Pahrump Health And Rehabilitation
4501 N Blagg Road, Pahrump, NV 89060 · For profit - Corporation · 120 certified beds · (775) 751-6600 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for mishandling residents’ money or property (F0565)
- it has 1 actual-harm citation
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $40,427 in federal fines (most recent 2024-10-11)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 13.7% | 12.6% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.7% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.2% | 1.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.6% | 1.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 9.8% | 5.1% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.0% | 2.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 16.6% | 13.5% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 25.6% | 22.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 96.3% | 89.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.0% | 5.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 12.9% | 15.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.3% | 17.1% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 2.9% | 1.8% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 74.5% | 80.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 36.0% | 23.2% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 5.0% | 9.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.44 | 1.85 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.25 | 1.45 | 1.80 | worse |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
55.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 99 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 35.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 68 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.28 therapist hours per resident per day in 2026Q1 — more than 43% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 35% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 55.1%CMS range 44.4–65.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.3%CMS range 8.3–16.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 35.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 32.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 20.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 96.5% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 91.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 8.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.1%CMS range 2.8–9.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.40 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 101.8 residents a day — about 85% occupied, or roughly 18 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.32 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.72 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.97 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.12 hrs/resident/day on weekends vs 3.40 on weekdays — 8% thinner on weekends. RN hours go from 0.78 to 0.55 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 12 most serious are shown; the remaining 11 are one tap away and print in full.
- Immediate jeopardy · J2024-04-09 · tag F0678 — failed to provide CPR when needed — isolatedProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure a resident with a full code status was provided basic life support (BLS) after having been found unresponsive for 1 of 9 sampled residents (Resident 1). The deficient practice deprived the resident of life-saving measures, specifically cardiopulmonary resuscitation (CPR) which may have potentially increased the resident's chances of recovery and survival. Findings include: Resident 1 (R1) R1 was admitted on [DATE] and readmitted on [DATE], with diagnoses including Alzheimer's disease with late onset, nutritional deficiency, and urinary tract infection (UTI). A provider order for life-sustaining treatment (POLST) dated [DATE], revealed R1 was evaluated by the physician assistant to have decisional capacity and the resident elected to be a full code (attempt CPR in the event of cardiopulmonary arrest). A quarterly social services assessment dated [DATE], revealed R1 expressed wanting to remain full code. A nursing progress note…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2024-10-11 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to 1) monitor and report a decline in function for 1 of 19 residents (Resident 65) and 2) identify and report a resident's increase in pain related to worsening contractures for 1 of 19 unsampled residents (Resident 14). The deficient practice placed the residents at risk for diminished function and potentially an impact on the physical, mental and psychosocial well-being of the residents. Findings include: Resident 14 (R14) R14 was admitted on [DATE] with diagnoses including contractures of the right hand and foot. According to the Minimum Data Set, R14 scored a 03 which indicated the resident was not able to make needs well known. R14 was also diagnosed with aphasia (inability to articulate spoken words). Review of R14's care plan revised on 03/26/2024, identified: - Resident had limited physical mobility related to cerebral vascular accident (stroke). Goals included: - The resident will remain free of complications…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-19 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review the facility failed to ensure the physician ordered dressing changes for a midline catheter (a small flexible tube inserted into a vein of the upper arm) for 1 of 33 sampled residents (Resident 84). The deficient practice had the potential for the midline catheter to become infected due to the dressing not being changed.Findings include:Resident 84 (R84) was admitted to the facility on [DATE] with diagnoses including osteomyelitis of vertebra, sacral and sacrococcygeal region, urinary tract infection, and acute kidney failure. On 12/16/2025 at 11:22 AM, R84 was lying in bed with a midline catheter in the upper left arm. The midline dressing was not dated.A Physician Order dated 