Cycle 1
Health 2025-09-04 · Fire 2025-09-04
22 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
14 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Fallon, NV
Highland Manor Of Fallon Rehabilitation LLC
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $124,459 in total fines with 22 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
550 North Sherman Street, Fallon, NV
(775) 423-7800
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
102
Certified beds
Average residents
89
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Charly Bello Family, The Maze Family, The Swain Family, & Walter Myers
Operator or chain grouping
Approved since
2005-05-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
18 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.32
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.92
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.10
All reported nurse hours · state 4.34 · national 3.89
Licensed hours
1.18
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
2.75
Weekend nurse staffing · state 3.85 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.85 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.34
CMS adjusted RN staffing hours
Adjusted total hours
3.33
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
80%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
65%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,977
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.11
Composite VBP score used to determine payment impact.
Payment multiplier
0.9837
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.27
Baseline 18.18% · Performance 19.91% · Measure score 3.27 · Achievement 3.27 · Improvement 0
Healthcare-associated infections
1.63
Baseline 7.36% · Performance 7.35% · Measure score 1.63 · Achievement 1.63 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
2.63
Baseline 4.25 hours · Performance 3.82 hours · Measure score 2.63 · Achievement 2.63 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.69% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 92 · Observed rate 14.13% · Lower 95% interval 8.76% |
| Discharge to community | 45.29% |
50.57%
5.3 pts worse
|
No Different than the National Rate · Eligible stays 79 · Observed rate 40.51% · Lower 95% interval 34.91% |
| Medicare spending per beneficiary | 1.22 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 96.49% |
95.27%
1.2 pts better
|
Numerator 55 · Denominator 57 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 57 |
| Discharge self-care score | 57.89% |
53.69%
4.2 pts better
|
Numerator 22 · Denominator 38 |
| Discharge mobility score | 65.79% |
50.94%
14.9 pts better
|
Numerator 25 · Denominator 38 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 57 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.35% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 76 · Observed rate 6.58% · Lower 95% interval 3.86% |
| Staff COVID-19 vaccination coverage | 9.09% |
8.2%
0.9 pts better
|
Numerator 10 · Denominator 110 |
| Staff flu vaccination coverage | 26.17% |
42%
15.8 pts worse
|
Numerator 39 · Denominator 149 |
| Discharge function score | 65.79% |
56.45%
9.3 pts better
|
Numerator 25 · Denominator 38 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 95.83% |
96.28%
0.5 pts worse
|
Numerator 23 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 18.18% |
25.2%
7 pts worse
|
Numerator 6 · Denominator 33 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.8
0.5 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.2 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.3 |
1.5
1.8 pts worse
|
1.8
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 3.7 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
91.5%
6.5 pts better
|
93.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.3% · Q3 97.4% · Q4 98.8% · 4Q avg 98.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.7% |
89.6%
1.1 pts better
|
95.5%
4.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
2.3%
0.7 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.9% · Q3 1.3% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.3% |
4.9%
3.4 pts worse
|
11.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 17.1% · Q4 11.8% · 4Q avg 8.3% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
5.6%
0.3 pts worse
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 11.3% · Q3 2.9% · Q4 4.2% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.2% |
22.2%
7 pts better
|
19.6%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 17.3% · Q3 16.2% · Q4 13.3% · 4Q avg 15.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.6% |
18.5%
0.1 pts worse
|
16.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 22.0% · Q3 17.3% · Q4 16.1% · 4Q avg 18.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.3% |
19.1%
4.2 pts worse
|
16.3%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 35.1% · Q3 16.7% · Q4 12.3% · 4Q avg 23.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.5% |
14.2%
4.3 pts worse
|
14.9%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 29.2% · Q3 13.4% · Q4 11.0% · 4Q avg 18.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
1.8%
0.6 pts better
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.5% |
1.8%
1.7 pts worse
|
1.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.8% · Q3 2.8% · Q4 3.9% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.7% |
16.5%
1.2 pts worse
|
19.8%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.2% · Q2 22.7% · Q3 19.2% · Q4 9.6% · 4Q avg 17.7% |
| Percentage of long-stay residents with pressure ulcers | 1.7% |
5.5%
3.8 pts better
|
5.1%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.5% · Q3 0.0% · Q4 3.3% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.6% |
84.1%
4.5 pts worse
|
81.7%
2.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 74.1% · Q3 77.4% · Q4 61.8% · 4Q avg 79.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.8% |
9.8%
2 pts worse
|
12.0%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.8% · Observed 12.2% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.6%
0.7 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.4% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.6% |
80.7%
1.1 pts worse
|
79.7%
0.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.4% |
23.4%
4 pts better
|
23.9%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.4% · Observed 20.7% · Expected 25.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-22 · Fire 2024-08-22
34 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
17 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Cycle 3
Health 2023-06-08 · Fire 2023-06-08
29 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-09-04
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-10-02
D · Potential for more than minimal harm
2025-09-04
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-09-04
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-09-04
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-09-04
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-04
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-10-22
D · Potential for more than minimal harm
2025-09-04
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-09-01
D · Potential for more than minimal harm
2025-09-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-22
D · Potential for more than minimal harm
2025-09-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-09-29
D · Potential for more than minimal harm
2025-09-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-10-02
D · Potential for more than minimal harm
2025-09-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-10-02
D · Potential for more than minimal harm
2025-09-04
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-09-29
D · Potential for more than minimal harm
2025-09-04
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-10-02
F · Potential for more than minimal harm
2024-08-22
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-10-06
F · Potential for more than minimal harm
2024-08-22
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-10-06
F · Potential for more than minimal harm
2024-08-22
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-06
F · Potential for more than minimal harm
2024-08-22
