Health Inspection - GARDNERVILLE HEALTH & REHAB CENTER

F-Tag F656

Harm Level: Minimal harm or 31739

Residents Affected: Few (CNA) employed greater than one year had a performance review completed annually for 1 of 3 CNAs

F-F656

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 37 295082 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295082 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gardnerville Health & Rehabilitation Center 1573 South Muller Pkwy Gardnerville, NV 89410

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0730 Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or 31739 potential for actual harm Based on personnel record review and interview, the facility failed to ensure a Certified Nursing Assistant Residents Affected - Few (CNA) employed greater than one year had a performance review completed annually for 1 of 3 CNAs reviewed for completed performance review. This deficient practice had the potential to affect all residents when the facility did not identify areas of CNA performance in need of insevice education/training.

Findings include:

Employee #9

Employee #9 was hired on 08/31/2023 as a CNA.

Employee #9's personnel record lacked documentation a performance review had been completed in 2024.

On 04/30/2025 at 11:45 AM, the Director of Nursing verbalized having been responsible for completing CNA performance evaluations and confirmed Employee #9 had not received a performance review upon the employee's one year anniversary.

The facility policy titled, Nursing Personnel Education and Training, published 11/2016, documented employee reviews were to be completed every 12 months and identify areas of improvement and competencies to be completed as needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 37 295082 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295082 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gardnerville Health & Rehabilitation Center 1573 South Muller Pkwy Gardnerville, NV 89410

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49557 potential for actual harm Based on observation, interview, clinical record review, and document review the facility failed to ensure Residents Affected - Few medications were administered with an error rate of less than five percent (%). There were 26 opportunities observed and two errors. The medication error rate was 7.69%.

Findings include:

Resident #38

Resident #38 was admitted to the facility on [DATE REDACTED], with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery, intracardiac thrombosis, not elsewhere classified, and ventricular tachycardia, unspecified.

On 04/30/2025 at 8:14 AM, a Registered Nurse (RN)1 began preparing medications for Resident #38. The RN1 verbalized some of the resident's ordered medications were out of stock in the medication cart and the RN1 would need to go to the medication storage room to see if there was additional stock of the medications available.

On 04/30/2025 at 8:18 AM, while in the medication storage room, the RN1 accessed an automated medication dispensing system, managed by the contracted pharmacy. The RN1 verbalized there were no doses of Pradaxa available, and the RN1 would need to call the pharmacy.

On 04/30/2025 at 8:30 AM, the RN1 administered medications to Resident #38. The medications administered did not include Pradaxa.

A Physician's Order dated Pradaxa oral capsule 150 milligrams (mg), give 150 mg capsule by mouth one time a day for thrombus treatment. The order date was 02/25/2025.

Resident #38's Medication Administration Record (MAR) documented the 04/30/2025 dose of Pradaxa 150 mg was not administered and indicated the medication was OO. The MAR key documented OO equated to

On Order from Pharmacy.

Resident #15

Resident #15 was admitted to the facility on [DATE REDACTED], with diagnoses including obstructive and reflux uropathy, unspecified and encounter for surgical aftercare following surgery on the genitourinary system.

On 05/01/2025 at 7:40 AM, an RN2 began preparing medications for Resident #15. The RN2 verbalized the resident's physician ordered Finasteride was not in the medication cart, the RN would reorder the medication

in the electronic medical record, and would have to call the pharmacy.

On 05/01/2025 at 7:44 AM, the RN2 administered medications to Resident #15. The medications administered did not include Finasteride.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 37 295082 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295082 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gardnerville Health & Rehabilitation Center 1573 South Muller Pkwy Gardnerville, NV 89410

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Resident #15's MAR documented Finasteride oral tablet 5 mg, give 5 mg by mouth one time a day for benign enlargement of prostate. Wear gloves when handling. The order start date was 02/27/2025. The MAR Level of Harm - Minimal harm or documented the 05/01/2025 dose of Finasteride 5 mg was not administered and indicated the medication potential for actual harm was OO. The MAR key documented OO equated to On Order from Pharmacy.

Residents Affected - Few On 05/01/2025 at 11:17 AM, the Regional Director of Clinical Operations (RDCO) verbalized facility did not have a policy related to medication administration errors.

On 05/01/2025 at 2:25 PM, the Director of Nursing (DON) explained the DON's expectation of nursing staff when administering medications to residents was the follow the rights of medication administration. Rights of medication administration included the right resident, right dose, right medication, and the right route. Additionally, nurses were expected to check each medication prior to administration, assure the right medication had been delivered from the pharmacy, assess pain or vital signs as necessary, and use alcohol-based hand sanitizer when entering and exiting a resident's room. Medication administration errors included administering the wrong medication, missing a medication for an unexplained reason, and not administering the medication at the scheduled time.

The DON explained if a medication was not onsite to administer to a resident, the nurse was to check the automated medication dispensing system and call the pharmacy. If a medication was on order from the pharmacy, the nurse should notify the physician. The physician could give an order to administer the medication when it arrived from the pharmacy if the medication was going to be delivered the same day.

The DON verbalized the DON would have to look up if failing to administer a physician ordered medication and the absence of documentation of contact with the pharmacy and notification of the physician would be considered a medication error.

On 05/01/2025 at 2:25 PM, the DON verbalized the DON would review Resident #38 and #15's clinical records related to the medications marked OO during the 04/30/2025 and 05/01/2025 AM medication pass.

