Resident #27 developed Extended-Spectrum Beta-Lactamase E. coli in March 2025 after rooming with Resident #32, who had tested positive for the same multidrug-resistant organism in February. Federal inspectors found that Gardnerville Health & Rehabilitation Center violated infection control protocols by keeping the residents together despite having 18 empty beds available.
The infected roommate, Resident #32, had returned from the hospital in late February with confirmed ESBL E. coli in their urine. Lab results from February 17 showed the organism was "confirmed as an ESBL producer" — meaning it could resist multiple antibiotics. Centers for Disease Control guidelines require such residents be placed in private rooms or cohorted only with others who have the identical infection.
Instead, staff placed Resident #32 back in a shared room with Resident #27, who had no such infection.
"The IP confirmed Resident #32 should have been placed in a private room upon return to the facility," the inspection report states. The Infection Preventionist acknowledged the February lab report "indicated the organism was resistant to multiple drugs."
By March 19, Resident #27 began complaining of painful urination and frequency. A urine culture collected that day came back positive for ESBL E. coli — the same organism that had infected the roommate a month earlier. The lab results showed resistance to 13 different antibiotics, including commonly used drugs like ciprofloxacin, gentamicin, and ceftriaxone.
Resident #27 required immediate intravenous antibiotic treatment. Medical records show the resident received Ceftolozane-Tazobactam IV, then Meropenem 500 milligrams every eight hours, followed by oral Linezolid 600 milligrams twice daily for 14 days.
On April 4, physicians ordered Resident #27 into isolation. The order specified "resident to be in private room with no roommate" and required all care be provided in the room with meals served on disposable trays.
During the inspection, Resident #27 became tearful while describing the isolation's impact. "The resident explained the resident had really bad anxiety and the isolation made the anxiety worse," inspectors documented. The resident said they had "been in isolation for approximately one month" and complained of nausea and vomiting from the antibiotics.
The facility's own infection tracking documents confirm the timeline. Monthly infection reports show Resident #32 developed a healthcare-associated UTI with E. coli ESBL on February 13, 2025. Resident #27's infection was logged as healthcare-associated on March 25 — more than a month after sharing the room with the infected roommate.
A contact precautions sign was posted outside their shared room during the inspection, requiring staff to wear gowns and gloves. A Licensed Practical Nurse assigned to both residents confirmed "the contact precautions were in place due to Extended-Spectrum Beta-Lactamase in the resident's urine" and that "both residents were on contact precautions."
The same CNA provided care to both residents during shifts, despite the infection risk.
When questioned by inspectors, the Director of Nursing and Infection Preventionist initially claimed residents on contact precautions could have roommates "if the roommate had the same organism." But they later acknowledged that Resident #27 did not have the same infection when initially placed with Resident #32.
"The first time the facility was aware of and had documentation of Resident #27 testing positive for ESBL E. coli was 03/25/2025, after sharing a room with Resident #32," the Infection Preventionist admitted.
The facility's own policy, updated in January 2025, states that contact transmission can occur "by directly touching the resident, through contact with the resident's environment, or by using contaminated gloves or equipment." It specifies that options for contact precautions include "a private room" or "cohorting with another infected or colonized resident."
CDC guidelines are even more explicit. The 2007 Isolation Precautions guideline, updated in September 2024, states that "placement of a resident in a single room is preferred when there is concern about transmission of an infectious agent." For residents with multidrug-resistant organisms like ESBL, the CDC recommends contact precautions in addition to standard precautions.
Extended-Spectrum Beta-Lactamase organisms are particularly concerning because they can break down many common antibiotics, leaving fewer treatment options. The CDC classifies ESBL-producing bacteria as a serious antibiotic resistance threat.
Meanwhile, another resident faced a different kind of neglect. Resident #19 told inspectors they hadn't received regular showers as scheduled and had to give themselves bed baths. "The resident explained feeling itchy and bad about themselves when not receiving regular scheduled showers," the report states.
Medical records showed Resident #19, who required substantial assistance with bathing according to their care plan, missed scheduled showers or baths on 15 different dates between February and April 2025. The resident was supposed to receive twice-weekly showers on Mondays and Fridays, but documentation was missing for multiple scheduled dates with no record of refusals or alternative arrangements.
A nurse apprentice explained that shower refusals should be documented on skin observation sheets and reported to the Infection Preventionist, but no such documentation existed for the missed dates.
The Director of Nursing confirmed during the inspection that there was "no documented evidence the resident was offered a shower or bath" on the 15 missed dates and "no documentation Resident #19 had refused or was unavailable during the shift."
Staffing records show the facility operated with minimal nursing coverage during the period when the infections occurred. In early March 2025, only one nurse worked the night shift for five consecutive days. The Director of Nursing confirmed the facility sometimes had shifts "when only one nurse was in the facility to provide nursing care to all residents."
Resident #27 remains on contact precautions, with physician orders extending isolation until 72 hours after antibiotic treatment ends. The resident who should never have been exposed to a drug-resistant infection now faces weeks more of the isolation that worsens their anxiety and depression.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gardnerville Health & Rehabilitation Center from 2025-05-01 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Gardnerville Health & Rehabilitation Center
- Browse all NV nursing home inspections