3050 N Ormsby Road, Carson City, NV 89703 · Carson City County · (775) 841-4646
120 certified beds, about 93 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1999
CMS Care Compare ratings, data as of September 1, 2026 · CCN 295067 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on May 14, 2026, inspectors cited 25 health deficiencies (the Nevada average is 9.7, the national average 9.2).
Of 88 health citations since October 2023, 1 was rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).
CMS lists 1 fine totaling $60,464 in the last three years; the largest was $60,464, and the latest is dated May 29, 2024.
Nurses and nurse aides worked 2.81 hours per resident per day, against 4.34 across Nevada and 3.86 nationally. Registered nurses accounted for 0.76 of those hours.
58.0% of nursing staff left within the year CMS measured (Nevada average 45.1%).
CMS links it to Evergreen Healthcare Group, an affiliated group of 43 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 88 health citations on file.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1) proper hand hygiene was performed by dietary staff, 2) refrigerated food was stored properly, 3) food was discarded by the expiration date, and 4) the outside propane gas grill (Barbecue) was cleaned appropriately. This deficient practice had the potential to affect all residents in the facility by increasing the risk of infection and foodborne illnesses.
Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure the data collected for infection surveillance was used to identify the potential cause of facility acquired infections and prevent further facility acquired infections for 5 of 5 months reviewed for 2026. This deficient practice had the potential to result in residents contracting preventable infections and poor infection control practices continuing due to a lack of targeted education provided to facility staff.
Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to: 1) ensure a resident had the right to wear personal clothing, 2) provide a shower to a paraplegic resident who wished to take a shower, and 3) treat a resident with respect and dignity when a certified nursing assistant addressed the resident in a degrading manner, for 2 of 19 sampled residents (Resident #3 and #81). The deficient practice had to potential to cause psychosocial harm and mental anguish resulting from not being treated with dignity and respect.
Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure a resident was provided with education related to the common side effects and treatment purpose of a psychotropic medication prior to the resident receiving the medication for 2 of 19 sampled residents (Residents #5 and #64). This deficient practice had the potential for a resident to receive medication without the resident having had the opportunity to make an informed decision regarding the medication prior to receiving the medication.
Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to provide reasonable accommodation by not ensuring a resident's electric wheelchair was repaired and made available for use for 1 of 19 sampled residents (Resident #8). This deficient practice had the potential to cause the resident emotional distress.
Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's right to make choices about aspects of life in the facility that were significant to the resident, by not providing an appropriate wheelchair that would allow the resident to get out of bed, for 1 of 19 sampled residents (Resident #3). This deficient practice had the potential to cause psychosocial distress to the resident.
Inspectors wroteBased on interview, clinical record review and document review, the facility failed to ensure 1 of 19 sampled residents (Resident #97) was protected from resident-to-resident physical abuse. This deficient practice had the potential to result in pain, physical injury and mental anguish to residents.
Inspectors wroteBased on interview, clinical record review and document review, the facility failed to ensure 1 of 19 sampled residents (Resident #62) was protected from potential misappropriation of property when an allegation a nurse stole the resident's medication was not reported to the Abuse Coordinator timely. This deficient practice placed all residents in the facility at risk for misappropriation of property due to delayed suspension of the alleged perpetrator and delayed investigation of the allegation.
Inspectors wroteBased on observation, interview, record review, and document review, the facility failed 1) to ensure a resident's chronic pain care plan included non-pharmacological interventions to manage the resident's pain for 1 of 19 sampled residents (Resident #2). This deficient practice had the potential to result in a resident's pain not being managed effectively. 2) to ensure a resident's dialysis care plan included interventions staff could implement to get the resident to agree to go to dialysis and education staff were to provide to the resident when the resident refused dialysis treatments for 1 of 19 sampled residents (Resident #97). This deficient practice had the potential to result in the resident experiencing life-threatening complications related to missing dialysis treatments without adequate knowledge of the possible outcomes of refusal. [...]
Inspectors wroteBased on personnel record review, document review, and interview, the facility failed to ensure 2 of 20 sampled employees (Employee #4 and #17) had current cardiopulmonary resuscitation (CPR) training. This deficient practice placed residents at risk from an employee not having completed all employment eligibility requirements.
Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a resident's care related to a gastrointestinal (GI) infection was coordinated between the facility and the resident's established GI physician for 1 of 19 sampled residents (Resident #44) and interventions were implemented, including administration of physician ordered medications, to address a resident's constipation for 1 of 19 sampled residents (Resident #97). This deficient practice had the potential to result in a resident not receiving timely treatment and suffering from complications of a prolonged parasitic infection in the resident's GI tract or fecal impaction.
Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a resident's report of pain was addressed with an intervention to reduce the pain level to the resident's acceptable level of pain for 1 of 19 sampled residents (Resident #2). This deficient practice had the potential to result in a resident experiencing prolonged pain at a level unacceptable to the resident causing the resident to experience diminished quality of life and emotional well-being.
Inspectors wroteBased on clinical record review, document review and interview, the facility failed to ensure residents with trauma diagnoses were assessed by the facility to recognize and respond to the effects of the trauma and implementation of interventions for 2 of 19 sampled residents (Resident #12 and #88). This deficient practice had the potential to result in a resident experiencing re-traumatization due to the lack of assessments to recognize trauma-specific interventions.
Inspectors wroteBased on personnel record review and interview, the facility failed to ensure a Certified Nursing Assistant (CNA) employed for more than one year had an annual performance review completed annually for 1 of 4 CNAs reviewed for completed performance reviews (Employee #9). This deficient practice had the potential to affect all residents when the facility did not identify areas of CNA performance in need of in-service education or training.
Inspectors wroteBased on observation, interview, clinical record review and document review, the facility failed to ensure 1) a medication was not left on a resident's bedside table and unattended by authorized staff for 1 of 3 residents observed during medication administration (Resident #4) and 2) expired medications were removed from 1 of 2 medication storage rooms and 1 of 2 medication carts inspected for medication storage. This deficient practice had the potential to result in residents and staff without authorization to have unsupervised access to medications and for expired medications to be administered to residents.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a dietary recommendation was followed. This deficient practice had the potential to affect the resident's wellbeing and overall health.
Inspectors wroteBased on observation, interview, clinical record review and document review the facility failed 1) to prepare food as required for residents on a physician ordered therapeutic diet, 2) to ensure a resident received a minced and moist diet as ordered and failed to prepare or serve meals in a form that met the resident's need for 1 of 19 sampled residents (Resident # 3). This deficient practice had the potential for reduced meal intake due to not following the prescribed diet order, and increased the risk of difficulty swallowing, which could lead to choking and/or aspiration.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the outside garbage receptacles were sealed (lid closed) and free of debris on the surrounding pavement. This deficient practice had the potential to affect all residents in the facility by increasing the risk of pest and foodborne illnesses.
Inspectors wroteBased on document review and interview, the facility failed to update the facility assessment following a change in the medical provider group. This deficient practice had the potential to result in the facility assessment not accurately reflecting the current medical provider or clinical responsibilities of the newly contracted medical provider group providing necessary services to residents.
Inspectors wroteBased on interview and document review, the facility failed to designate a member of the facility's interdisciplinary team responsible for coordinating the care of residents receiving hospice services. This deficient practice had the potential to result in uncoordinated care and a lack of communication between the facility and the hospice providers, delays of resident care, inadequate monitoring, and an increased risk of unmet physical, emotional, and psychosocial needs for residents receiving hospice services.
Inspectors wroteBased on document review and interview, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify and address system-level issues related to 1) the facility's lack of a designated hospice coordinator, and 2) concerns related to the personnel training requirements on abuse, cardiopulmonary resuscitation (CPR) and first-aid certifications. This deficient practice had the potential to prevent the QAPI committee from implementing an ongoing, data driven process to monitor performance concerns and develop corrective actions, limiting the facility's ability to recognize patterns, prevent recurrence of problems, and ensure sustained improvement in resident care and facility operations related to employee requirements.
Inspectors wroteBased on document review and interview, the facility failed to provide the Quality Assurance and Performance Improvement (QAPI) committee member signature attendance sheets for the second, third, and fourth quarters of 2025. This deficient practice had the potential to result in the facility's failure to demonstrate the required QAPI committee members had participated in the quarterly meetings as required.