On 05/01/2025 at 5:05 PM, the DON verbalized the DON was not able to provide documentation of notification of the physician, orders for alternate medications, or orders allowing staff to administer the medications late for Resident #38 and #15. The DON verbalized the DON had explained to the nurse there needed to be documentation of contact with both the physician and the pharmacy when a medication was not available to administer at the scheduled time.

The facility policy titled Medication Administration General Guidelines, reviewed 01/2025, documented medications were to be administered as prescribed and in accordance with manufacturer's specifications, good nursing principles and practices. Prior to administration, staff were to review and confirm medication orders for each individual resident on the Medication Administration Record (MAR). Medications were to be administered within 60 minutes of scheduled time, except before or after meal orders, which were to be administered based on mealtimes. If a dose of regularly scheduled medication was withheld, refused, or given at other than the scheduled time, the nurse shall document the dose was withheld, refused, or given at other than scheduled time, and enter an explanatory note.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 37 295082 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295082 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gardnerville Health & Rehabilitation Center 1573 South Muller Pkwy Gardnerville, NV 89410

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 The Davis's Drug Guide for Nurses, 12th edition, documented incorrect drug administration covered many problems. Misidentification of a patient, incorrect route of administration, missed doses, or improper drug Level of Harm - Minimal harm or preparation were types of errors which could occur during the administration phase. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 37 295082 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295082 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gardnerville Health & Rehabilitation Center 1573 South Muller Pkwy Gardnerville, NV 89410

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 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 Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49557 Residents Affected - Few Based on observation, interview, and document review the facility failed to ensure a multi-dose vial was labeled with the date the vial was opened in 1 of 1 medication storage rooms inspected. This deficient practice placed residents at risk for injection with expired Tuberculin Purified Protein Derivative (PPD) solution and potentially inaccurate Tuberculin PPD skin test results.

Findings include:

On [DATE REDACTED] at 3:39 PM, during an inspection of the medication storage room and in the presence of the Infection Preventionist (IP), a vial of Tuberculin PPD (Mantoux) 5 Tuberculin Units (TU)/ 0.1 milliliters (ml) was found in the medication storage refrigerator. The vial lacked a cap, and a puncture site was observed in

the rubber stopper. The vial and the manufacturer box lacked an open date. The manufacturer box included instructions to discard the vial within 30 days of opening.

The IP confirmed the vial of Tuberculin PPD solution was open and lacked an open date written on the vial and the box. The IP verbalized the vial would need to be destroyed due to the lack of an open date.

The facility policy titled Medication Administration Injectable Vials and Ampules, reviewed ,d+[DATE REDACTED], documented the date opened and initials of the first person to use the vial were to be recorded on multi-dose vials.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 37 295082 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295082 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gardnerville Health & Rehabilitation Center 1573 South Muller Pkwy Gardnerville, NV 89410

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 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. Level of Harm - Minimal harm or potential for actual harm 30748

Residents Affected - Few Based on interview and document review, the facility failed to ensure the Facility Assessment (FA) was reviewed, updated, included input from and was approved by facility leadership and management Quality Assessment and Assurance (QAA) Committee. The deficient practice could result in the facility not being able to determine what resources were necessary to care for its residents competently.

Findings include:

On 04/30/2025, a review of the FA presented by the Interim Executive Director (IED), dated 03/25/2025, lacked documented evidence of an attendance sheet indicating a review of the FA contents by facility QAA Committee. The previous FA was requested from the IED. However, the FA documented individuals involved

in completing the FA, to include the following:

-Administrator

-Director of Nursing (DON)

-Governing Body Representative

-Medical Director

-Direct Care Representative

-Resident Representative.

On 04/30/2025 at 8:40 AM, the IED presented the previous FA, dated 08/29/2024. The IED verbalized the previous FA was placed in the shred pile and had to be located by staff.

The FA dated 08/29/2024, documented an attendance sheet for review of the FA. The attendance sheet documented the following attendees:

-Admissions

-The Center Finance Manager

-The Housekeeping Manager

-The Director of Rehabilitation/Physical Therapist

-Minimum Data Set

-Activity Director

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 37 295082 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295082 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gardnerville Health & Rehabilitation Center 1573 South Muller Pkwy Gardnerville, NV 89410

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 -Director of Nursing Services

Level of Harm - Minimal harm or -Maintenance potential for actual harm -Resident Council President Residents Affected - Few -Medical Director

On 04/30/2025 at 9:39 AM, the IED explained the facility followed the FA dated 03/25/2025, and the FA dated 08/29/2024, was null and void. The IED verbalized there was not an attendance sheet documenting

review of the FA dated 03/25/2025, and confirmed the required members of facility leadership and management were not a part of the revision and implementation of the 03/25/2025 FA.

The IED confirmed there was no review from the QAA Committee related to the 03/25/2025 FA and the IED was the only one who created the 03/25/2025 FA and implemented the FA. The IED admitted the FA completed on 03/25/2025 was not a valid FA based on the federal regulations and requirements.

The facility did not have a policy and procedure related to reviewing, updating, or implementing the FA and

the required members who were to attend.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 37 295082 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295082 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gardnerville Health & Rehabilitation Center 1573 South Muller Pkwy Gardnerville, NV 89410

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49557

Residents Affected - Few Based on observation, interview, clinical record review, and document review the facility failed to ensure 1) As Needed (PRN) medications were documented timely for 1 of 6 residents observed for medication administration (Resident #7) and 2) a wound care order was entered into the Electronic Medical Record (EMR) for 1 of 13 sampled residents (Resident #12). This deficient practice had the potential for duplicate administration of PRN medications, accurate Medication Administration Records (MARs) to not be available for review during a change in condition or required transfer to the hospital, and for staff providing care to a resident to not be aware of physician ordered care.

