Gardnerville Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Gardnerville Health & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Feb 1, 2022

  Based on observation, interview, and document review, the facility failed to ensure 1) staff received the training necessary to correctly identify the location of an exit door alarm and ensure all residents were accounted for, 2) 2 of 5 residents identified as at risk for elopement did not elope from the facility (Residents #1 and #2), 3) 1 of 8 sampled residents was provided the services necessary to prevent a fall (Resident #2). Findings include: Exit door alarms On 01/26/22 at 1:50 PM, a Licensed Practical Nurse (LPN) communicated an alarm would sound off when any of the facility's exit doors were opened. Staff responded to the alarm panel located at the facility's nurse's station when an alarm was heard. […]

• Actual harm, isolatedF689Aug 5, 2026

  Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident with a history of falls and deemed a high fall risk per assessments completed by the Physical Therapist (PT) received interventions during activities of daily living (ADL) care to mitigate the resident's risk of fall resulting in the resident sustaining a fall with injury for 1 of 5 residents reviewed for facility reported incidents (FRI) (Resident #2). This deficient practice resulted in the resident sustaining a fracture to resident's left lower extremity with the potential to result in the resident experiencing increased levels of pain and difficulty with ADLs causing the resident to experience a decrease in quality of life. […]

• Actual harm, isolatedF690May 1, 2025

  Based on observation, interview, clinical record review, and document review the facility failed to ensure 1 of 13 sampled residents (Resident #27) received appropriate care to prevent a urinary tract infection (UTI) when facility policy and Centers for Disease Control and Prevention (CDC) recommendations related to Transmission-Based Precautions (TBP) were not followed and the resident remained in a shared room with another resident known to have an active infection with a Multidrug-Resistant Organism (MDRO). This deficient practice resulted in potentially avoidable isolation of the resident, UTI with an MDRO, and treatment with Intravenous (IV) antibiotics (ABX). […]

• No harm, potential for more than minimal, widespreadF883Jun 29, 2026

  Based on clinical record review, interview, and document review, the facility failed to ensure 5 of 5 residents reviewed for immunizations (Resident #15, #5, #59, #46, and #1) were eligible to receive pneumococcal vaccines by failing to assess immunization status, determine if additional vaccine doses were indicated based on current Center for Disease Control and Prevention (CDC) recommendations and identifying contraindications or precautions prior to making a vaccine determination. […]

• No harm, potential for more than minimal, widespreadF880May 1, 2025

  Based on observation, interview, clinical record review, and document review, the facility failed to ensure Transmission-Based Precautions (TBP) were implemented according to facility policy and Centers for Disease Control and Prevention (CDC) recommendations for 1 of 13 sampled residents (Resident #27) and Enhanced-Barrier Precautions (EBP) were implemented for 3 of 5 residents meeting criteria for EBP (Resident #20, #6, and #15). This deficient practice had the potential to increase risk of spreading infectious organisms throughout the facility. […]