GARDNERVILLE, NV - Federal inspectors documented significant medication and infection control violations at Gardnerville Health & Rehabilitation Center during a May 2025 inspection that revealed a dangerous medication error rate and failures to contain drug-resistant bacteria.
Dangerous Medication Error Rate Exceeds Federal Limits
The facility recorded a medication error rate of 7.69 percent during the inspection period, substantially exceeding the federal maximum of 5 percent. Inspectors observed 26 medication administration opportunities and documented two critical errors involving life-saving medications.
In one case, a registered nurse failed to administer Pradaxa, a blood-thinning medication prescribed to prevent dangerous blood clots in a resident with a history of stroke and heart rhythm problems. The medication was marked as "on order" from the pharmacy, but nursing staff failed to contact the physician about the missed dose or document any follow-up actions.
A second medication error involved Finasteride, prescribed for a resident with prostate enlargement. Similar to the first case, the medication was unavailable but staff failed to follow proper protocols for notifying physicians about missed critical medications.
The facility's Director of Nursing acknowledged that missing physician-ordered medications without proper documentation and physician notification constituted medication errors. Staff were expected to check automated dispensing systems, contact pharmacies, and notify physicians when medications were unavailable, but these protocols were not followed in either documented case.
Drug-Resistant Bacteria Allowed to Spread Between Roommates
Perhaps most concerning was the facility's failure to properly isolate residents infected with Extended-Spectrum Beta-Lactamase (ESBL) producing E. coli, a dangerous drug-resistant bacteria that can cause life-threatening infections.
The inspection revealed that two residents infected with the same strain of ESBL E. coli were housed together despite federal guidelines requiring private rooms for such infections. The bacteria is resistant to multiple antibiotics and poses serious health risks, particularly to vulnerable nursing home residents.
Resident #32 first tested positive for ESBL E. coli on February 12, 2025, but continued sharing a room with Resident #27. By March 25, Resident #27 had contracted the same drug-resistant infection. Laboratory reports confirmed both residents carried identical strains of the bacteria that showed resistance to 13 different antibiotics, including commonly used drugs like Ciprofloxacin and Ceftriaxone.
"I've been in isolation for approximately one month," Resident #27 told inspectors, becoming tearful while explaining how the isolation worsened existing anxiety disorders.
Despite having 18 empty beds available in February 2025, the facility chose to house the infected residents together rather than providing the private rooms required by federal infection control standards. This decision likely contributed to the spread of the dangerous bacteria between the two residents.
Missing Enhanced Barrier Precautions for High-Risk Residents
Inspectors also found the facility failed to implement Enhanced Barrier Precautions (EBP) for three residents at high risk for infection transmission. These residents had urinary catheters and open wounds that required special protective measures, but staff were not wearing appropriate gowns and gloves during care.
EBP protocols are designed to prevent the spread of drug-resistant organisms in nursing homes by requiring protective equipment during direct care activities. The facility's own policy required EBP for residents with urinary catheters, wounds, and feeding tubes, but these protections were not in place during the inspection.
Medical Risks and Patient Safety Concerns
Missing critical medications can have serious health consequences. Pradaxa helps prevent stroke-causing blood clots in residents with heart rhythm disorders - missing even a single dose can increase stroke risk. Finasteride treats enlarged prostate conditions that can lead to urinary retention and kidney problems if left untreated.
Drug-resistant infections like ESBL E. coli are particularly dangerous in nursing home settings where residents often have weakened immune systems. These bacteria can cause urinary tract infections that progress to life-threatening bloodstream infections. The limited antibiotic options make treatment extremely challenging and increase mortality rates.
Enhanced barrier precautions serve as a critical defense against infection transmission. Research shows proper use of protective equipment can reduce healthcare-associated infections by up to 70 percent in long-term care facilities.
Additional Violations Compound Safety Concerns
The inspection uncovered several other deficiencies that compromised resident safety:
- Unlabeled medication vials in storage areas, including an opened tuberculin test vial lacking a date label, creating risk of administering expired medications - Missing performance reviews for nursing assistants, preventing identification of training needs - Inadequate facility assessments completed without required committee input, potentially leaving resource gaps unidentified - Incomplete medical records, including wound care performed without proper physician orders and delayed medication documentation
The facility also failed to maintain required quality improvement programs, with administrators unable to provide documentation of any performance improvement projects completed in the past year due to lost electronic records after staff changes.
Infection Control Policy Failures
The facility's infection control policies met federal standards on paper but were not implemented consistently. While policies required private rooms for residents with drug-resistant infections, staff housed infected residents together citing room availability - despite having empty beds available.
Similarly, policies required enhanced precautions for high-risk residents, but no protective equipment stations or warning signs were placed outside appropriate rooms during the inspection period.
Regulatory Context and Oversight
These violations occurred during a routine federal inspection conducted by the Centers for Medicare & Medicaid Services. The facility must submit correction plans addressing each deficiency and demonstrate sustained compliance to avoid potential penalties including fines or loss of federal funding.
Federal nursing home standards require medication error rates below 5 percent and strict infection control protocols to protect vulnerable residents. The combination of medication failures and infection control lapses represents a pattern of safety deficiencies that could impact resident health outcomes.
The inspection findings highlight ongoing challenges in nursing home medication management and infection prevention, particularly with increasingly antibiotic-resistant organisms and complex medication regimens common in long-term care settings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gardnerville Health & Rehab Center from 2025-05-01 including all violations, facility responses, and corrective action plans.
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