Findings include:

Resident #7

Resident #7 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including emphysema, unspecified and cervicalgia.

On 05/01/2025 at 8:14 AM, during the AM medication administration pass, a Registered Nurse (RN) began preparing medication for Resident #7. The RN verbalized the resident complained of back pain and rated the pain a five out of ten.

On 05/01/2025 at 8:18 AM, the RN administered two tablets of Acetaminophen 325 milligrams (mg) to Resident #7.

A Physician's Order dated 12/18/2024, documented Acetaminophen oral tablet, give 650 mg by mouth every six hours as needed for pain. Not To Exceed (NTE) three grams per day.

On 05/01/2025 at 10:40 AM, Resident #7's MAR lacked documentation of the administration of Acetaminophen. The RN confirmed the RN administered two tablets of Acetaminophen 325 mg to Resident #7 during the AM medication pass. The RN reviewed the resident's MAR and confirmed the MAR lacked documentation of the PRN administration. The RN explained it was important to document the administration of PRN medications at the time of administration because residents could only receive a certain number of doses and there were a specified number of hours required between each dose.

On 05/01/2025 at 2:25 PM, the Director of Nursing (DON) verbalized when medications were administered to

a resident, it was the DON's expectation the administration be documented in the resident's MAR within 15 minutes of the resident taking the medication. The DON explained timely documentation of medication administration was important for accuracy and resident safety. If a resident had to be sent to the hospital it was necessary to have an accurate MAR to send with the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 37 295082 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295082 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gardnerville Health & Rehabilitation Center 1573 South Muller Pkwy Gardnerville, NV 89410

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 The facility policy titled Medication Administration General Guidelines, reviewed 01/2025, documented the individual who administered the medication dose was to record the administration on the resident's MAR Level of Harm - Minimal harm or immediately following the medicating being given. If a PRN medication was administered, the following potential for actual harm documentation was to be provided: date and time of administration, dose, complaints or symptoms for which

the medication was given, results achieved from giving the dose and the time the results were noted, and the Residents Affected - Few signature or initials of the person recording the administration/results.

Resident #12

Resident #12 was admitted to the facility on [DATE REDACTED], with diagnoses including primary generalized osteoarthritis and type two diabetes mellitus with other circulatory complications.

On 04/28/2025 at 7:54 AM, Resident #12 was lying in bed. The resident's head was wrapped with a gauze bandage.

On 04/28/2025 at 11:15 AM, the Director of Nursing identified the facility's Infection Preventionist (IP) by name.

A Staff List provided by the facility identified the IP as a Resident Care Manager (RCM)/Registered Nurse.

On 04/28/2025 at 2:29 PM, the IP and a Licensed Practical Nurse (LPN) were in Resident #12's room.

A Nursing Progress Note dated 04/28/2025 at 1:01 AM, documented Resident #12 returned from the emergency room with a negative Computed Tomography (CT) scan. The resident had a dressing on the resident's head for a cranial abrasion. Staff would keep the dressing on until morning. Staff would keep the wound clean and dry until healed.

A Nursing Progress Note dated 04/28/2025 at 5:28 PM, documented an LPN and the RCM went into Resident #12's room and evaluated the resident's head injury, an abrasion on the top of the resident's head.

The LPN cleansed the resident's hair with soap and water, cleansed the abrasion with wound cleanser and patted dry. The RCM applied Xeroform (a sterile, non-adherent wound dressing impregnated with petrolatum blend) and wrapped the resident's head.

Resident #12's clinical record lacked an order for wound care related to the abrasion on Resident #12's head.

On 05/01/2025 at 5:00 PM, the IP explained the IP performed weekly evaluations on all wounds in the facility and floor nurses performed dressing changes in between the evaluations. If any new skin impairments were identified, the floor nurse would notify the IP, and the IP would complete an evaluation. The IP confirmed staff were required to obtain an order from the physician prior to performing wound care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 37 295082 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295082 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gardnerville Health & Rehabilitation Center 1573 South Muller Pkwy Gardnerville, NV 89410

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 The IP confirmed the IP was familiar with Resident #12. The IP verbalized the resident had an abrasion on

the resident's head resulting from a fall. The IP verbalized the IP had cleansed the abrasion and during an Level of Harm - Minimal harm or observation the following day, the abrasion was gone. The IP reviewed the Nursing Progress Note dated potential for actual harm 04/28/2025 at 5:28 PM, and confirmed the IP had applied Xeroform to the resident's head. The IP explained

the IP had spoken to and received approval from the physician prior to performing the wound care however Residents Affected - Few the IP had forgotten to document the order in the resident's record.

The facility policy titled Skin Integrity, updated 01/2025, documented for skin impairment identified with admission (included but was not limited to abrasions, bruises, burns) the licensed nurse was to notify the physician, obtain a treatment order (if needed), and document on the Treatment Administration Record (TAR) after the order was implemented. If skin impairment was identified after admission, the licensed nurse was to complete all steps required for impairments identified upon admission in addition to implementation of new interventions, notifying and documenting the notification to physician and resident/representative, and initiating alert charting.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 37 295082 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295082 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gardnerville Health & Rehabilitation Center 1573 South Muller Pkwy Gardnerville, NV 89410

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm 46301

Residents Affected - Few Based on interview, record review and document review, the facility failed to develop and implement at least one Performance Improvement Project (PIP) per year. This deficient practice had the potential to adversely impact each resident's well-being.