11/27/2025 documented may insert midline for intravenous (IV) antibiotics. R84's medical record lacked a physician order for midline dressing changes. On 12/17/2025 at 12:18 PM, a Licensed Practical Nurse (LPN) explained residents with IV lines would have the dressing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure 1) a smoking safety evaluation was completed to determine whether a resident was safe to smoke independently or required supervision for 1 of 33 sampled residents (Resident 39); and 2) and prevent residents or staff from smoking in the facility enclosed courtyard. The deficient practice had the potential to place residents, staff, and visitors at risk of injury related to smoking.Findings include:1) Resident 39 (R39) was admitted [DATE], readmitted [DATE], with diagnosis including paraplegia, anxiety disorder, and schizoaffective disorder. R39 was listed on the facility's smokers list.A Care Plan dated 11/30/2025, documented resident was a smoker.On 12/16/2025 at 11:22 AM, R39 reported going outside the facility grounds to smoke independently.On 12/18/2025 at 7:10 AM, R39 was observed outside, across the street from the facility, seated in a wheelchair and smoking alone without staff supervision.A Smoking Safety…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-19 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and document review the facility failed to communicate to the dialysis center, the need for contact precautions related to infectious dermatitis for 1 of 33 sampled residents (Resident 11). The deficient practice had the potential to place others at risk for transmission of infection. Findings include:Resident 11 (R11) was admitted to the facility on [DATE] with diagnoses including spinal stenosis of lumbar region, polyneuropathy, and end stage renal disease dependance on renal dialysis. On 12/16/2025 at 1:18 PM, R11 had rash that staff treated with medication and isolation and the resident goes to dialysis. A Physician Order, undated, documented dialysis Monday, Wednesday and Friday.A Nursing Progress note dated 11/26/2025 documented the Director of Nursing (DON) was notified of a new rash with small pustule like areas. A Physician Order dated 12/08/2025, documented contact precautions as recommended for residents known or suspected to be infected with infectious agents…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-19 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and document review the facility failed to ensure medication was not left unattended on top of a medication cart. The deficient practice had the potential for placing residents at risk for improper use of medication.Findings include: On 12/18/2025 at 8:12 AM, a medication bottle of fluticasone propionate nasal spray 50 micrograms (a medication used for nasal symptoms such as congestion, sneezing, runny nose, and nasal itching), was observed on top of a mediation cart in the hallway, unattended and accessible to any person walking by. The nurse was observed inside a nearby resident's room. On 12/18/2025 at 8:15 AM, a Registered Nurse (RN), confirmed had left the medication unattended on top of the medication cart and walked away to enter a resident's room. The RN acknowledged should not have left the medication unattended and accessible to all due to resident safety risks if ingested or used by a resident. On 12/18/2025 at 11:29 AM, the Director of Nursing (DON), stated medication should not have been left out unattended. The DON explained if a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-19 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and document review, the facility failed to ensure 1) the use of protective personal equipment (PPE) for 1 of 33 sampled residents (Resident 18) and 2 unsampled residents (Resident 16 and 115) on contact precautions and enhanced barrier precautions and 2) report an outbreak of infectious dermatitis to the state health authority. The deficient practice had the potential for the spread of infectious organisms.Findings include:1) On 12/17/2025 at 11:45 AM, a Certified Nursing Assistant (CNA) explained if a resident was on contact precautions, staff were to apply personal protective equipment (PPE) as listed on the signage prior to entering the resident room and remove prior to exiting the resident room. For residents that require Enhanced Barrier Precautions (EBP) the PPE would be applied when staff were providing direct care tasks for the residents. A. On 12/18/2025 at 9:28 AM, R115 had a sign posted to the left of the door which documented the following: -Contact Precautions everyone must clean hands, including before entering and when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-11 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and document review, the facility failed to ensure food concerns raised by the resident group were acted on, followed through and facility's actions (if any) were communicated back to the resident group. The deficient practice had the potential to have negative psycho-social outcomes to the residents. Findings include: On 10/09/2024 in the morning, Resident 51 (R51) was alert, oriented, and answered questions appropriately. R51 revealed being the President of the Resident Council. R51 explained the resident council meets on a regular basis every month to discuss any concerns to be brought to the attention of the facility staff. Discussions during the resident council were recorded by a staff member during the meeting. The Resident Council President indicated on the following dates the resident council discussed concerns regarding meals with no follow up or response from the facility: - 06/06/2024 - 07/11/2024 - 08/2024 - 09/06/2024 - 10/04/2024 On 10/09/2024 at 11:03 AM, the Resident Council President indicated food has been discussed on a regular basis, but the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-11 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and document review, the facility failed to ensure 1) kitchen staff were wearing appropriate facial coverings