Based on record review, interview, and document review, the facility failed to ensure nursing staff followed physician orders for medication hold parameters, reassessed a resident with critically abnormal vital signs, implemented appropriate interventions for hypotension, and notified the attending physician of significant changes in condition for 1 of 50 sampled residents (Resident 206). This deficient practice contributed to a delay in necessary medical intervention for Resident R206, who was later found unresponsive, leading to activation of emergency response measures and subsequent death.Findings included:Resident 206 (R206) was originally admitted on [DATE] with diagnoses including atrial fibrillation, hypotension, supraventricular tachycardia, hypertension, and the presence of a… …
F684 citations in Nevada
Quality of care · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Nevada cites F684 more often than its own record predicts
1.26 times the share F684 takes of citations nationally.
Of every deficiency written in Nevada in 2025, this is the portion that was F684.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Nevada surveyors wrote
F684 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 record review, interviews, and document review, the facility failed to ensure a resident was protected from over sedation for one unsampled resident. The deficient practice led to resident being over sedated, requiring hospitalization . Findings include: Resident 25 (R25) R25 was admitted on [DATE] with diagnoses including chronic pain and body mass index 19.9 or less. A progress note dated 04/19/2024, documented R25 was sent to hospital after possible overdose, exhibiting signs and symptoms of altered mental status and did not respond after two (2) doses of naloxone (Narcan, drug to reverse effects of opioid medication) were given. …
Based on observation, interview, record review, and document review, the facility failed to ensure the medication was administered as ordered for 2 of 10 (Residents 2 and 3). The deficient practice had the potential to result in ineffective treatment, exacerbation of existing medical conditions, recurrence or progression of symptoms, avoidable discomfort or distress and compromised resident safety. Findings include:Based on observation, interview, record review, and document review, the facility failed to ensure the medication was administered as ordered for 2 of 10 (Residents 2 and 3). …
The short window
Recent years
| Year | Share of Nevada citations | vs expected |
|---|---|---|
| 2023 | 5.56% | 1.53× |
| 2024 | 4.73% | 1.18× |
| 2025 | 5.40% | 1.26× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Nevada surveyors cite →
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