Findings include:

On 05/01/2025 at 5:12 PM, the Interim Executive Director (IED), Director of Nursing (DON) and the Lead Administrator of Nevada (LAN) revealed Quality Assurance Performance Improvement (QAPI) committee meetings were held monthly and usual attendees included the Administrator, the Medical Director, and the DON.

On 05/01/2025 at 5:15 PM, the LAN explained the facility was unable to furnish documentation or describe a PIP completed within the past year due to the facility using an electronic system to document the PIP and

after the former Administrator left, the Quality Assurance (QAA) committee, no longer had access.

The IED was unsure and was not able to confirm if the facility had any current PIPs and was not able to provide documentation for one. The IED stated having been the Administrator at this facility for a short time and was not able to find where the electronic documents were filed or if they were filed. The IED confirmed

the QAPI committee had not been made aware of the facility's failure to follow facility policy, federal, and state law related to reporting of allegations of abuse, neglect, mistreatment, misappropriation of property and exploitation to determine if additional action was necessary.

The Quality Assurance/Process Improvement (QAPI) Plan, dated 03/2024, documented QAPI committee meetings would be held monthly. Performance Improvement Projects (PIPs) were evaluated ongoing for effectiveness by the Quality Assurance (QAA) Committee. The QAA committee oversees the Center QAPI program and were tasked with identifying areas requiring performance improvement, collective data, developing and implementing corrective action and creating monitors to determine and validate changes were effective and sustained.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 37 295082 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295082 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gardnerville Health & Rehabilitation Center 1573 South Muller Pkwy Gardnerville, NV 89410

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49557 potential for actual harm Based on observation, interview, clinical record review, and document review, the facility failed to ensure Residents Affected - Many Transmission-Based Precautions (TBP) were implemented according to facility policy and Centers for Disease Control and Prevention (CDC) recommendations for 1 of 13 sampled residents (Resident #27) and Enhanced-Barrier Precautions (EBP) were implemented for 3 of 5 residents meeting criteria for EBP (Resident #20, #6, and #15). This deficient practice had the potential to increase risk of spreading infectious organisms throughout the facility.

Findings include:

Transmission-Based Precautions

Resident #32

Resident #32 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including chronic respiratory failure with hypoxia and chronic kidney disease, stage four (severe).

On 04/28/2025 at 7:31 AM, a sign was attached to the door frame of Resident #32 and Resident #27's room.

The sign indicated the room had contact precautions in place, requiring a gown and gloves be donned prior to entering the room. A Personal Protective Equipment (PPE) cart was in the hall outside the room. The cart contained gowns, gloves, surgical masks and N95 masks.

On 04/28/2025 at 7:47 AM, a Licensed Practical Nurse (LPN) assigned to care for Resident #32 and Resident #27 verbalized the contact precautions were in place due to Extended-Spectrum Beta-Lactamase (ESBL) in the resident's urine. The LPN confirmed two residents were staying in the room and verbalized both residents were on contact precautions.

The following were included in Resident #32's clinical record:

A Results Report for a urinalysis, complete with reflex to culture. The collection date was 02/12/2025, and

the reported date was 02/17/2025. The report documented a urine culture result of greater than 100,000 CFU/ ml of E. coli. The therapy comments section of the report documented the organism was confirmed as

an ESBL producer.

Orders-Administration Notes dated 02/20/2025 and 02/21/2025, documented Ertapenem Sodium solution reconstituted, one gram IV every 24 hours for UTI for ten days. Awaiting peripherally inserted central catheter line placement.

A Daily Skilled Note dated 02/28/2025, documented Resident #32 had a right arm midline. Resident on regimen of Ertapenem x4 days to be completed 03/01/2025, no adverse reaction noted.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 37 295082 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295082 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gardnerville Health & Rehabilitation Center 1573 South Muller Pkwy Gardnerville, NV 89410

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 04/29/2025 at 3:22 PM, the Infection Preventionist (IP) verbalized an MDRO was a multidrug-resistant organism. Residents were at high risk for contracting an MDRO if an ABX was inappropriately prescribed, Level of Harm - Minimal harm or when a catheter was inserted when not necessary or without using sterile technique, and when there was a potential for actual harm lack of appropriate PPE. TBP included contact, droplet, and airborne precautions. The IP explained the intent of TBP was to protect the resident and keep residents from transmitting organisms to other residents. Residents Affected - Many

On 04/29/2025 at 3:33 PM, during an interview with the Director of Nursing (DON) and the IP, the DON and IP explained residents requiring TBP included residents infected with MDROs. Nursing was allowed to implement TBP, following the facility's policy for infection control and per CDC guidelines. If a resident was

on contact precautions, the resident may be allowed to have a roommate if the roommate had the same organism.

The IP and DON confirmed TBP were in place for Resident #27 on 04/28/2025. The DON confirmed Resident #27 had a roommate, Resident #32, and verbalized the residents had shared a room for a long time.

On 04/30/2025 at 2:27 PM, during an interview with the DON, the IP, and the Regional Director of Clinical Operations (RDCO), the DON explained the indication for placing Resident #27 on TBP was ESBL E. coli in

the resident's urine. The DON confirmed Resident #32 had been infected with the same organism.

The IP verbalized Resident #32 was positive for ESBL E. coli per the results of a urine culture collected on 02/12/2025. Resident #32 was sent to the hospital not long after the collection of the urine specimen, returned to the facility on [DATE REDACTED], and was placed on contact precautions. The DON denied Resident #32 was placed in a private room upon return to the facility and explained the resident was placed in a shared room with Resident #27.

