Based on clinical record review, personnel record review, document review, and interview, the facility failed to ensure employees trained to complete sections of the Minimum Data Set (MDS) 3.0 Resident Assessments for 16 of 18 sampled residents (Resident #3, #4, #7, #23, #24, #42, #78, #90, #99, #101, #5, #9, #10, #21, #34, and #84) were qualified for 2 of 2 employees trained to complete sections of the MDS Resident Assessments (Employee #8 and #9). This deficient practice had the potential to affect the accuracy of MDS assessments for the entire resident census by allowing unqualified or insufficiently trained staff to complete critical assessment sections and had the potential to result in inaccurate care planning and delivery, which could negatively impact resident outcomes.Findings… …
F839 citations in Nevada
Administration Deficiencies
Employ staff that are licensed, certified, or registered in accordance with state laws.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Nevada cites F839 more often than its own record predicts
2.91 times the share F839 takes of citations nationally.
Of every deficiency written in Nevada in 2025, this is the portion that was F839.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Nevada surveyors wrote
F839 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 clinical record review, document review and interview, the facility failed to ensure a health provider's clinical documentation was representative of the provider's accurate licensure. Findings include: Review of Provider visits of 74 of 89 resident records starting on 02/07/2024, documented the Provider as a Doctor of Medicine (MD). A search of the Provider in the National Provider Identifier Registry resulted in the Provider having been licensed as an Advanced Practice Registered Nurse (APRN), not an MD. On 05/28/2024 at 9:57 AM, the Provider confirmed the Provider was licensed as an APRN. The Provider verbalized the Provider had not been aware the documentation into resident records was documented as an MD. …
The short window
Recent years
| Year | Share of Nevada citations | vs expected |
|---|---|---|
| 2024 | 0.13% | 2.25× |
| 2025 | 0.16% | 2.91× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Nevada surveyors cite →
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