Citations in Nevada
Statistics, citations and compliance trends for long-term care facilities in Nevada.
Statistics for Nevada (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Nevada
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 admitted with bilateral primary osteoarthritis of the knee received Hydrocodone-Acetaminophen for pain management after a physician order was entered and the medication was administered on multiple days. The President of Clinical Services could not locate a signed consent, and the DON confirmed informed consent had not been obtained before administration of the opioid and that it should have been obtained so the resident was aware of the risks and benefits.
A resident with polyneuropathy, ankylosing spondylitis, osteoarthritis, and spinal stenosis had a physician order for daily chair time and required a 2-person Hoyer Lift for transfers. Staff did not consistently honor the resident’s request to get out of bed, citing short staffing, and the resident was often only assisted out of bed for showers or a few times per week instead of daily.
A resident with chronic respiratory failure, COPD, pulmonary hypertension, and oxygen dependence repeatedly asked to have an ID wrist band removed, but it remained on the resident’s wrist during multiple observations. The resident said the LPN insisted the band be worn at all times, while the LPN confirmed the resident had requested removal for months. Staff stated the wrist bands were used as a double check for med admin, and the DON and Administrator were unaware the resident’s request had not been communicated to staff.
Failure to protect a resident from peer physical abuse: a resident punched another resident in the face in the activity room, causing a superficial abrasion and minimal bleeding. The aggressor had a documented hx of prior aggressive behaviors toward staff and others, but the care plan did not address those behaviors before the incident. The injured resident later avoided the activity room and stated the other resident was dangerous.
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.
Failure to Obtain Consent for Opioid Pain Medication
Penalty
Summary
The facility failed to ensure informed consent was obtained for an opioid pain medication for Resident #137, who was admitted with bilateral primary osteoarthritis of the knee. A physician ordered Hydrocodone-Acetaminophen 10-325 mg, one tablet by mouth every four hours as needed for pain management, and the medication was administered on multiple days in June 2026. During interview, the President of Clinical Services stated that a signed consent for the Hydrocodone-Acetaminophen could not be located, and the DON later confirmed that consent had not been obtained before the medication was administered. The DON also confirmed that consent should have been obtained so the resident was aware of the risks and benefits of the medication.
Failure to Accommodate Resident’s Daily Transfer Preference
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of Resident #26 when the resident requested to get out of bed. Resident #26 was admitted and readmitted with diagnoses including polyneuropathy, ankylosing spondylitis, osteoarthritis, and spinal stenosis. A physician’s order dated 04/24/2026 directed that the resident get up in a chair every day per resident and doctor, and the care plan identified altered physical mobility related to impaired balance, weakness, pain, and decreased activity tolerance. The care plan also specified use of a Hoyer Lift and two staff for transfers. Documentation reviewed showed that bed-to-chair transfers did not occur on multiple dates in May and June 2026. During interview, Resident #26 stated the resident wanted to get out of bed once or more per day but was often unable to because staff said the facility was short staffed. The resident reported being assisted out of bed twice weekly for showers and said the resident complained to the physician, which led to the daily wheelchair order. A CNA, LPN, and the DON confirmed the resident required two-person Hoyer Lift assistance and that daily transfers were not always accommodated, with the resident instead being assisted out of bed approximately two to three times per week.
Resident Was Not Given Choice to Remove Identification Wrist Band
Penalty
Summary
The facility failed to ensure Resident #23 was afforded the choice of wearing an identification wrist band. Resident #23 was admitted with diagnoses including chronic respiratory failure with hypoxia, COPD, pulmonary hypertension, and dependence on supplemental oxygen. On 06/22/2026, the resident was observed sitting on the side of the bed with a plastic wrist band on the left wrist that identified the resident’s name, room number, and allergies. At that time, the resident stated the wrist band was not wanted and reported having asked the facility to remove it several times. The resident also stated the Unit Manager LPN would ensure the wrist band was worn at all times and would have a fit if the resident was found without it. On 06/23/2026, the Unit Manager LPN confirmed the resident had been requesting removal of the wrist band since February 2025 and stated monthly audits were completed to ensure residents were wearing wrist bands and that the information was correct. The LPN also stated that during a staff meeting that morning, staff were told that if a resident did not want to wear the wrist band, it was to be removed and the removal documented in the care plan. Despite this, the wrist band remained on the resident’s wrist during later observations on 06/24/2026 and 06/25/2026. The RN stated the wrist bands were used as a double check for accurate medication administration, and the DON confirmed residents were asked to wear wrist bands for verification during medication administration. The DON and Administrator both stated they were not aware of the resident’s request or that the instruction to remove the wrist band had not yet been disseminated to nursing staff or Unit Managers.
Failure to Protect Resident from Peer Physical Abuse
Penalty
Summary
The facility failed to ensure a resident was protected from abuse when Resident #43 punched Resident #49 on the left side of the face in the activity room. Nursing staff heard an altercation in the activity room, and Resident #49 reported that Resident #43 had punched the resident. A physical exam found a superficial abrasion to the left posterior ear with minimal bleeding. Resident #49 was admitted and readmitted with diagnoses including acquired absence of the right leg above knee and major depressive disorder, recurrent, unspecified. Resident #43 had a documented history of aggressive behavior before the incident, including throwing a water pitcher at a Physical Therapist, screaming, cursing, and swinging fists at a CNA, being verbally abusive and aggressive toward staff, and slapping a CNA's hand. A progress note on the day of the incident documented that Resident #43 physically hit another resident in the activity room and stated, "I don't care that I did that." The care plan for Resident #43 did not include interventions to address physically aggressive behaviors before the incident, and the DON confirmed this omission. Resident #49 later stated the resident avoided the activity room after the incident and believed Resident #43 was dangerous.
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Compliance trends in Nevada
Data through May 2026Comparisons below measure the most recent period Jun 2025 – May 2026 against the prior period Jun 2024 – May 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
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