The DON and IP reviewed Resident #32's urine culture result report dated 02/17/2025. The DON confirmed

the therapy comments section at the bottom of the report documented the organism was confirmed as an ESBL producer. The IP acknowledged the report indicated the organism was resistant to multiple drugs. The IP confirmed Resident #32 should have been placed in a private room upon return to the facility on [DATE REDACTED].

Resident #27

Resident #27 was admitted to the facility on [DATE REDACTED], with diagnoses including spastic hemiplegia affecting right dominant side, bipolar II disorder, major depressive disorder, recurrent, unspecified, anxiety disorder, unspecified, and post-traumatic stress disorder, chronic.

On 04/28/2025 at 2:53 PM, Resident #27 verbalized the resident was on isolation precautions related to a UTI. The resident was taking ABX to treat the UTI and complained of nausea and vomiting since starting the ABX. Resident #27 became tearful during interview and verbalized the resident had been in isolation for approximately one month. The resident explained the resident had really bad anxiety and the isolation made

the anxiety worse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 37 295082 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295082 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gardnerville Health & Rehabilitation Center 1573 South Muller Pkwy Gardnerville, NV 89410

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 04/28/2025 at approximately 3:30 PM, a Certified Nursing Assistant (CNA) was preparing to enter Resident #27's room. The CNA affirmed the CNA was assigned to provide care to both Resident #27 and Level of Harm - Minimal harm or Resident #32 during the shift. potential for actual harm

The following were included in Resident #27's clinical record: Residents Affected - Many

A Progress Note dated 03/19/2025 documented Resident #27 complained of dysuria and frequency. Nurse spoke to the physician and obtained an order for a urinalysis (UA).

A Lab Results Report, with a collection date of 03/19/2025 and a reported date of 03/24/2025, documented a urine culture result of greater than 100,000 Colony Forming Units (CFU)/ milliliter (ml) of ESBL producing Escherichia coli (E. coli). The organism showed resistance to the following: Ampicillin, Ampicillin/Sulbactam, Cefazolin, Cefepime, Ceftazidime, Ceftriaxone, Cefuroxime, Ciprofloxacin, Gentamicin, Levofloxacin, Nitrofurantoin, Tobramycin, and Trimethoprim/Sulfamethoxazole.

An Orders-Administration Note dated 03/24/2025, documented Ceftolozane-Tazobactam IV solution reconstituted 1.5 (1-0.5) grams (GM). Use 1.5 GM IV every eight hours for E. coli/ ESBL UTI.

A Nursing Progress Note dated 03/25/2025, documented new order obtained for Meropenem 500 milligrams (mg) IV every eight hours for UTI. New order for Normal Saline (NS) one liter for rehydration. 22 gauge to left wrist started, no complaints of pain, no signs or symptoms of infiltration. NS infusing, will continue to monitor.

An Orders-Administration Note dated 04/04/2025, documented resident to be in isolation due to ESBL in urine. Meals to be given on disposable trays. All care provided by staff to be done in room. Resident to be in private room with no roommate. Every day and night shift for isolation precautions.

A Physician's Order dated 04/14/2025, documented Linezolid oral tablet 600 mg, give one tablet by mouth two times a day for UTI for 14 days.

A Physician's Order dated 04/17/2025, documented contact precautions for enterococcus faecalis in urine. Every day and night shift until 05/01/2025. End contact isolation 72 hours after ABX regimen is complete.

A Daily Census Report dated 02/24/2025, documented there were 18 empty beds in the facility.

The facility's Monthly Line Listing of infections for February 2025, documented Resident #32 had a UTI. The date of infection was listed as 02/13/2025. The pathogen/organism was E. coli ESBL, the infection was healthcare associated, and contact precautions were initiated. Resident #32's clinical record documented on 02/13/2025, the resident was sharing a room with Resident #27.

The facility's Monthly Line Listing of infections for March 2025, documented Resident #27 had a UTI. The date of infection was listed as 03/25/2025. The pathogen/organism was E. coli, the infection was healthcare associated, and contact precautions were initiated.

The facility's CNA and nurse schedule for March 2025 documented one nurse worked in the facility during

the night shift on 03/01/2025 through 03/05/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 37 295082 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295082 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gardnerville Health & Rehabilitation Center 1573 South Muller Pkwy Gardnerville, NV 89410

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 04/29/2025 at 4:32 PM, the DON explained an adequate number of staff to care for residents in the facility varied by acuity. At a minimum, the facility would staff one nurse and three CNAs at night. The DON Level of Harm - Minimal harm or confirmed the facility had shifts when only one nurse was in the facility to provide nursing care to all potential for actual harm residents.

Residents Affected - Many On 04/30/2025 at 2:27 PM, the IP explained 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 facility's Monthly Line Listing of infections for March 2025, documented Resident #27 had a UTI. The date of infection was listed as 03/25/2025. The pathogen/organism was E. coli, the infection was healthcare associated, and contact precautions were initiated.

The facility policy titled Transmission Based Precautions, published 01/2025, documented it was the policy of

the facility to implement Transmission-Based Precautions (TBP) for residents known to be, or suspected of being, infected with infectious agents. The four types of TBP included contact, droplet, airborne, and enhanced barrier precautions. The need to implement TBP was determined by the IP, DON, and/or consultation with the local health department. Precautions were based on CDC guidelines. Contact, or touch, was the most common and most significant mode of transmission of infectious agents. Contact transmission could occur by directly touching the resident, through contact with the resident's environment, or by using contaminated gloves or equipment. Options for residents on contact precautions could include a private room, cohorting with another infected or colonized resident or sharing a room with a resident with limited risk factors.