Inspectors wroteBased on observation, interview and document review, the facility failed to maintain the ice machine in good repair. This deficient practice had the potential to result in contamination of the ice and affect resident safety.
Inspectors wroteBased on personnel record review and interview, the facility failed to ensure elder abuse prevention training was completed timely for 6 of 20 sampled employees (Employee #2, #3, #16, #17, #18, and #19). This deficient practice had the potential to place all residents at risk for abuse and neglect.
Inspectors wroteBased on document review and interview the facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) upon discharge for 1 of 3 sampled residents (Resident #13). This deficient practice had the potential to limit the resident's ability to understand and exercise their Medicare appeal rights regarding termination of covered services.
Inspectors wroteBased on clinical record review, interviews and document review, the facility failed to protect a resident's right to be free from neglect when licensed nurses failed to notify the physician of a diabetic resident's multiple episodes of hypoglycemia (low blood glucose) and when a Registered Nurse (RN) administered oral glucose gel, not in accordance with physician orders, to an unresponsive resident experiencing severe hypoglycemia for 1 of 14 sampled residents (Resident #8). This deficient practice had the potential to result in lack of necessary adjustments to the resident's medication orders and plan of care and for additional episodes of hypoglycemia to occur placing the resident at risk for organ damage, coma, and death.
Inspectors wroteBased on interviews and document review, the facility failed to provide documented evidence the facility conducted a thorough investigation of an incident suspicious for neglect of 1 of __ sampled residents (Resident #8). This deficient practice had the potential for ongoing physical and/or psychosocial harm to residents due to allegations of neglect not being thoroughly investigated and documented to ensure appropriate protections were put in place to prevent future neglect.
Inspectors wroteBased on observation, interview, and document review, the facility failed to obtain cooking temperatures and holding temperatures of chicken prior to plating the chicken to serve to residents for lunch service. This deficient practice posed a potential risk to safety and health standards which could lead to contamination and place residents at risk of foodborne illness.
Inspectors wroteBased on clinical record review, document review, and interview, the facility failed to ensure the coordination of hospice care between the facility and hospice agencies and ensure the activities and services detailed in the hospice agency's care plan were provided to residents, documented by the hospice agency and received by the facility for 3 of 6 residents on hospice services (Resident #230, #50, and #4). The deficient practice had the potential to compromise the overall quality of hospice care due to the lack of coordination between the facility and hospice agencies and had the potential to jeopardize the health and safety of residents under hospice care in the facility.
Inspectors wroteBased on record review and interview, the facility failed to ensure the proper Medicare Notice of Medicare Non-Coverage letter was completed and provided for 2 of 3 unsampled residents selected for beneficiary notification review. The deficient practice resulted in non-compliance with Medicare requirements, that could hinder the resident's ability to make informed decisions regarding their coverage and care.
Inspectors wroteBased on interview and document review the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were transmitted timely for 4 of 10 months, starting June 2024. The deficient practice had the potential to impact resident care by delaying the resident care plan.
Inspectors wroteBased on clinical record review, interview, and document review the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for 1 of 19 sampled residents (Resident #4) and 1 of 3 residents sampled for closed records (Resident #79). This deficient practice had the potential to deprive residents of necessary care and services relative to current health management needs in the facility and upon discharge home.
Inspectors wroteBased on clinical record review, interview, and document review, the facility failed to develop a person-centered Comprehensive Care Plan for the use of insulin, for 1 of 19 sampled residents (Resident #32). This deficient practice had the potential to result in residents not receiving care and services to meet their needs related to the use of insulin.
Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure behaviors monitored were associated with the specific condition indicated by the physician for the use of psychotropic medications for 1 of 19 sampled residents (Resident #32). The deficient practices had the potential to cause residents to use an unnecessary medication with possible adverse effects.
Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure 1) temperatures were monitored and recorded on each shift for 1 of 4 medication storage refrigerators, 2) medications were not stored with food items in 1 of 4 medication storage refrigerators, 3) a multi-dose vial was discarded within 28 days of opening, and 4) a medication cart was not left unsecured and unattended. The deficient practices had the potential to contaminate medication with food products, compromise medication integrity by not maintaining and recording the daily refrigerator temperatures between 36-46 degrees Fahrenheit (F), place the residents and staff at risk of receiving expired/outdated vaccines, and to allow unauthorized access to medications on the medication cart in the 200 Hallway.
