification to a resident and/or the resident's representative upon transfer to an acute care hospital. This deficiency was identified during a review of the clinical records and interviews with facility staff. The resident, who had been admitted to the facility with diagnoses including hypertensive heart disease with heart failure and acute on chronic systolic heart failure, was transferred to the hospital due to difficulty breathing and acute hypoxia. However, there was no documented evidence that the resident or their representative received written notification of the right to exercise a bed hold provision at the time of transfer. The Director of Nursing confirmed that the facility did not provide the required notification when the resident was transferred to the hospital. The facility's policy, revised in October 2022, stated that residents and/or their representatives should be informed in writing of the bed hold provision upon admission and again before transfer to a hospital. In cases of emergency transfer, the second notice was to be provided within 24 hours. Despite this policy, the notification was omitted from the transfer checklist, leading to the oversight.
Fire Alarm System Failure During Drill
Penalty
Summary
The facility failed to ensure that the fire alarm system functioned properly during a fire drill, as the alarm did not sound in the front part of the building, including critical areas such as the front lobby, staff administrative offices, resident therapy gym, private dining room, and the resident dining room. This issue was identified during a fire drill conducted on January 14, 2025, at 1:28 PM, when the fire alarm was activated at a nurse's station. Although emergency strobe lights were activated throughout the facility, the absence of an audible alarm in these areas was confirmed through observations and interviews with staff members. The Maintenance Director was unaware of the malfunction and expressed that the expectation was for the alarm to sound throughout the entire building. Interviews with a Certified Occupational Therapist Assistant (COTA) and the Dietary Director confirmed that they did not hear the alarm in their respective areas during the drill, although they noticed the strobe lights. The Director of Rehabilitation noted that there were five residents in the therapy gym at the time of the drill. The facility's policy, revised in July 2021, emphasized the importance of keeping residents, staff, and visitors safe during such events, highlighting the significance of the deficiency.
Failure to Provide Prescribed Physical Therapy Due to Staffing Issues
Penalty
Summary
The facility failed to provide physical therapy (PT) services as per the physician's order for a resident who was admitted with a fracture of the superior rim of the left pubis. The physician's order specified PT evaluation and treatment five times a week for eight weeks, starting shortly after admission. However, the resident's comprehensive care plan did not reflect the frequency of treatments as ordered by the physician. The resident expressed concern about not receiving PT for several days due to a lack of PT staff, which was confirmed by both a registered nurse and a physical therapist. The facility had recently transitioned to a new company for PT services, which led to staffing issues. The Director of Nursing (DON) confirmed that the PT Director, who was also a treating therapist, took a leave of absence, and the facility struggled to find coverage. As a result, the resident received fewer PT sessions than prescribed, with only four sessions in one week and just one session in another week, instead of the required five sessions per week. This discrepancy was acknowledged by the DON as being due to staffing challenges.
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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.
Illustrative
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Nursing homes near Carson City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ormsby Post Acute Rehabilitation | 1.3 mi | — | 34 | 0 |
| Northstar Post Acute | 1.7 mi | ★★★★★ | 42 | 0 |
| Mountain View Health And Rehabilitation | 2.5 mi | ★★★★★ | 22 | 0 |
| Gardnerville Health & Rehabilitation Center | 15.5 mi | ★★★★★ | 3 | 0 |
| Life Care Center Of Reno | 19 mi | ★★★★★ | 0 | 0 |
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