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-to-resident sexual abuse allegation was not thoroughly investigated, and the resident was not promptly protected or monitored after the allegation. In a separate issue, a handwritten sign with personal care instructions was posted above another resident's bed, and an RT, LPN, RN, and CNA all acknowledged it was a privacy and dignity concern and against facility policy.
Failure to Submit Final Abuse Investigation Reports: The facility did not submit required final investigative reports to the SA after alleged abuse incidents involving two residents. One resident with epilepsy, dementia, schizophrenia, and reduced mobility was involved in a witnessed altercation with a roommate after a dispute over the TV, and the incident was investigated and verified, but the final report was not filed. Another resident with schizoaffective disorder, bipolar type, schizophrenia, and dementia also had a completed abuse investigation, but no final report was submitted within the required timeframe.
Failure to Readmit Resident After Hospital Transfer: A resident with quadriplegia, chronic pain, constipation, and anxiety reported chest tightness, chills/diaphoresis, headache, and abdominal discomfort. The RN assessed the resident, offered transfer to the local ER, and after the resident declined that option, the DON arranged transport by facility van to another ER with the RN accompanying the resident. The resident was medically stable for transfer, but while the resident was out, housekeeping was asked to clean the room and the resident declined multiple times; afterward, an administrative decision was made not to readmit the resident.
Failure to document thorough investigations for alleged abuse and neglect incidents involving multiple residents. An LPN overheard one resident accuse another of kicking, a CNA reported a skin tear during a brief change involving a combative resident, and another incident involved one resident touching another in the dining room followed by a slap to the hand. The CNO could not produce the investigation records for these FRIs, and the DON stated investigations should include staff interviews, camera review, additional interviews as needed, and written documentation of findings.
A resident with quadriplegia, chronic pain, constipation, and anxiety was sent to an ER after reporting chest tightness and other symptoms, choosing transport to a different ER after declining the local ER. While the resident was out, housekeeping was asked to clean the room, but the resident declined multiple times, and the facility then decided not to readmit the resident. The record did not document the specific needs the facility could not meet or the attempts made to meet the resident’s needs before the readmission denial.
A resident with quadriplegia, chronic pain, constipation, and anxiety was transferred from the facility to an ER after reporting chest tightness, chills/diaphoresis, headache, and abdominal discomfort. The RN accompanied the resident after the resident declined the local ER and chose another ER, but the facility did not provide written bed-hold notice to the resident or the resident’s family/legal rep at the time of transfer. The SSD could not verify documentation of the bed-hold notice, and the resident’s discharge notice had later been rescinded after the Ombudsman said there was insufficient justification for discharge.
Failure to Protect Resident from Abuse and Maintain Privacy
Penalty
Summary
The facility failed to ensure a resident was free from abuse when a resident-to-resident sexual abuse allegation was not thoroughly investigated and the resident was not promptly protected or monitored after the allegation. The report states this involved 1 of 52 sampled residents, Resident 45, and that the deficient practice had the potential to place the resident at risk for continued abuse, emotional distress, fear, anxiety, a diminished sense of safety, and delayed implementation of interventions necessary to protect the resident from further abuse. The facility also failed to protect the privacy and confidentiality of Resident 58. Resident 58 was admitted with diagnoses including chronic obstructive pulmonary disease. During observation, a handwritten sign reading, "Attention please no briefs chucks only!!" was posted above the resident's bed and remained there on a later observation. Staff members including a Respiratory Therapist, LPN, RN, and CNA each acknowledged the sign was visible above the bed and stated it was a privacy, dignity, and policy issue. A facility Residents Rights policy stated residents have the right to privacy and confidentiality with personal care and medical records, and that resident medical and personal care information is private and staff are required to respect and uphold resident privacy at all times.
Failure to Submit Final Abuse Investigation Reports
Penalty
Summary
The facility failed to submit final investigative reports to the state agency after alleged abuse incidents involving two residents. For Resident 85, who was readmitted with diagnoses including epilepsy, dementia, schizophrenia, and reduced mobility, an initial report was submitted after a CNA witnessed a disagreement over a television that escalated into the resident slapping a roommate on the face. The residents were separated, a room change was made, the administrator was notified, law enforcement was called, and the incident was investigated and verified. The initial report documented that there were no injuries and no changes in condition or behavior, but the facility did not submit the required final report to the state agency. For Resident 84, who was admitted with diagnoses including schizoaffective disorder, bipolar type, schizophrenia, and dementia, the abuse investigation had been completed, but no final report had been submitted. The Director of Social Services acknowledged that a final report should have been completed and submitted within the required five-day timeframe. The facility policy required reporting within five working days of an incident sufficient information describing the results of the investigation, any corrective actions taken, and whether the allegation was verified.
Failure to Readmit Resident After Hospital Transfer
Penalty
Summary
The facility failed to promote and protect a resident’s right to be treated with respect and dignity and to make informed decisions when it declined to readmit the resident after an acute hospitalization. Resident #35 was admitted with diagnoses including quadriplegia, abnormal posture, chronic pain, idiopathic constipation, and anxiety. The resident had previously received a 30-day involuntary discharge notice for failure to pay, possession of marijuana, recording staff without consent, and violation of a behavior agreement, but the administrator later rescinded that notice until an appropriate and safe alternative placement could be secured. On 05/12/2026, the resident reported chest tightness, chills/diaphoresis, headache, and abdominal discomfort to the RN. The RN assessed the resident, obtained vital signs, and offered transfer to the local ER, which the resident refused, stating the resident had been there multiple times and they had not done anything. The resident requested another ER, and the DON presented two options: go to the local ER for possible ER-to-ER transfer, or be transported by the facility van to another ER with the RN accompanying the resident if stable. The resident chose the second option, and the RN transported the resident to an acute care hospital ER. A physician note documented the resident was medically stable for transfer and had declined evaluation at the local ER. While the resident was out of the facility, housekeeping was asked to clean the resident’s room, but the resident declined multiple times, which was documented as an infection control concern. An administrative decision was then made not to readmit the resident, and the justification for the Notice of Decision Not to Readmit was reviewed by the physician.
