Ormsby Post Acute Rehabilitation
ORMSBY POST ACUTE REHABILITATION in CARSON CITY, NV — inspection on March 26, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
blood glucose, Glucagon should have been administered as ordered by the physician.On 03/26/2026 at
or care.
The Administrator/Abuse Coordinator denied having documentation of the facility's
Coordinator was not clinical however, recalled staff found Resident #8 unresponsive and the RN was supposed to have administered a different type of medication.On 03/26/2026 at 4:05 PM, the CNO verbalized the CNO contacted the facility's medical director and nurse practitioner, and neither were able to find documentation a physician was notified on 01/15/2026 and 01/17/2026 of Resident #8's blood glucose being outside the parameters in the physician's orders.The facility's Licensed Practical Nurse/Registered Nurse Job Description, undated, documented the primary purpose of the position was to identify and meet the medical, physical and psychosocial needs of reach resident in accordance with physician orders and the plan of care. A summary of principal accountabilities included administering all medications and treatments in accordance with the physician order for each resident, monitoring and evaluating each resident's response to current medications and treatments, notifying the provider as indicated with any new or concerning observations/findings, and communicating changes in condition to the DON, the resident's provider and resident's representative as indicated.The American Diabetes Association's Standards of Care in Diabetes - 2026, dated 01/2026, 6.
Glycemic Goals, Hypoglycemia and Hyperglycemic Crises, documented level 1 hypoglycemia was defined as glucose less than 70 mg/ dl and greater than or equal to 54 mg/ dl.
Level 2 hypoglycemia was defined as glucose less than 54 mg/ dl.
Level 3 hypoglycemia was a severe event characterized by altered mental and/or physical status requiring assistance for treatment of hypoglycemia, irrespective of glucose level.
Hypoglycemia had a broad range of negative health consequences and level 3 hypoglycemia could progress to loss of consciousness, seizure, coma, or death.
Recurrent level 2 and/or level 3 hypoglycemia was an urgent medical issue and required intervention with treatment plan adjustment, behavioral intervention, delivery of diabetes self-management education and use of technology to assist with hypoglycemia prevention and identification.The facility policy titled Blood Glucose Monitoring, dated 04/11/2025, documented the facility would perform blood glucose monitoring per physician's orders.
The procedure included but was not limited to the following steps: verifying the physician's order, collecting the blood sample from the fingertip, reading the digital display to receive the blood glucose result, reporting critical test results to the physician timely, and documenting the procedure.The facility policy titled Abuse, Neglect, and Exploitation, dated 04/11/2025, documented neglect was the failure of the facility, its employees, or service providers to provide goods and services to a resident which were necessary to avoid physical harm, mental anguish, or emotional distress.Cross reference tag F610FRI 2723311
295067 03/26/2026
Ormsby Post Acute Rehabilitation 3050 N Ormsby Road Carson City, NV 89703
conducted a thorough investigation of an incident suspicious for neglect of 1 of __ sampled residents
to residents due to allegations of neglect not being thoroughly investigated and documented to ensure appropriate protections were put in place to prevent future neglect.
Findings include:Resident #8Resident #8 was admitted to the facility on [DATE], with diagnoses including type one diabetes mellitus with other circulatory complications and type one diabetes mellitus with diabetic autonomic (poly) neuropathy.A final Facility Reported Incident (FRI) report submitted by the facility on [DATE], documented the report was related to an incident on [DATE] involving Resident #8.
The incident type was neglect and the allegation against the alleged perpetrator was verified. A Certified Nursing Assistant (CNA) found Resident #8 unresponsive and clammy at approximately 1:00 AM on [DATE]. A Registered Nurse (RN) assessed the resident, checked the resident's blood glucose with a result of 31, and administered oral glucose gel outside of order guidelines.
The RN did not administer the prescribed medication (Glucagon) per physician order. A finger stick blood glucose level was checked again and remained 31.
Emergency Medical Services (EMS) arrived, administered 10% Dextrose to Resident #8, the resident briefly regained consciousness, then became unresponsive and Cardiopulmonary Resuscitation (CPR) was initiated by EMS. CPR was unsuccessful and Resident #8 expired.On [DATE] at 3:00 PM, the Administrator/Abuse Coordinator denied the Administrator/Abuse Coordinator had documentation of the facility's investigation of the incident on [DATE], involving Resident #8.
The Administrator/Abuse Coordinator explained the facility's former Director of Nursing (DON) had the documentation and the Administrator/Abuse Coordinator was unable to locate the information in the former DON's office.
Additionally, the Administrator/Abuse Coordinator verbalized being unable to access many electronic files following the facility's change of ownership in February 2026.The facility policy titled Abuse, Neglect, and Exploitation, dated [DATE], documented an immediate investigation was warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occurred.
Written procedures for investigation included but were not limited to: identifying staff responsible for the investigation, identifying and interviewing all involved persons (including the alleged victim, alleged perpetrator, witnesses, and others who may have knowledge of the allegations) and providing complete and thorough documentation of the investigation.Cross reference tag F600FRI 2723311