Facility Watch Inspection records for every certified US nursing home

Ormsby Post Acute Rehabilitation

3050 N Ormsby Road
Carson City, NV 89703
(775) 841-4646

Special Focus Facility — SFFAbuse icon
CCN
295067
Certified beds
120
Ownership
For profit - Limited Liability company
Chain
Evergreen Healthcare Group

Nurse staffing

4.03
Total nurse staffing hours per resident per day, case-mix adjusted

Registered nurses: 0.94 hours per resident per day

Nursing staff turnover: 63% a year

Derived by CMS from the Payroll-Based Journal and refreshed quarterly.

Inspection history

Inspected March 26, 2026

2 citations · from a complaint investigation · Health
D
F0600 No actual harm with potential for more than minimal harm · Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Deficient, Provider has date of correction · corrected April 30, 2026
D
F0610 No actual harm with potential for more than minimal harm · Isolated

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected April 30, 2026

Inspected March 27, 2025

10 citations · from a complaint investigation · Health
D
F0582 No actual harm with potential for more than minimal harm · Isolated

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Deficient, Provider has date of correction · corrected April 14, 2025
D
F0640 No actual harm with potential for more than minimal harm · Isolated

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Deficient, Provider has date of correction · corrected April 14, 2025
D
F0641 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident receives an accurate assessment.

Deficient, Provider has date of correction · corrected April 14, 2025
D
F0656 No actual harm with potential for more than minimal harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected April 14, 2025
D
F0757 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Deficient, Provider has date of correction · corrected April 14, 2025
D
F0761 No actual harm with potential for more than minimal harm · Isolated

Ensure 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.

Deficient, Provider has date of correction · corrected April 14, 2025
D
F0842 No actual harm with potential for more than minimal harm · Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Deficient, Provider has date of correction · corrected April 14, 2025
D
F0940 No actual harm with potential for more than minimal harm · Isolated

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Deficient, Provider has date of correction · corrected April 14, 2025
E
F0849 No actual harm with potential for more than minimal harm · Pattern

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Deficient, Provider has date of correction · corrected April 14, 2025
F
F0812 No actual harm with potential for more than minimal harm · Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected April 14, 2025

Inspected September 18, 2024

4 citations · from a complaint investigation · Health
D
F0600 No actual harm with potential for more than minimal harm · Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Deficient, Provider has date of correction · corrected November 3, 2024
D
F0602 No actual harm with potential for more than minimal harm · Isolated

Protect each resident from the wrongful use of the resident's belongings or money.

Deficient, Provider has date of correction · corrected November 3, 2024
D
F0658 No actual harm with potential for more than minimal harm · Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Deficient, Provider has date of correction · corrected November 3, 2024
D
F0757 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Deficient, Provider has date of correction · corrected November 3, 2024

Inspected May 29, 2024

41 citations · from a complaint investigation · Health
C
F0839 No actual harm with potential for minimal harm · Widespread

Employ staff that are licensed, certified, or registered in accordance with state laws.

Deficient, Provider has date of correction · corrected July 24, 2024
C
F0841 No actual harm with potential for minimal harm · Widespread

Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0552 No actual harm with potential for more than minimal harm · Isolated

Ensure that residents are fully informed and understand their health status, care and treatments.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0558 No actual harm with potential for more than minimal harm · Isolated

Reasonably accommodate the needs and preferences of each resident.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0600 No actual harm with potential for more than minimal harm · Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0602 No actual harm with potential for more than minimal harm · Isolated

Protect each resident from the wrongful use of the resident's belongings or money.