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-10-06
F · Potential for more than minimal harm
2024-08-22
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-10-06
F · Potential for more than minimal harm
2024-08-22
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-10-06
E · Potential for more than minimal harm
2024-08-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-06
E · Potential for more than minimal harm
2024-08-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-06
E · Potential for more than minimal harm
2024-08-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-10-06
E · Potential for more than minimal harm
2024-08-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-06
E · Potential for more than minimal harm
2024-08-22
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-10-06
E · Potential for more than minimal harm
2024-08-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-08-22
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-08-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-08-22
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-08-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-08-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-06
E · Potential for more than minimal harm
2023-06-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-06-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-06-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-06-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-07-28
Inspection history
Recent health citations
G · Actual harm
2025-09-04
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-10-17
F · Potential for more than minimal harm
2025-09-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-10-17
E · Potential for more than minimal harm
2025-09-04
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-10-17
E · Potential for more than minimal harm
2025-09-04
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-09-04
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-09-04
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-09-04
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-09-04
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-09-04
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-09-04
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-09-04
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-09-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-09-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-09-04
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-09-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-09-04
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-09-04
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-09-04
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-09-04
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-09-04
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-09-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-09-04
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2025-10-17
E · Potential for more than minimal harm
2025-01-22
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2025-02-07
G · Actual harm
2024-11-12
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-11-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-12-06
F · Potential for more than minimal harm
2024-08-22
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-10-06
F · Potential for more than minimal harm
2024-08-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-06
E · Potential for more than minimal harm
2024-08-22
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-10-06
E · Potential for more than minimal harm
2024-08-22
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-10-06
E · Potential for more than minimal harm
2024-08-22
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-08-22
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-08-22
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-08-22
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-08-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-08-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-08-22
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-08-22
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-08-22
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-08-22
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-08-22
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-08-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-08-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-08-22
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-08-22
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-08-22
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-08-22
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-08-22
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-08-22
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-08-22
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-04-30
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-04-30
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-04-30
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-04-30
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-26
D · Potential for more than minimal harm
2024-04-30
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-06-26
D · Potential for more than minimal harm
2024-04-30
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-04-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-17
E · Potential for more than minimal harm
2023-09-11
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-09-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-09-11
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-09-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-10-05
F · Potential for more than minimal harm
2023-06-08
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-06-08
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-04-24
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-05-19
Penalties and ownership
What sits behind the stars
$71,656
2025-09-04
Fine
Fine · fine $71,656
Fine
$18,564
2024-11-12
Fine
Fine · fine $18,564
Fine
$34,239
2023-06-08
Fine
Fine · fine $34,239
Fine
$0
2023-06-08
Payment Denial
Payment Denial · denial start 2023-08-05 · 34 days
34 day denial
Ownership
Maze Family Limited Partnership
5% Or Greater Direct Ownership Interest · Organization
Charly Bello Family Limited Partnership
5% Or Greater Direct Ownership Interest · Organization
Myers, Katie
5% Or Greater Indirect Ownership Interest · Individual
Myers, Walter
5% Or Greater Indirect Ownership Interest · Individual
Swain, Holly
5% Or Greater Indirect Ownership Interest · Individual
Swain, Jared
5% Or Greater Indirect Ownership Interest · Individual
Mahrt, David
5% Or Greater Indirect Ownership Interest · Individual
Pickd LLC
5% Or Greater Direct Ownership Interest · Organization
Cottonwood Healthcare LLC
Operational/Managerial Control · Organization
Mahrt, David
Operational/Managerial Control · Individual
Mahrt, David
Corporate Officer · Individual
Miller, Denver
Operational/Managerial Control · Individual
Miller, Trevor
Operational/Managerial Control · Individual
Myers, Walter
Operational/Managerial Control · Individual
Myers, Walter
Corporate Officer · Individual
Slattery & Holman P.c.
Operational/Managerial Control · Organization
Swain, Jared
Corporate Officer · Individual
Nearby options
Other facilities in reach
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1-star overall rating with 2-star inspections with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Wingfield Skilled Nursing And Rehabilitation Cente
Sparks, NV
2-star overall rating with 3-star inspections with $75,670 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Hearthstone
Sparks, NV
1-star overall rating with 1-star inspections with Special Focus status with $78,254 in total fines with 15 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Jump out
Supporting pages
City page
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See how this facility ranks inside its city.
1 facilitiesCounty
Churchill County
County ranking page for nearby alternatives.
1 facilitiesChain
The Charly Bello Family, The Maze Family, The Swain Family, & Walter Myers
Chain page for the operating group.
18 facilities