Inspectors wroteBased on observation, interview, clinical record review and document review, the facility failed to ensure resident information was not visible on an unattended computer screen facing a public area and a clinical record was complete for 1 of 19 sampled residents (Resident #8). This deficient practice had the potential for unauthorized access to residents' protected health information and for care provided to residents, resident response to care provided, and refusals of care to not be documented and available for review as necessary.
Inspectors wroteBased on observation, interview, and document review, the facility failed to document facility training and competencies required for a Registered Nurse (RN) to provide resident care (Employee #22). The deficient practice had the potential to negatively affect resident quality of life and/or jeopardize resident safety when training competencies and orientation were not met prior to providing resident care.
Inspectors wroteVerbal abuse A FRI submitted 06/23/2024, documented LPN1 was responding to a call light by Resident #3, and while providing care, LPN1 began yelling at the resident. Yelling was heard by other staff in the facility. Resident #3 Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with a primary diagnosis of acute reversible ischemia of large intestine, extent unspecified. On 09/18/2024 at 12:19 PM, Resident #3 explained on the date of the incident, Resident #3 turned on the call light after having had a bowel movement. Resident #3 explained the LPN came to answer the call light, but the LPN had an ear plug in and was talking with someone on the phone. The LPN undid the resident's briefs and turned the resident on the left side. The LPN left the room and after 20 minutes, Resident #3 began calling out for help. [...]
Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a resident's insulin was not self-administered by a staff member for 1 of 12 sampled residents (Resident #2). This deficient practice had the potential to result in a resident not having an adequate amount of insulin available to treat the diagnosed condition for which the medication was prescribed.
Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure professional standards for prescribing medications were followed by a practitioner for 1 of 12 sampled residents (Resident #1). This deficient practice had the potential to result in a resident suffering an adverse health outcome from receiving medications for diagnoses the resident did not have.
Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a resident was not administered medications without a diagnosis related to the indication for the use of the medications for 1 of 12 sampled residents (Resident #1). This deficient practice resulted in a resident requiring hospitalization to monitor for adverse side effects of the unnecessary medications.
Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a potential incidence of misappropriation of a resident's prescribed narcotic pain medication was investigated for misappropriation of property for 1 of 2 residents reviewed for potential narcotic diversion (Resident #44). This deficient practice could lead to undetected narcotic diversion from residents causing increased pain and diminished quality of life. Additionally, the facility failed to thoroughly investigate a resident's allegation of abuse and ensure a suspended employee did not continue to work in the facility until an investigation was completed for 1 of 19 sampled residents (Resident #19). Resident #19 alleged a male staff member touched the resident inappropriately while checking the resident's brief. [...]
Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure 1) the Infection Preventionist (IP) had the skills necessary to review lab results to determine the appropriateness of implementing transmission-based precautions (TBP) 2) a nurse administering medications had completed a competency for medication administration. [...]
Inspectors wroteBased on observation, interview and document review, the facility failed to ensure food preparation counters were kept clear of personal items with the potential to cross contaminate food for the facility census; and failed to ensure staff performed hand hygiene while serving meal trays to residents.
Inspectors wroteBased on interview and document review the facility failed to demonstrate effective and knowledgeable administration by not ensuring an allegation of sexual abuse was thoroughly investigated and an alleged perpetrator of sexual abuse was not allowed to continue to work in the facility until an investigation was completed (see tag F610), 2) the Infection Preventionist (IP) had the skills and knowledge necessary to accurately monitor and track infections and antibiotic use. The IP's failure to consistently track infections and antibiotic use from the onset of the infection through to the resolution of the infection had the potential to result in residents developing infections with Multi Drug Resistant Organisms (MDRO). Further potential to spread infections with MDROs througout the facility's entire resident census of 89; [...]
