Based on interview, record review, and document review, the governing body of the facility failed to oversee services performed by a contracted vendor, including ensuring the accuracy of documentation of resident behaviors, for 2 of 13 sampled residents (Resident 4 and 6). This deficient practice had the potential to result in inappropriate tiering and state payments for residents in the Medicaid Behaviorally Complex Care Program.Findings include:The investigation included a review of a document titled Behavior Frequency Documentation Data Sheet, consisting of four pages used for tracking resident behaviors:Page 1 contained columns for the date, tracked behaviors, Other, and staff initials, along with a grid for days 1-31 and instructions directing staff to check applicable behaviors… …
F837 citations in Nevada
Administration Deficiencies
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Nevada cites F837 more often than its own record predicts
3.01 times the share F837 takes of citations nationally.
Of every deficiency written in Nevada in 2025, this is the portion that was F837.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Nevada surveyors wrote
F837 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 ensure a Governing Body was actively providing oversight of management for the operation of the facility. Findings include: On 07/05/23 at 2:08 PM, the Director of Nursing could not verbalize individuals on the facility Governing Body nor how often the Governing Body had meetings and could not provide documentation of meetings. The Administrator was currently out of the building. The Facility Assessment last reviewed 05/08/23, listed the name of the Governing Body Representative. The representative was not the Administrator. The facility was unable to provide sign-in sheets for the Governing Body meetings within the past 12 months. …
The short window
Recent years
| Year | Share of Nevada citations | vs expected |
|---|---|---|
| 2023 | 0.19% | 2.51× |
| 2025 | 0.16% | 3.01× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Nevada surveyors cite →
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