during food preparation and 2) molded strawberries were not being prepped for service. The deficient practice placed residents at risk for food related illnesses from ingesting contaminated food. Findings include: On 10/08/24 at 8:45 AM, the kitchen director and a cook were observed to have full beards and were not wearing beard nets during the initial tour of the kitchen. The kitchen director stated they should have been wearing beard nets. On 10/10/24 at 11:27 AM, observed another cook preparing multiple fruit salad plates, used strawberries that came from a container with a heavily molded strawberry. The cook was made aware of the molded strawberry, picked it up and attempted to throw it out of the container. The kitchen director who was watching the encounter told the cook to throw out the entire container of strawberries stating that the other strawberries were also contaminated. The kitchen director stated the staff member will need to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-11 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to develop a baseline care plan for a resident who was admitted with a condom catheter for 1 of 19 sampled residents (Resident 140). The deficient practice had the potential to place the resident at risk for not receiving appropriate care related to the condom catheter which included perineal care and site monitoring. Findings include: Resident 140 (R140) R140 was admitted on [DATE], with diagnoses including chronic kidney disease stage 3 and atherosclerotic vascular disease. On 10/08/2024 at 10:43 AM, R140 laid flat in bed with eyes closed, a family member was at bedside. The family member indicated the resident was in the hospital for eight days following a fall at home and R140 had significantly declined in cognitive and physical abilities since the hospitalization. The family member explained R140 had only half a kidney left, was incontinent and had a urinary catheter which was placed in the hospital. The family member…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-11 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure 1) a physician's PRN order for an anti-anxiety medication had a stop date for 1 of 19 sampled residents (Resident 70) and 2) a gradual dose reduction was attempted for a psychotropic medication for 2 of 19 sampled residents (Residents 23 and 70). The deficient practice placed the residents at risk for receiving unnecessary medications. Findings include: The facility policy titled Psychotropic Drugs, documented psychotropic drugs were any drug which affects brain activities associated with mental processes and behavior. Residents taking psychotropic medications would undergo a gradual dose reduction unless contraindicated. As needed psychotropic medications were limited to 14 days unless a rationale was provided by the practitioner and documented in the medical record. Resident 70 (R70) R70 was admitted on [DATE] and readmitted on [DATE] with diagnoses including mood disorder and anxiety disorder. 1) An active physician order…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-11 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure outdated and expired vaccine vials were discarded in accordance with the facility's policy. Specifically, two opened vials of Influenza vaccine (formula Year 2023-2024) were found inside the medication refrigerator. The deficient practice placed residents at risk for receiving outdated and expired Influenza vaccine during flu season 2024-2025. Findings include: On [DATE] at 9:12 AM, an inspection of the medication refrigerator in the 100-Hall storage room revealed two vials of Flucelvax Quadrivalent Influenza vaccine (formula 2023-2024), Lot number AU313OB. Both vials were opened with contents, not labeled with open date, and had an expiration date of [DATE]. On [DATE] at 9:15 AM, the Resident Care Manager (RCM) confirmed the observation and explained RCMs were responsible for checking the medication rooms on a monthly basis to inspect for expired patient care medications and items. The RCM could not speak to why the Influenza…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 11 citations
- Potential for harm · D2024-10-11 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure 1) a hospice physician's order to get resident out of bed daily was followed and, 2) hospice aides reported a loosened pressure ulcer dressing to the facility nurse for 1 of 19 sampled residents (Resident 15). The deficient practice had the potential to negatively impact quality of life by depriving the resident of environmental stimulation and social interaction and placed the resident at risk for wound complications. Findings include: Resident 15 (R15) R15 was admitted on [DATE], with diagnoses including multiple sclerosis and hospice status. A hospice physician's order dated 07/12/2024, documented to get R15 out of bed to chair daily. The medical director for the skilled nursing facility (SNF) wrote an order dated 07/12/2024, to get R15 out of bed to chair daily during day shift. The quarterly minimum data set (MDS) dated [DATE], revealed R15 had a brief interview of mental status (BIMS) of 15 (intact cognition),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-09 · tag F0940 — failed to train staff — patternDevelop, implement, and/or maintain an effective training program for all new and existing staff members.