Past Non-Compliance · corrected July 24, 2024
D
F0609 No actual harm with potential for more than minimal harm · Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0622 No actual harm with potential for more than minimal harm · Isolated

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0656 No actual harm with potential for more than minimal harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0657 No actual harm with potential for more than minimal harm · Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0677 No actual harm with potential for more than minimal harm · Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0678 No actual harm with potential for more than minimal harm · Isolated

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0686 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0691 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0695 No actual harm with potential for more than minimal harm · Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0698 No actual harm with potential for more than minimal harm · Isolated

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0712 No actual harm with potential for more than minimal harm · Isolated

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0725 No actual harm with potential for more than minimal harm · Isolated

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0755 No actual harm with potential for more than minimal harm · Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0759 No actual harm with potential for more than minimal harm · Isolated

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0842 No actual harm with potential for more than minimal harm · Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0851 No actual harm with potential for more than minimal harm · Isolated

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0880 No actual harm with potential for more than minimal harm · Isolated

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0887 No actual harm with potential for more than minimal harm · Isolated

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0941 No actual harm with potential for more than minimal harm · Isolated

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0943 No actual harm with potential for more than minimal harm · Isolated

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Deficient, Provider has date of correction · corrected July 24, 2024
E
F0658 No actual harm with potential for more than minimal harm · Pattern

Ensure services provided by the nursing facility meet professional standards of quality.

Deficient, Provider has date of correction · corrected July 24, 2024
E
F0761 No actual harm with potential for more than minimal harm · Pattern

Ensure 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.

Deficient, Provider has date of correction · corrected July 24, 2024
E
F0883 No actual harm with potential for more than minimal harm · Pattern

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Deficient, Provider has date of correction · corrected July 24, 2024
E
F0942 No actual harm with potential for more than minimal harm · Pattern

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Deficient, Provider has date of correction · corrected July 24, 2024
E
F0944 No actual harm with potential for more than minimal harm · Pattern

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Deficient, Provider has date of correction · corrected July 24, 2024
E
F0945 No actual harm with potential for more than minimal harm · Pattern

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Deficient, Provider has date of correction · corrected July 24, 2024
E
F0949 No actual harm with potential for more than minimal harm · Pattern

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Deficient, Provider has date of correction · corrected July 24, 2024
F
F0726 No actual harm with potential for more than minimal harm · Widespread

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Deficient, Provider has date of correction · corrected July 24, 2024
F
F0812 No actual harm with potential for more than minimal harm · Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected July 24, 2024
F
F0835 No actual harm with potential for more than minimal harm · Widespread

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Deficient, Provider has date of correction · corrected July 24, 2024
F
F0865 No actual harm with potential for more than minimal harm · Widespread

Have a plan that describes the process for conducting QAPI and QAA activities.

Deficient, Provider has date of correction · corrected July 24, 2024
F
F0881 No actual harm with potential for more than minimal harm · Widespread

Implement a program that monitors antibiotic use.

Deficient, Provider has date of correction · corrected July 24, 2024
F
F0946 No actual harm with potential for more than minimal harm · Widespread

Provide training in compliance and ethics.

Deficient, Provider has date of correction · corrected July 24, 2024
J
F0610 Immediate jeopardy to resident health or safety · Isolated

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected July 24, 2024

Inspected February 16, 2024

5 citations · from a complaint investigation · Health
D
F0552 No actual harm with potential for more than minimal harm · Isolated

Ensure that residents are fully informed and understand their health status, care and treatments.

Deficient, Provider has date of correction · corrected March 11, 2024
D
F0600 No actual harm with potential for more than minimal harm · Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Deficient, Provider has date of correction · corrected March 11, 2024
D
F0656 No actual harm with potential for more than minimal harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected March 11, 2024
D
F0657 No actual harm with potential for more than minimal harm · Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Deficient, Provider has date of correction · corrected March 11, 2024
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected March 11, 2024

Inspected October 16, 2023

1 citation · from a complaint investigation · Health
D
F0600 No actual harm with potential for more than minimal harm · Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Deficient, Provider has date of correction · corrected October 30, 2023

Inspected July 5, 2023

33 citations · from a complaint investigation · Health
C
F0837 No actual harm with potential for minimal harm · Widespread

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Deficient, Provider has date of correction · corrected August 15, 2023
D
F0550 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Deficient, Provider has date of correction · corrected August 15, 2023
D
F0552 No actual harm with potential for more than minimal harm · Isolated

Ensure that residents are fully informed and understand their health status, care and treatments.