Inspectors wroteBased on interview and document review the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify 1) concerns related to the identification for the need of Enhanced Barrier Precautions (EBP) and Transmission Based Precautions (TBP), 2) an Advanced Practice Registered Nurse (APRN) signed documentation with the credentials of Medical Doctor, 3) a lack of thorough investigation related to resident abuse, 4) the lack of an effective process for tracking and reconciling narcotic medications, including hospice medications, 5) the facility lacked a designated Hospice Coordinator, and 6) concerns related to screening and offering pneumococcal vaccines.
Inspectors wroteBased on document review and interview, the facility failed to ensure 1) the facility's form titled Line Listing for Infections by Resident, (Line Listing Report) completed by the Infection Preventionist (IP) included the necessary elements the IP needed for tracking infections and antibiotic use, 2) the IP accurately documented on the Line Listing for Infections form each month and included 10 of 31 residents prescribed antibiotics for infections from 01/01/2024 - 05/23/2024, on the form (Resident #5, #24, #71, #62, #54, #60, #9, #69, #72, and #66) with the potential to affect the facility's entire resident census of 89, and 3) staff and residents received education related to antibiotic use and the Antibiotic Stewardship Program (ASP).
Inspectors wroteBased on interview and document review, the facility failed to ensure compliance and ethics training was completed timely for 15 of 20 sampled employees (#1, #2, #3, #4, #5, #6, #7, #9, #10, #11, #14, #16, #18, #19 and #20). Employee #1 Employee #1 was hired as the Administrator on 03/30/2024. Employee #1's personnel record documented compliance and ethics training completed on 04/26/2024, 27 days after hire. Employee #2 Employee #2 was hired as the Director of Nursing (DON) on 11/01/2021. Employee #2's personnel record documented the last compliance and ethics training was completed on 04/24/2024. The employee's record lacked documented evidence compliance and ethics training had been completed for 2023. Employee #3 Employee #3 was hired as the Activities Director on 03/06/2023. [...]
Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure resident's medications were not left, unsecured, at a resident's bedside for 2 of 19 sampled residents (Residents #5 and #339), medicated powders were not applied by unlicensed staff for 1 of 19 sampled residents (Residents #5) and medications were not left unsecured on a medication cart while a Certified Nursing Assistant (CNA) was watching the cart. This deficient practice had the potential for a resident to administer medication at a dose not prescribed creating increased potential for adverse medication reactions and for a resident to not receive necessary monitoring and assessment for the application of medicated powders.
Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure 1) medications were not left unsecured on a medication cart while a Certified Nursing Assistant (CNA) was to watch the medication cart, 2) medications were stored according to manufacturer guidelines, 3) discontinued medications were removed from a medication cart, and 4) medications were labeled. Unsecured Medication On [DATE] at 10:07 AM, upon entry into the Brookside nursing station, the medication cart parked on the outside of the nursing station was seen with greater than 20 over the counter plastic bottles with pills in the bottles sitting on top of medication cart. A CNA was at the nursing station watching the medications. The CNA left as soon as the nurse came out of the restroom. [...]
Inspectors wroteBased on interview, clinical record review, and document review the facility failed to ensure 1) 2 of 5 residents sampled for influenza vaccinations (Residents #62 and #9) were screened for eligibility to receive an influenza vaccine, education regarding the vaccine was provided to the resident and/or the resident representative, and the vaccine was offered and either administered or declined, and 2) 7 of 16 residents eligible to receive a pneumococcal vaccine (Residents #9, #80, #85, #77, #23, and #242) were screened for eligibility to receive a pneumococcal vaccine, education regarding the vaccine was provided to the resident and/or the resident representative, and the indicated pneumococcal vaccine was offered and either administered or declined.
Inspectors wroteBased on personnel record review, interview and document review, the facility failed to ensure resident rights training was completed by staff for 9 of 20 sampled employees (Employee #1, #6, #9, #11, #14, #16, #18, #19 and #20).
Inspectors wroteBased on interview and document review, the facility failed to ensure Quality Assurance Performance Improvement (QAPI) training had been completed to include objectives of resident care needs for 15 of 20 sampled employees (Employee #1, #2, #4, #5, #6, #7, #9, #10, #11, #12, #14, #16, #18, #19 and #20).
