Based on interview, record review, and document review, the facility failed to ensure a baseline care plan was developed and implemented including instructions for peripheral intravenous (IV) catheter identified during the initial assessment for 1 of 54 sampled residents (Resident 168). The deficient practice placed the resident at risk of neglect and complications to insertion site.Findings include:Resident 168 (R168) was admitted on [DATE] with diagnoses including surgical aftercare following surgery on the genitourinary system, elevated white blood cell count, and adult failure to thrive.A nursing admission note dated 05/02/2026 documented R168 was admitted to facility with peripheral IV in place to right antecubital (AC), 22 gauge, not currently receiving IV medications.A nursing… …
F655 citations in Nevada
Baseline care plan · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Nevada cites F655 more often than its own record predicts
3.24 times the share F655 takes of citations nationally.
Of every deficiency written in Nevada in 2025, this is the portion that was F655.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Nevada surveyors wrote
F655 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, record review, and document review, the facility failed to ensure the care plan was provided to the resident and/or representative for 11 of 13 sampled residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11). Findings include: The facility policy Baseline Care Plan revised 05/19/2021, documented the facility must provide the resident and/or their representative with copies of the baseline care plan. Resident #1 (R1) R1 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Care Plans for pain management, advanced directives, fall risk, activities of daily living assistance, discharge plans, skin integrity, and use of a Foley catheter were initiated for R1 on 03/09/2021. …
The short window
Recent years
| Year | Share of Nevada citations | vs expected |
|---|---|---|
| 2023 | 2.59% | 3.24× |
| 2024 | 1.79% | 2.60× |
| 2025 | 2.13% | 3.24× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Nevada surveyors cite →
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