The CDC document titled 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, updated 09/2024, documented MDROs were generally defined as microorganisms which were resistant to one or more classes of antimicrobial agents. MDROs of concern included those producing ESBL. Documented outbreaks in long-term care facilities were caused by various viruses and bacteria and could lead to substantial morbidity and mortality and increased medical costs. Prompt detection and implementation of effective control measures were required. Placement of a resident in

a single room was preferred when there was concern about transmission of an infectious agent, including residents on contact and droplet precautions. Recommendations for residents infected or colonized with an MDRO judged as clinically important by the infection control program included contact in addition to standard precautions.

Enhanced Barrier Precautions

Resident #6

Resident #6 was admitted to the facility on [DATE REDACTED], with diagnoses including other low back pain and fusion of spine, cervical region.

A Weekly Skin Evaluation dated 04/23/2025, documented an unstageable pressure injury on Resident #6's coccyx. The wound measured 10 centimeters in length and 9 centimeters in width. The documented dressing order was: cleanse with wound cleanser, pat dry, apply hydrogel sheet, apply padded foam bordered dressing, apply barrier cream surrounding bordered dressing. Wound care was to be provided daily and as needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 37 295082 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295082 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gardnerville Health & Rehabilitation Center 1573 South Muller Pkwy Gardnerville, NV 89410

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Resident #15

Level of Harm - Minimal harm or Resident #15 was admitted to the facility on [DATE REDACTED], with diagnoses including encounter for surgical potential for actual harm aftercare following surgery on the genitourinary system and encounter for fitting and adjustment of urinary device. Residents Affected - Many

A Physician's Order dated 04/13/2025, documented Foley catheter size 22 French (FR), balloon 30 cubic centimeters (cc). Change as needed for damage, occlusion, or obtaining urinalysis (UA).

Resident #20

Resident #20 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including encounter for surgical aftercare following surgery on the genitourinary system and encounter for fitting and adjustment of urinary device.

A Physician's Order dated 04/09/2025, documented Foley catheter size 16 FR, balloon ten cc. Change as needed for damage, occlusion, or obtaining a UA.

On 04/28/2025 at 7:29 AM, during a tour of the facility, no EBP signage and PPE cart was located outside

the rooms of Resident #6, #15, and #20.

On 04/29/2025 at 11:33 AM, during a tour of the facility, no EBP signage and PPE cart was located outside

the rooms of Resident #6, #15, and #20.

On 04/29/2025 at 3:33 PM, during an interview with the DON and the IP, the DON verbalized the intent of EBP was to protect residents from contracting organisms in the facility. The DON explained EBP was to be used for residents with open wounds, feeding tubes, and Foley catheters. The DON and IP confirmed Resident #20 and Resident #15 had indwelling Foley catheters in place and Resident #6 had an open wound. The DON and IP confirmed Residents #20, #15, and #6 did not have EBP in place.

The facility policy titled Transmission Based Precautions, published 01/2025, documented when a resident was colonized with an MDRO or the status of colonization was unknown, EBP was utilized per CDC guidance to reduce the spread of an MDRO. Residents requiring EBP regardless of confirmed MDRO status included residents with tracheostomies, wound, enteral tubes, central IV catheters, and urinary catheters. Staff caring for a resident on EBP were to wear a gown and gloves during the following: dressing, bathing, transferring, providing hygiene, changing linens or briefs, device care, and wound care.

Cross reference tag

F-Tag F690

Harm Level: TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49557

Residents Affected: Few sampled for vaccinations (Resident #12) was offered timely pneumococcal vaccination to complete the

F-F690.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 37 295082 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295082 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gardnerville Health & Rehabilitation Center 1573 South Muller Pkwy Gardnerville, NV 89410

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49557 potential for actual harm Based on clinical record review, interview, and document review the facility failed to ensure 1 of 5 residents Residents Affected - Few sampled for vaccinations (Resident #12) was offered timely pneumococcal vaccination to complete the recommended pneumococcal vaccine schedule. This deficient practice had the potential to result in residents contracting a preventable illness.

Findings include:

Resident #12

Resident #12 was admitted to the facility on [DATE REDACTED], with diagnoses including type two diabetes mellitus with other circulatory complications and chronic diastolic (congestive) heart failure.

Resident #12's Immunization Audit Report documented the resident had received the 23-valent pneumococcal polysaccharide (PPSV23) vaccine on 06/17/2021, 12/03/2018, and 10/15/2013. The Immunization Audit Report and Resident #12's clinical record lacked documentation the resident previously received any other pneumococcal vaccines. The following vaccines were documented as pending immunization: PCV13, PPSV23, PCV15, and PCV20.

A Resident Multi-Vaccine Consent Form dated 04/13/2025, documented Resident #12 was eligible for the pneumococcal vaccine. The form lacked a signature from the resident/resident representative consenting to or declining the vaccine.

On 04/29/2025 at 3:55 PM, the Infection Preventionist (IP) explained the facility determined a resident's eligibility for the pneumococcal vaccine based on the resident consenting to the vaccine, if the resident had received the vaccine in the past, and per Centers for Disease Control and Prevention (CDC) recommendations. The IP verbalized the IP had been working to screen all residents in the facility for vaccination history and eligibility to receive various vaccines.

On 05/01/2025 at 4:29 PM, the IP verbalized if a resident was eligible for a vaccine, the IP would document pending immunization in the resident's record. The IP verbalized pending immunization indicated the resident gave consent and was due/eligible for the vaccine/s. The IP confirmed Pneumococcal Conjugate Vaccine (PCV) vaccines PCV20, PCV21, and PCV15 had not been administered to Resident #12.