Inspectors wroteBased on interview and document review, the facility failed to provide timely infection control training to all staff to ensure proper procedures and standards of the program for 7 of 20 sampled employees (#1, #9, #11, #14, #16, #18 and #19).
Inspectors wroteBased on interview and document review, the facility failed to ensure behavioral health training was completed timely for 10 of 20 sampled employees (Employee #1, #4, #5, #9, #10, #11, #14, #16, #19 and #20). Employee #1 Employee #1 was hired as the Administrator on 03/30/2024. Employee #1's personnel record documented behavioral health training completed on 05/24/2024, 55 days after hire. Employee #4 Employee #4 was hired as the Dietary Manager on 06/15/21. Employee #4's personnel record documented the last behavioral health training was completed on 05/24/2024. The employee's record lacked documented evidence behavioral health training had been completed for 2023. Employee #5 Employee #5 was hired as the Social Services Director on 05/01/2024. Employee #5's personnel record documented behavioral health training completed on 05/27/2024, 26 days after hire. [...]
Inspectors wroteBased on interview, clinical record review, and document review the facility failed to obtain informed consent for a psychoactive medication prior to the administration of the medication for 3 of 19 sampled residents (Resident #23, #28 and #66).
Inspectors wroteBased on observation and interview, the facility failed to ensure the current menu was posted, allowing residents to review and request an alternative if preferred.
Inspectors wroteBased on observation, clinical record review, interview, and document review, the facility failed to ensure a resident was protected from employee-to-resident verbal abuse for 1 of 19 sampled residents (Resident #3).
Inspectors wroteBased on record review, document review, and interview the facility failed to prevent the misappropriation of funds for 1 of 3 residents reviewed for closed records (Resident #52). Findings Include: Resident #52 Resident #52 was admitted to the facility on [DATE], with diagnoses including cerebral infarction due to embolism of left middle cerebral artery, major depressive disorder, recurrent, unspecified, and hypertensive urgency. A Facility Reported Incident (FRI) report dated 05/10/2024, documented on 05/09/2024, Resident #52 was discharged to another facility on hospice. After arriving at the new facility it was discovered the resident's wallet, containing a credit card, was missing and someone was using the credit card. [...]
Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a potential incidence of misappropriation of a resident's prescribed narcotic pain medication was reported for misappropriation of property for 1 of 2 residents reviewed for potential narcotic diversion (Resident #44). This deficient practice could lead to undetected narcotic diversion from residents causing increased pain and diminished quality of life.
Inspectors wroteBased on interview, record review, and document review the facility failed to provide the required documentation for discharge when a resident was transferred to an acute care hospital for 1 of 9 residents reviewed for Facility Reported Incidents and Complaint investigations (Resident #77).
Inspectors wroteBased on clinical record review, interview, and document review, the facility failed to develop a person-centered Comprehensive Care Plan for 1) the use of insulin, and include the correct diagnosis for 1 of 19 sampled residents (Resident #50), and 2) for infection control related to indwelling devices and a history of Multi-drug Resistent Organisms (MDRO), including the use of Enhanced Barrier Precautions (EBP) for 1 of 9 residents reviewed for Facility Reported Incidents and Complaint investigations (Resident #77).
Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure the care plan for a resident with a history of falls was updated following an unwitnessed fall for 1 of 19 sampled residents (Resident #5). This deficient practice could prevent the implementation of new interventions to prevent the resident from further falls with the potential for the resident to become injured from a preventable fall.
Inspectors wroteBased on interview, clinical record review and document review the facility failed to provide showers to a dependent resident for 1 of 19 sampled residents (Resident #3).
Inspectors wroteBased on personnel record review, document review, and interview, the facility failed to ensure nursing staff were trained and certified to perform Cardio-Pulmonary Resuscitation (CPR) in the event of a resident cardiac arrest for 1 of 5 sampled licensed nurses (Employee #2). The deficient practice could result in a negative outcome for a resident in cardiac arrest while awaiting the arrival of emergency medical personnel.
Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure 1) wound care was provided as ordered and a resident's plan of care, including medications for pain and symptom management, was coordinated with a contracted hospice provider for 1 of 19 sampled residents (Resident #9), 2) a resident was evaluated after a fall per facility policy for 1 of 19 sampled residents (Resident #5), 3) an order was in place prior to administering medication to a resident for 1 of 6 residents observed during medication administration (Resident #5), 4) the pharmacy, the physician and an on-call manager were notified when ordered medications were not available in the facility for 1 of 19 sampled residents (Resident #23) and 5) the physician was notified when a resident's blood sugar was over a certain level for 1 of 19 sampled residents (Resident #50). [...]
Inspectors wroteBased on observation, clinical record review, interview, and document review, the facility failed to ensure 1 of 19 sampled residents (Resident #62) did not develop a new wound and failed to ensure the new wound was reported timely to the wound care team, physician orders for treatment were obtained prior to providing wound care, and nutritional support for wound healing was assessed resulting in the wound developing into a stage II pressure injury (PI).
Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure a resident's urostomy drainage bag was kept off the floor while the resident was laying in bed for 1 of 19 sampled residents (Resident #3).
Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure oxygen was administered as ordered for 1 of 19 sampled residents (Resident #339).
Inspectors wroteBased on observation, clinical record review, interview, and document review the facility failed to ensure Dialysis Transfer forms were completed and maintained for 2 of 19 sampled residents (Resident #80 and #57).
Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure physician visits were completed timely for 1 of 19 sampled residents (Resident #9). This deficient practice could result in a resident not receiving assessments a physician can perform.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a sufficient number of licensed nurses were scheduled to perform resident care according to the Facility Assessment for 1 of 2 shifts during the weekends in December of 2023.
Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure ordered medications were available and administered for 2 of 6 residents observed for medication administration (Resident #88 and #5) and 1 of 19 sampled residents (Resident #23).
Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure medications were administered with an error rate of less than 5 percent (%). There were 47 opportunities and four medication errors. The medication error rate was 8.51%.
Inspectors wroteBased on clinical record review, document review and interview, the facility failed to complete Medication Administration Records (MAR) for the administration of an anti-coagulant for 1 of 19 sampled residents (Resident #66), and to ensure documentation in resident records accurately represented the licensure of a Provider for 74 of 89 residents (Residents #2, #3, #4, #5, #8, #9, #10, 12, #14, #15, #16, #19, #20, #21, #23, #24, #25, #26, #27, #28, #29, #30, #31, #33, #34, #36, #37, #38, #39, #40, #41, #42, #44, #45, #46, #49, #50, #53, #54, #55, #56, #59, #60, #61, #62, #63, #64, #65, #66, #68, #69, #70, #71, #72, #73, #74, #75, #76, #78, #79, #80, #83, #85, #238, #239, #240, #241, #242, #243, #244, #245, #246, #338, and #339), and failed to ensure complete resident clinical records were maintained for 2 of 19 sampled residents (Resident #80 and #68).
Inspectors wroteBased on interview and document review, the facility failed to accurately report weekend staffing coverage documented on the payroll-based staffing (PBJ) requirements submitted to the Center for Medicare and Medicaid Services (CMS).
Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure 1) a resident with a multi-drug resistant organism (MDRO) infection ( an infection with a germ resistant to an antibiotic, for which certain treatments would not work or would be less effective) was not provided care with the use of transmission based precautions (TBP) to prevent the spread of the MDRO to other residents in the facility for 1 of 19 sampled residents (Resident #9). [...]
Inspectors wroteBased on clinical record review, interview, and document review the facility failed to ensure a Registered Nurse (RN) was screened for eligibility to receive a COVID-19 (COVID) booster vaccine, education regarding the vaccine was provided, and the vaccine was offered and either administered or declined.
Inspectors wroteBased on personnel record review, interview and document review, the facility failed to ensure communications training was completed by staff for 4 of 20 sampled employees (Employee #11, #14, #16, and #20).
Inspectors wroteBased on personnel record review, interview and document review, the facility failed to ensure elder abuse training was completed timely for 5 of 20 sampled employees (Employee #1, #4, #14, #19 and #20).
Inspectors wroteBased on clinical record review, document review and interview, the facility failed to ensure a health provider's clinical documentation was representative of the provider's accurate licensure.
Inspectors wroteBased on clinical record review, document review and interview, the Medical Director of the facility failed to ensure a health provider's clinical documentation was representative of the provider's accurate licensure.