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure 1) the emergency crash cart was free of expired supplies, 2) staff were trained on the suction equipment, oral airway device and automated external defibrillator (AED) and 3) mock code drills were conducted quarterly once per shift in accordance with facility policy. The deficient practice placed residents' safety at risk as a result of poor-quality response to an emergency such as aspiration, choking and cardiopulmonary arrest. Emergency Crash Cart On [DATE] at 9:23 AM, a Registered Nurse (RN) and the Resident Care Manager (RCM) were present for an inspection of the emergency crash cart located in the 500-Hall and 600-Hall nurse's station. The crash cart checklist for [DATE] and [DATE] reflected the emergency crash cart was checked daily with no missed entries. The RN and RCM indicated the night shift staff were assigned check the contents of the crash cart. The RCM confirmed the following observations: - six Amsino brand…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-09 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and document review, the facility failed to complete or document the status of the orthopedic follow-up consultation for fractured bilateral feet for 1 of 4 sampled residents (Resident 2). This deficient practice had the potential to delay the necessary medical intervention and exacerbate the resident's pain and complications. Findings include: Resident 2 (R2) R2 was admitted on [DATE], with diagnoses including a closed fracture, a nondisplaced fracture of the lateral malleolus of the right fibula, a fifth metatarsal bone, a left foot, and weakness. A Physician order dated 01/30/2023, documented to follow up with an orthopedic surgeon in one week. A Care Plan dated 02/02/2023, documented R2 had an alteration in musculoskeletal status related to a fracture of bilateral feet. The interventions included the following for weight bearing status and to see physician orders. A Physician Progress Note dated 02/09/2023, documented the Chief Complaint / Nature of the Presenting Problem:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-30 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review, the facility failed to ensure a resident's room was in good repair and free of debris on the floor for one of four residents (Resident (R)41) rooms observed for a clean, homelike environment out of a sample of 18 residents. Findings include: Review of facility policy titled, Homelike Environment, updated July 2015 revealed, Policy Statement: Resident rooms are personalized and organized in a matter that promotes independence through a homelike environment. Procedure: . c. Room is free of hazards. During an observation and interview on 11/27/2023 at 2:11 PM, R41's room revealed scrapes on the wall behind the bed with pieces of the wall laying in a pile on the floor. The baseboard was not attached to the wall. R41 was asked about the wall damage, R41 was not aware of the wall damage. During an interview on 11/30/2023 at 2:33 PM, the Maintenance Director was asked how often rounds were made to look for needed repairs in the rooms. The Maintenance Director would go into the rooms and look for life safety issues but, did not use a form…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-30 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the RAI [Resident Assessment Instrument] Manual, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for three out of 18 sampled residents (Residents (R)21, R28, and R64). Findings include: During an interview on 11/30/2023 at 3:11 PM, the Administrator stated the facility did not have any policies regarding MDS assessments. The Administrator stated the facility used the RAI Manual for guidance on completion of MDS assessments. Review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11 October 2023 revealed, The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b) (1) (xviii), (g) and (h) require that (1) the assessment accurately reflects the resident's status . the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. 1. Review of the undated admission Record in the electronic medical record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-30 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the RAI [Resident Assessment Instrument] Manual, the facility failed to develop comprehensive care plans for two of 18 sampled residents (Residents (R)21 and R62). Specifically, R21 did not have a care plan to address R21's deteriorated dental condition, and R62 did not have a care plan to address oxygen use. This had the potential for the residents to have unmet care needs. Findings include: During an interview on 11/30/2023 at 3:11 PM, the Administrator stated the facility did not have a policy for care planning and used the RAI Manual for guidance. Review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11 October 2023 read in pertinent part, The RAI helps nursing home staff gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan . the care plan becomes each resident's unique path toward achieving or maintain their highest practical level of well-being. 1. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-30 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of CNA [Certified Nursing Assistant] Competency Oral Hygiene document, and record review, the facility failed to ensure one out of three dependent residents reviewed for activities of daily living (Resident (R)21), out of a sample of 18 residents, was provided with adequate oral hygiene. Findings include: During an interview on 11/30/2023 at 3:11 PM, the Administrator stated the facility did not have a policy for oral care/oral hygiene; however, provided an undated document titled, CNA [certified nursing assistant] Competency Oral Hygiene document. The CNA Oral Hygiene document directed staff to, Collect items (i.e., toothbrush, toothpaste, mouthwash, water cup, basin, etc.) . apply gloves, then brush teeth in a circular motion, brushing gums, teeth, tongue (as able). Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R21 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, dysphagia…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-30 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure two of two sampled residents (Resident (R)21 and R28) who were bedridden were offered activities of their interest. This deficient practice had the potential for the residents to not have their psychosocial well-being met. Findings include: Review of the facility's policy manual titled Activity Program, dated July 2015 revealed, Policy Statement: The Center provides an ongoing program of activities designed to meet the interests as well as a physical, mental, and psychosocial well-being of each resident. Policy Statement: The Activity Staff offers specialized activities to meet specific resident needs. The Activity Department's primary purpose is to provide a varied activity program addressing each resident's needs. 1. Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R21 was admitted to the facility on [DATE] with diagnoses including multiple…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and competency review, the facility failed to ensure the nurse providing wound care followed physician orders for one of two wound care observations for (Resident (R) 21). This failure had the potential to cause wounds to become more complex requiring more extensive and/or intrusive treatments. Findings include: Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R21 was admitted to the facility on [DATE] with a diagnosis of multiple sclerosis, contractures, and adult failure to thrive. Review of R21's Order Summary from the EMR Orders tab showed: Wound care: Left buttocks DTI [deep tissue injury] cleanse with NS [normal saline], pat to dry apply Blastx [an antimicrobial wound gel] and C. Alginate [calcium alginate, an absorbent wound dressing] with foam dressing every MWF [Monday, Wednesday and Friday] and PRN [as needed] Re- Evaluate weekly every day shift every Mon, Wed, Fri for pressure wound and Wound care: Right…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of manufacturer's guidelines, and facility policy review, the facility failed to ensure appropriate respiratory services for two of three sampled residents (Resident (R)28 and R64) by failing to ensure a filter was in the Bilevel Positive Airway Pressure (BIPAP) machine, masks and tubing were cleaned and stored when not in use for a BIPAP machine and nebulizer machine, and a physician order was in place for a resident on oxygen (O2). This had the potential for possible respiratory issues and/or infections. Findings include: Review of the undated manufacturer guidelines for BIPAP provided by the facility revealed on page eight, Cleaning: You should clean the device weekly as described. 1. Wash the water tub and air tubing in warm water using only mild detergent. 2. Rinse the water tub and air tubing thoroughly and allow to dry out of direct sunlight and/or heat. Checking.3, Check the air filter replace it at least every six months. Review of facility policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-30 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of the Centers for Disease Control (CDC) guidelines, and policy review, the facility failed to ensure hand hygiene was performed between glove changes and clean gloves were used during wound care for one Resident (R) 21 of two residents observed for wound care. This failure had the potential to create a higher bacterial load and/or wound infection causing a wound not to heal. Findings include: Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R21 was admitted to the facility on [DATE] with a diagnosis of multiple sclerosis, contractures, and adult failure to thrive. During an observation of wound care for R21 on 11/29/2023 at 11:00 AM, Registered Nurse (RN) 1 along with Certified Nursing Assistant (CNA) 5 revealed RN1 performed a hand wash in the bathroom. RN1 then laid out all treatment items on the overbed table on top of a clean surface, including extra gloves. RN1 donned (put on) gloves, removed the two…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$40,427 in federal fines across 2 penalties.
- $26,800 — penalty dated 2024-10-11
- $13,627 — penalty dated 2024-04-09
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to EVERGREEN HEALTHCARE GROUP — 44 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.5 | +0.5 vs chain |
| Health inspection | 3 of 5 | 2.4 | +0.6 vs chain |
| Staffing | 3 of 5 | 3.3 | -0.3 vs chain |
| Quality measures | 3 of 5 | 3.0 | ≈ chain avg |
The other 43 homes this chain runs (chain average 2.5★, per CMS)
Showing 40 of 43; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| PACIFIC NORTHWEST SNF OPERATIONS HOLDINGS (NV) LLC | Organization | DIRECT OWNERSHIP INTEREST | since 08/31/2023 |
| CH PACIFIC NORTHWEST HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 08/31/2023 |
| PACIFIC NORTHWEST SNF OPERATIONS HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 08/31/2023 |
| WITZCORP GLOBAL LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 08/31/2023 |
| HERZKA, YISROEL | Individual | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 08/31/2023 |
| YENOWITZ, YITZCHOK | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNF | since 07/02/2025 |
| EARL, STEVEN | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/31/2023 |
| RIKER, MICHELLE | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/31/2023 |
| COUVE FINANCIAL SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/08/2025 |
| COUVE HEALTHCARE CONSULTING LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/08/2025 |
| NEVADA SNF CONSULTING LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/08/2025 |
| PACIFIC NORTHWEST OPCO MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/08/2025 |
| PAHRUMP SNF OPERATIONS, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/27/2025 |
| JORGENSON, CRAIG | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/31/2023 |
| MORTILLARO, CATHY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/31/2023 |
| SPIELMAN, SHIMON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/31/2023 |
| THAYER, INEZ | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/31/2023 |
| PAHRUMP SNF REALTY LLC | Organization | ADP OF THE SNF | since 05/08/2025 |
CMS files one row per role, so the 37 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
10 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $194K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NV
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Nevada Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 295075. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-19, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.