The CDC document titled Pneumococcal Vaccine Timing for Adults, dated 10/2024, documented for adults [AGE] years or older who had received a PPSV23 vaccine at any age, the complete pneumococcal vaccine schedule included two options. Option A was to offer the PCV20 or PCV21 one year or more after the last dose of PPSV23. Option B was to offer PCV15 one year or more after the last dose of PPSV23.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 37 295082 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295082 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gardnerville Health & Rehabilitation Center 1573 South Muller Pkwy Gardnerville, NV 89410

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 The facility policy titled Influenza and Pneumococcal Vaccine Administration, updated 02/2025, documented pneumococcal vaccination occurred with residents, upon admission and with repeated vaccination occurring Level of Harm - Minimal harm or per CDC guidelines. Licensed nursing staff were to review and evaluate potential contraindications with potential for actual harm residents via the current version of the CDC Pneumococcal Vaccine Information Sheet. The electronic health

record was maintained with documentation of residents who received the vaccine, as well as those who Residents Affected - Few refused or did not get vaccinated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 37 295082 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295082 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gardnerville Health & Rehabilitation Center 1573 South Muller Pkwy Gardnerville, NV 89410

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 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. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49557

Residents Affected - Few Based on clinical record review, interview, and document review the facility failed to ensure 1 of 5 residents sampled for vaccinations (Resident #4) received or declined an updated/booster dose of COVID-19 (Covid) vaccine after being screened for eligibility. This deficient practice placed residents wishing to receive the Covid vaccine at risk of not receiving the vaccine and experiencing severe or prolonged illness, hospitalization , or death as a result of infection with the Covid virus.

Findings include:

Resident #4

Resident #4 was admitted to the facility on [DATE REDACTED], with diagnoses including type two diabetes mellitus without complications and hypertension.

Resident #4's Immunization Audit Report lacked documented evidence the resident had received any doses of the covid vaccine. The form documented a status of pending immunization for covid vaccine, entered by

the Infection Preventionist (IP) on 04/13/2025.

A Resident Multi-Vaccine Consent Form dated 04/13/2025, documented Resident #4 was eligible for the covid vaccine. The form lacked a signature from the resident/resident representative consenting to or declining the vaccine.

Resident #4's clinical record lacked documented evidence the covid vaccine was administered or declined.

On 04/29/2025 at 3:55 PM, the IP explained the facility determined a resident's eligibility for the covid vaccine based on the resident consenting to the vaccine, if the resident had received the vaccine in the past, and per Centers for Disease Control and Prevention (CDC) recommendations. The IP verbalized the IP had been working to screen all residents in the facility for vaccination history and eligibility to receive various vaccines.

On 04/30/2025 at 3:33 PM, the IP confirmed Resident #4's clinical record lacked documentation of previous vaccination with the covid vaccine and the resident should have received or declined the vaccine.

On 05/01/2025 at 4:29 PM, the IP verbalized if a resident was eligible for a vaccine, the IP would document pending immunization in the resident's record. The IP verbalized pending immunization indicated the resident gave consent and was due/eligible for the vaccine/s. The IP confirmed the covid vaccine had not been adminsitered to Resident #4.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 37 295082 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295082 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gardnerville Health & Rehabilitation Center 1573 South Muller Pkwy Gardnerville, NV 89410

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 A CDC document titled Stay Up to Date with COVID-19 Vaccines, updated 01/07/2025, documented everyone ages six months and older should get a 2024-2025 COVID-19 vaccine. Getting the 2024-2025 Level of Harm - Minimal harm or COVID-19 vaccine was especially important if you lived in a long-term care facility. People ages 65 and older potential for actual harm were considered up to date with covid vaccines when two doses of any 2024-2025 COVID-19 vaccine had been administered. It was recommended to administer the doses six months apart, with a minimum interval Residents Affected - Few of two months in between doses.

The facility policy titled SARS-CoV-2 (COVID-19) SNF, published 01/2025, documented the facility followed current CDC guidelines and recommendations to minimize exposure to respiratory pathogens including the virus causing COVID-19. Residents were to be offered recommended COVID-19 vaccinations upon admission and as eligible per CDC recommendations. A fact sheet including the risks and benefits of the vaccine was to be provided prior to offering the vaccine. Vaccine declination was to be documented in the resident's record and a log was to be maintained for those who accepted or declined vaccination.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 37 295082

F-Tag F695

Harm Level: TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46301

Residents Affected: Few who relied on staff for Activities of Daily Living (ADLs) received scheduled showers or baths as required for 1

F-F695

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 37 295082 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295082 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gardnerville Health & Rehabilitation Center 1573 South Muller Pkwy Gardnerville, NV 89410

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46301 potential for actual harm Based on observation, interview, record review and document review, the facility failed to ensure a resident Residents Affected - Few who relied on staff for Activities of Daily Living (ADLs) received scheduled showers or baths as required for 1 of 13 sampled residents (Resident #19). The deficient practice had the potential to increase skin breakdown, infections, odor, and bacteria buildup.

Findings include:

Resident #19

Resident #19 was admitted on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including intervertebral disc degeneration, lumbar region with discogenic back pain, muscle weakness, and atrial fibrillation.

On 04/28/2025 at 12:54 PM, Resident #19 verbalized not receiving showers regularly as scheduled and gave their own bed bath. The resident explained feeling itchy and bad about themselves when not receiving regular scheduled showers.

