Gardnerville Health & Rehabilitation Center omitted the anticoagulant Eliquis from Resident 29's assessment form, even though medication records showed staff gave the resident 5 milligrams of the drug twice daily throughout April 2025. The resident had been prescribed Eliquis since August 2024 to prevent blood clots.
The MDS Coordinator confirmed the assessment was inaccurate after inspectors pointed out the discrepancy. Federal guidelines classify anticoagulants as high-risk medications that require special monitoring because they can cause dangerous side effects affecting health, safety and quality of life.
The facility also failed to properly screen another resident for mental health services, despite the person developing psychosis and cognitive problems after admission.
Resident 4 had been living at the facility since 2013 with an initial screening that found "no Mental Illness, Mental Retardation, or Related Conditions." But the resident later developed unspecified psychosis in September 2024 and cognitive function problems in March 2025, according to medical records.
Nobody at the facility initiated a new screening to determine if the resident needed specialized behavioral health services.
The Licensed Social Worker told inspectors she had no responsibilities related to resident screening. The Admissions Director admitted not knowing what the screening process was, saying she had received no formal training on proper procedures.
"I don't know what a PASARR is but it's a requirement to have in a resident's clinical file prior to admission," the Admissions Director told inspectors.
The Administrator confirmed the facility had no employee handling the screening processes and called the system "fractured." The Administrator admitted not knowing what a Level II screening was or what purpose it would serve for residents.
Meanwhile, the Director of Nursing described Resident 4 as experiencing hallucinations, paranoia, anger and frustration "because the resident was seeing things that were not there."
The facility had published a policy in January 2025 requiring the Social Services Director to track screenings and ensure residents received proper evaluations. But staff interviews revealed no one was following the written procedures.
A third resident faced problems with oxygen care planning. Resident 34 required continuous oxygen at 2 liters per minute for chronic lung disease and heart failure, but the care plan contained no mention of oxygen use or respiratory monitoring needs.
Inspectors observed the resident sitting on the bed with the nasal cannula hanging below their chin. When a nurse entered and adjusted the oxygen equipment, she found the concentrator set to 3 liters instead of the prescribed 2 liters.
The nurse explained that Resident 34 often removed the nasal cannula at night, forcing staff to increase oxygen levels. But without proper care planning, staff had no written guidance for monitoring the resident's breathing or oxygen saturation levels.
The Director of Nursing confirmed oxygen use should be included in care plans and admitted Resident 34's plan lacked any problems, goals or interventions related to heart failure or oxygen therapy. She updated the care plan after inspectors raised the issue.
Federal regulations require nursing homes to develop comprehensive care plans describing all services needed to maintain residents' highest level of well-being. The plans must include measurable objectives and be revised when residents' conditions change.
The assessment failures at Gardnerville Health & Rehabilitation Center potentially deprived residents of necessary monitoring and specialized services. Accurate documentation helps ensure staff understand each resident's medical needs and safety risks.
For Resident 29, the missing anticoagulant information could have affected decisions about medication interactions, fall risk precautions and bleeding monitoring. Anticoagulants require careful oversight because they increase the risk of dangerous bleeding episodes.
Resident 4's unaddressed mental health screening meant the facility may have missed opportunities to provide appropriate psychiatric care or behavioral interventions. The resident's hallucinations and paranoia suggested possible needs for specialized treatment or environmental modifications.
The oxygen care planning gap for Resident 34 left staff without clear protocols for respiratory monitoring, potentially missing early signs of breathing difficulties or equipment problems.
All three violations were classified as having minimal harm or potential for actual harm, affecting few residents. But the pattern revealed systemic problems with assessment accuracy and care planning processes at the 89410 facility.
The inspection found staff either lacked training on proper procedures or weren't following established policies. The fractured screening system and missing care plan elements suggested broader organizational issues with clinical oversight and documentation standards.
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.
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