Based on observation, interview, record review, and document review, the facility failed to ensure:1) a resident was readmitted to the facility following hospitalization for 1 of 8 sampled residents (R1), and2) written criteria addressing residents hospitalized under a legal hold (L2K) was formulated and implemented. The deficient practice resulted in R1, who required medication management, assistance with activities of daily living, and nursing supervision, being left without housing, care, and access to prescribed medications, placing the resident at risk for serious harm, including deterioration in condition, hospitalization, or death.The deficient practice had the potential to affect other residents in the facility who required similar services if the practice continued.Findings… …
F627 citations in Nevada
Resident Rights Deficiencies
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Nevada cites F627 more often than its own record predicts
2.10 times the share F627 takes of citations nationally.
Of every deficiency written in Nevada in 2025, this is the portion that was F627.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Nevada surveyors wrote
F627 findings written in Nevada, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on interview and document review, the facility failed to permit a resident to return to the facility for one of two sampled residents (Resident 1). The deficient practice had the potential to disrupt the resident's care, safety and recovery leading to a cascade of negative outcomes.Findings Include:Resident 1 (R1) was admitted on [DATE] with diagnoses including convulsions, depression, and mood disorder. R1 had a Public Guardian. A Brief Interview for Mental Status (BIMS) indicated R1 had intact cognitive function.On 08/27/2026 at 1:10 PM, a Certified Nursing Assistant (CNA) verbalized on the day of the incident R1 became angry after a request was denied, blocked the Licensed Practical Nurse (LPN) supervisor from entering the room, and argued with the LPN supervisor. …
What else Nevada surveyors cite →
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