Failure to Document Thorough Investigations for Alleged Abuse and Neglect Incidents
Penalty
Summary
The facility failed to provide documented evidence that thorough investigations were completed for 3 of 4 facility reported incidents involving possible abuse or neglect. The incidents involved Resident #9, who had diagnoses including vascular dementia with agitation and insomnia; Resident #32, who had diagnoses including type 2 diabetes mellitus with diabetic neuropathy, hypertension, and chronic vascular disorders of the intestine; Resident #6, who had hemiplegia, aphasia, and vascular dementia with other behavioral disturbance; and Resident #28 and Resident #8, both residents with dementia-related diagnoses and behavioral symptoms. For FRI #2591438, the facility reported physical abuse after an LPN overheard Resident #32 yelling, “quit kicking me,” and observed Resident #9 seated nearby. Resident #32 reported that Resident #9 had kicked the resident’s leg three times. A behavior incident note documented that Resident #32 was yelling at Resident #9 to stop kicking, the residents were separated, and no injury or bruising was found on Resident #32. For FRI #2703876, Resident #6 was combative during a brief change and sustained a skin tear to the right hand; the resident pointed to the hand when asked and indicated the injury was self-inflicted by scratching. A skin/wound note documented the CNA reported the injury to the RN, who assessed the resident, cleansed the skin tear, and applied barrier cream. For FRI #3029831, the final report documented Resident #28 touched Resident #8’s back in the dining room, Resident #8 motioned for Resident #28 to move away, and when Resident #28 did not move away, Resident #8 slapped Resident #28 on the hand. On 07/30/2026, the CNO could not provide documentation of the facility’s investigations for FRIs #2591438, #2703876, and #3029831 and confirmed the documentation could not be located. The CNO stated the facility had submitted the initial and final reports to the State Agency, but could not recall the details of each investigation or how the conclusions were made. The DON stated investigations typically included staff interviews, camera review, additional interviews if needed, conclusions based on the information, and documentation of interviews and observations, but the facility did not have the investigation records available.
Failure to Document Readmission Decision and Resident Needs
Penalty
Summary
The facility failed to document the specific needs it could not meet and the attempts made to meet a resident’s needs when it declined to readmit the resident after an acute care hospitalization. Resident #35 was admitted with diagnoses including quadriplegia, abnormal posture, chronic pain, idiopathic constipation, and anxiety. The resident had previously received a 30-day involuntary discharge notice for failure to pay, possession of marijuana, recording staff without consent, and violation of a behavior agreement, but that notice was later rescinded until an appropriate and safe alternative placement could be secured. On the day the resident reported chest tightness, chills/diaphoresis, headache, and abdominal discomfort, the RN assessed the resident, obtained vital signs, and offered transfer to the local ER. The resident refused that option and chose to go to another ER, and the RN transported the resident there with paperwork. The resident was medically stable for transfer. While the resident was out of the facility, housekeeping was asked to clean the resident’s room, but the resident declined multiple times, which was noted as an infection control concern. An administrative decision was then made not to readmit the resident, and the justification for the notice of decision not to readmit was reviewed by the physician. Staff later confirmed the resident required catheter care and bowel care, had intermittent impulsive and verbally aggressive behaviors, and that the facility was able to meet the resident’s care needs.
Failure to Provide Written Bed-Hold Notice at Hospital Transfer
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to a resident and the resident’s family member or legal representative when the resident was transferred to an acute care hospital. Resident #35 was admitted with diagnoses including quadriplegia, abnormal posture, chronic pain, idiopathic constipation, and anxiety. On 05/12/2026, the resident reported chest tightness, chills/diaphoresis, headache, and abdominal discomfort to the RN. The RN assessed the resident, obtained vital signs, and offered transfer to the local ER, but the resident refused and requested transfer to another ER instead. The DON presented options, and the resident chose transport to another ER by facility van with the RN accompanying the resident. The resident arrived at the acute care hospital ER around 12:40 PM, and the RN handed paperwork to ER staff before returning to the facility. A physician note documented that the resident was medically stable for transfer and had declined evaluation at the local ER. While the resident was out of the facility, an administrative decision was made not to readmit the resident, and the justification for the notice of decision not to readmit was reviewed by the physician. During interview, the SSD confirmed residents generally received a 30-day discharge notice for involuntary discharges, stated the discharge notice for this resident had been rescinded after the Ombudsman said there was insufficient justification to discharge the resident, and could not verify whether the resident had signed the rescinded notice. The SSD also could not confirm whether the resident received written bed-hold notice at the time of hospital transfer and could not provide documentation of such notice.
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Compliance trends in Nevada
Data through Jun 2026Comparisons below measure the most recent period Jul 2025 – Jun 2026 against the prior period Jul 2024 – Jun 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): Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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 Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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. Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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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