Inspectors wroteBased on interview, medical records review, and policy review the facility failed to obtain a consent prior to the administration of a psychotropic medication for 1 of 21 sampled residents (Resident #14).
Inspectors wroteBased on clinical record review, interview, and document review, the facility failed to protect the residents' right to be free from verbal abuse for 7 of 21 sampled residents (Resident #1, #2, #3, #7, #9, #10, #11) , physical abuse for 2 of 21 sampled residents (Resident #5, #6), and sexual abuse for 1 of 21 sampled residents (Resident #12).
Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a care plan was developed and implemented related to the use of a psychotropic medication for 1 of 21 residents (Resident #14).
Inspectors wroteBased on observation, interview, clinical record review and document review the facility failed to update a fall care plan with the most recent fall and new interventions for 1 of 21 sampled residents (Resident #14).
Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a fall risk assessment was accurately completed upon admission in an attempt to prevent future falls and completed an assessment after an actual fall for 1 of 21 sampled residents (Resident #14).
Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a resident was protected from verbal abuse from another resident for 1 of 5 sampled residents (Resident #1).
24 fire safety citations on file: 7 on May 14, 2026, 6 on March 27, 2025, 11 on May 29, 2024.
| Date | Penalty | Amount or length |
|---|---|---|
| May 29, 2024 | Fine | $60,464 |
| May 29, 2024 | Payment Denial | 6 days from July 18, 2024 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Nevada | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 2.81 | 4.34 | 3.86 |
| Registered nurses | 0.76 | 1.12 | 0.69 |
| All nursing staff on weekends | 2.48 | 3.86 | 3.42 |
| Nurse aides | 1.42 | ||
| Licensed practical nurses | 0.64 | ||
| Nursing staff turnover (share who left in a year) | 58.0% | 45.1% | 45.8% |
| Registered nurse turnover | 40.0% | 43.4% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.45 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 2.95 on weekdays and 2.48 on weekends, 16% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 3.8% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.48 in April to June 2025 to 2.81 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 2.81 | 0.76 | 2.95 | 2.48 | 3.8% | 0 of 90 | 93 |
| Oct to Dec 2025 | 3.54 | 0.82 | 3.74 | 3.01 | 10.7% | 0 of 92 | 89 |
| Jul to Sep 2025 | 3.41 | 0.86 | 3.65 | 2.80 | 9.7% | 0 of 92 | 87 |
| Apr to Jun 2025 | 3.48 | 0.79 | 3.69 | 2.95 | 4.9% | 0 of 91 | 86 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Nevada, Jan to Mar 2026 | 3.88 | 0.85 | 4.05 | 3.46 | 2.7% | 0.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Nevada, all employers | |||
| CNAs (nursing assistants) | $21.87 | $18.80 to $23.07 | 8,100 |
| LPNs and LVNs | $36.62 | $31.70 to $38.26 | 3,350 |
| Registered nurses | $49.84 | $41.76 to $57.82 | 27,070 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Nevada | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 13.1 | 12.6 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 1.6 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.3 | 1.9 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.6 | 2.0 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.5 | 1.8 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 15.6 | 13.5 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 1.5 | 5.4 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 9.9 | 17.1 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 20.9 | 23.2 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 18.4 | 9.6 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.8 | 1.9 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.4 | 1.4 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Ormsby Post Acute Rehabilitation's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (54.0% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
54.0% this home
No different from the national rate
US median of homes 51.5% · Nevada: 9 better, 7 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 127 eligible stays.
10.5% this home
No different from the national rate
US median of homes 10.7% · Nevada: 0 better, 5 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 169 eligible stays.
5.9% this home
No different from the national rate
US median of homes 7.1% · Nevada: 1 better, 0 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 104 eligible stays.
56.4% this home
Median of homes: Nevada60.3% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 39 residents counted.
0.0% this home
Median of homes: Nevada0.4% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 59 residents counted.
3.7% this home
Median of homes: Nevada1.6% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 59 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Nevada91.8% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 15 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: Legal Business Name Not Available. CMS links this home to Evergreen Healthcare Group, a group of 43 nursing homes averaging 2.4 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Ownership data not available |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.