The Minimum Data Set (MDS) 3.0 in section GG dated 02/13/2025, indicated substantial/maximal assistance with showering and bathing self.

Resident #19's Care Plan initiated on 04/17/2025, indicated resident required substantial/max assist by one staff for ADL care related to bathing/showering.

Resident #19's medical record for February, March and April 2025 lacked documented evidence the resident received either a shower, bath or bed bath twice a week as scheduled on the following dates:

-02/13/2025

-02/17/2025

-02/27/2025

-03/13/2025

-03/17/2025

-03/20/2025

-03/24/2025

-03/27/2025

-03/31/2025

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 37 295082 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295082 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gardnerville Health & Rehabilitation Center 1573 South Muller Pkwy Gardnerville, NV 89410

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 -04/03/2025

Level of Harm - Minimal harm or -04/07/2025 potential for actual harm -04/14/2025 Residents Affected - Few -04/18/2025

-04/21/2025

-04/28/2025

Resident #19's medical record lacked documented evidence the resident refused a shower or bath during

the above-mentioned dates, and shower or bath were not provided on other days to compensate for the missed shower or bath as scheduled.

On 04/30/2025 at 10:47 AM, a nurse apprentice explained showers were provided to residents twice a week depending on the shower schedule for each resident. Skin Observation and Shower sheets were utilized to document if a shower or bath was provided to the resident. If the shower or bath was denied by the resident,

the staff would document the refusal on the Skin Observation and Shower sheet and turned into the Infection Preventionist. Another means of documenting the shower or bath was in the electronic health record (EHR).

On 04/30/2025 at 11:00 AM, an observation of the shower schedule was posted at the nursing station, indicated showers were designated twice a week for Resident #19 (room [ROOM NUMBER]), which were Mondays and Fridays.

On 05/01/2025 at 2:41 PM, the Director of Nursing (DON) explained the Certified Nursing Assistant (CNA) was to report to the on-shift nurse if the resident refused showers. The CNA was to document the shower on

the Skin Observation and Shower sheet and in the EHR.

Resident #19's documented showers from February to April were reviewed with the DON. The DON confirmed there was no documented evidence the resident was offered a shower or bath on 02/13/2025, 02/17/2025, 02/27/2025, 03/13/2025, 03/17/2025, 03/20/2025, 03/24/2025, 03/27/2025, 03/31/2025, 04/03/2025, 04/07/2025, 04/14/2025, 04/18/2025, 04/21/2025, and 04/28/2025. The DON confirmed the findings and indicated there was no documentation Resident #19 had refused or was unavailable during the shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 37 295082 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295082 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gardnerville Health & Rehabilitation Center 1573 South Muller Pkwy Gardnerville, NV 89410

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49557 Residents Affected - Few Based on observation, interview, clinical record review, and document review the facility failed to ensure 1 of 13 sampled residents (Resident #27) received appropriate care to prevent a urinary tract infection (UTI) when facility policy and Centers for Disease Control and Prevention (CDC) recommendations related to Transmission-Based Precautions (TBP) were not followed and the resident remained in a shared room with another resident known to have an active infection with a Multidrug-Resistant Organism (MDRO). This deficient practice resulted in potentially avoidable isolation of the resident, UTI with an MDRO, and treatment with Intravenous (IV) antibiotics (ABX).

Findings include:

Resident #32

Resident #32 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including chronic respiratory failure with hypoxia and chronic kidney disease, stage four (severe).

On 04/28/2025 at 7:31 AM, a sign was attached to the door frame of Resident #32 and Resident #27's room.

The sign indicated the room had contact precautions in place, requiring a gown and gloves be donned prior to entering the room. A Personal Protective Equipment (PPE) cart was in the hall outside the room. The cart contained gowns, gloves, surgical masks and N95 masks.

On 04/28/2025 at 7:47 AM, a Licensed Practical Nurse (LPN) assigned to care for Resident #32 and Resident #27 verbalized the contact precautions were in place due to Extended-Spectrum Beta-Lactamase (ESBL) in the resident's urine. The LPN confirmed two residents were staying in the room and verbalized both residents were on contact precautions.

The following were included in Resident #32's clinical record:

A Results Report for a urinalysis, complete with reflex to culture. The collection date was 02/12/2025, and

the reported date was 02/17/2025. The report documented a urine culture result of greater than 100,000 CFU/ ml of E. coli. The therapy comments section of the report documented the organism was confirmed as

an ESBL producer.

Orders-Administration Notes dated 02/20/2025 and 02/21/2025, documented Ertapenem Sodium solution reconstituted, one gram IV every 24 hours for UTI for ten days. Awaiting peripherally inserted central catheter line placement.

A Daily Skilled Note dated 02/28/2025, documented Resident #32 had a right arm midline. Resident on regimen of Ertapenem x 4 days to be completed 03/01/2025, no adverse reaction noted.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 37 295082 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295082 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gardnerville Health & Rehabilitation Center 1573 South Muller Pkwy Gardnerville, NV 89410

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 On 04/29/2025 at 3:22 PM, the Infection Preventionist (IP) verbalized an MDRO was a multidrug-resistant organism. Residents were at high risk for contracting an MDRO if an ABX was inappropriately prescribed, Level of Harm - Actual harm when a catheter was inserted when not necessary or without using sterile technique, and when there was a lack of appropriate PPE. TBP included contact, droplet, and airborne precautions. The IP explained the intent Residents Affected - Few of TBP was to protect the resident and keep residents from transmitting organisms to other residents.