Deficient, Provider has date of correction · corrected July 29, 2023
D
F0561 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Deficient, Provider has date of correction · corrected July 29, 2023
D
F0580 No actual harm with potential for more than minimal harm · Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Deficient, Provider has date of correction · corrected August 15, 2023
D
F0600 No actual harm with potential for more than minimal harm · Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Deficient, Provider has date of correction · corrected July 29, 2023
D
F0655 No actual harm with potential for more than minimal harm · Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Deficient, Provider has date of correction · corrected July 29, 2023
D
F0656 No actual harm with potential for more than minimal harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected July 29, 2023
D
F0657 No actual harm with potential for more than minimal harm · Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Deficient, Provider has date of correction · corrected August 15, 2023
D
F0677 No actual harm with potential for more than minimal harm · Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected July 29, 2023
D
F0679 No actual harm with potential for more than minimal harm · Isolated

Provide activities to meet all resident's needs.

Deficient, Provider has date of correction · corrected July 29, 2023
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected September 7, 2023
D
F0686 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected July 29, 2023
D
F0758 No actual harm with potential for more than minimal harm · Isolated

Implement 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.

Deficient, Provider has date of correction · corrected August 15, 2023
D
F0759 No actual harm with potential for more than minimal harm · Isolated

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected August 15, 2023
D
F0761 No actual harm with potential for more than minimal harm · Isolated

Ensure 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.

Deficient, Provider has date of correction · corrected August 15, 2023
D
F0867 No actual harm with potential for more than minimal harm · Isolated

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Deficient, Provider has date of correction · corrected August 15, 2023
D
F0883 No actual harm with potential for more than minimal harm · Isolated

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Deficient, Provider has date of correction · corrected August 15, 2023
D
F0887 No actual harm with potential for more than minimal harm · Isolated

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Deficient, Provider has date of correction · corrected August 15, 2023
D
F0943 No actual harm with potential for more than minimal harm · Isolated

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Deficient, Provider has date of correction · corrected August 15, 2023
D
F0947 No actual harm with potential for more than minimal harm · Isolated

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Deficient, Provider has date of correction · corrected August 15, 2023
D
F0949 No actual harm with potential for more than minimal harm · Isolated

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Deficient, Provider has date of correction · corrected August 15, 2023
E
F0584 No actual harm with potential for more than minimal harm · Pattern

Honor 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.

Deficient, Provider has date of correction · corrected July 29, 2023
E
F0941 No actual harm with potential for more than minimal harm · Pattern

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Deficient, Provider has date of correction · corrected August 15, 2023
E
F0942 No actual harm with potential for more than minimal harm · Pattern

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Deficient, Provider has date of correction · corrected August 15, 2023
E
F0944 No actual harm with potential for more than minimal harm · Pattern

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Deficient, Provider has date of correction · corrected August 15, 2023
E
F0945 No actual harm with potential for more than minimal harm · Pattern

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Deficient, Provider has date of correction · corrected August 15, 2023
E
F0946 No actual harm with potential for more than minimal harm · Pattern

Provide training in compliance and ethics.

Deficient, Provider has date of correction · corrected August 15, 2023
F
F0726 No actual harm with potential for more than minimal harm · Widespread

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Deficient, Provider has date of correction · corrected August 15, 2023
F
F0835 No actual harm with potential for more than minimal harm · Widespread

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Deficient, Provider has date of correction · corrected August 15, 2023
F
F0838 No actual harm with potential for more than minimal harm · Widespread

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Deficient, Provider has date of correction · corrected August 15, 2023
F
F0842 No actual harm with potential for more than minimal harm · Widespread

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Deficient, Provider has date of correction · corrected August 15, 2023
F
F0940 No actual harm with potential for more than minimal harm · Widespread

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Deficient, Provider has date of correction · corrected August 15, 2023

Penalties

DateTypeAmount
May 29, 2024Fine$60,464
May 29, 2024Payment Denial · 6 days

Ownership transfers

EffectiveSellerBuyer
08/31/2023Evergreen at Carson City LLCOrmsby SNF Operations LLC

From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.