Nevada ›Gardnerville

Gardnerville Health & Rehabilitation Center

1573 South Muller Pkwy, Gardnerville, NV 89410 · Douglas County · 60 certified beds · avg 50 residents/day · certified since Jul 20, 2004

Abuse citation flag (CMS)

Part of chain: EVERGREEN HEALTHCARE GROUP (44 facilities, chain avg rating 2.5★)

The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.

1/5
Health inspection rating (on-site)
1
Serious findings on record
$0
Fines, last 3 years
3.86
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · May 1, 2025 · F-0690

The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.

Why it matters: Poor continence and catheter care leads to infections, skin breakdown, and loss of dignity.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: May 23, 2025 (Deficient, Provider has date of correction)

All citations in the current public record (57)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
Jun 29, 2026D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Jun 29, 2026D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Mar 17, 2026D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
May 1, 2025▲ G · Actual harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
May 1, 2025F · Potential for harm, facility-wideThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
May 1, 2025D · Potential for harm, one-offThe facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. · from a complaint
May 1, 2025D · Potential for harm, one-offThe facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. · from a complaint
May 1, 2025D · Potential for harm, one-offThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
May 1, 2025D · Potential for harm, one-offThe facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services.
May 1, 2025D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
May 1, 2025D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
May 1, 2025D · Potential for harm, one-offThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
May 1, 2025D · Potential for harm, one-offThe facility did not observe each nurse aide's job performance or provide regular training as required.
May 1, 2025D · Potential for harm, one-offThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
May 1, 2025D · Potential for harm, one-offThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
May 1, 2025D · Potential for harm, one-offThe facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies.
May 1, 2025D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
May 1, 2025D · Potential for harm, one-offThe facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them.
May 1, 2025D · Potential for harm, one-offThe facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
May 1, 2025D · Potential for harm, one-offThe facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status.
May 1, 2025E · Potential for harm, repeatedThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
May 1, 2025D · Potential for harm, one-offThe facility did not protect residents from being involuntarily separated — kept apart from other residents, kept out of their own room, or confined to their room. Isolating a resident this way is a form of mistreatment. · from a complaint
May 1, 2025D · Potential for harm, one-offThe facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation. · from a complaint
Jun 26, 2024F · Potential for harm, facility-wideThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint
Jun 26, 2024F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jun 26, 2024F · Potential for harm, facility-wideThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jun 26, 2024D · Potential for harm, one-offThe facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand.
Jun 26, 2024D · Potential for harm, one-offThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Jun 26, 2024D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Jun 26, 2024D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Jun 26, 2024D · Potential for harm, one-offThe facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes.
Jun 26, 2024D · Potential for harm, one-offThe facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Jun 26, 2024D · Potential for harm, one-offThe facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Jun 26, 2024D · Potential for harm, one-offThe facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Jun 26, 2024D · Potential for harm, one-offThe facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status.
Jun 26, 2024D · Potential for harm, one-offThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Jun 26, 2024D · Potential for harm, one-offThe facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation.
Aug 31, 2023F · Potential for harm, facility-wideThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care.
Aug 31, 2023F · Potential for harm, facility-wideThe facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective.
Aug 31, 2023F · Potential for harm, facility-wideThe facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program.
Aug 31, 2023E · Potential for harm, repeatedThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Aug 31, 2023D · Potential for harm, one-offThe facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings.
Aug 31, 2023D · Potential for harm, one-offThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Aug 31, 2023D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Aug 31, 2023D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Aug 31, 2023D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Aug 31, 2023D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Aug 31, 2023D · Potential for harm, one-offThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Aug 31, 2023D · Potential for harm, one-offThe facility did not observe each nurse aide's job performance or provide regular training as required.
Aug 31, 2023D · Potential for harm, one-offThe facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Aug 31, 2023D · Potential for harm, one-offThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Aug 31, 2023D · Potential for harm, one-offThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Aug 31, 2023D · Potential for harm, one-offThe facility did not dispose of garbage and refuse properly.
Aug 31, 2023D · Potential for harm, one-offThe facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies.
Aug 31, 2023D · Potential for harm, one-offThe facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. · from a complaint
Aug 31, 2023D · Potential for harm, one-offThe facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months.
Aug 31, 2023D · Potential for harm, one-offThe facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (14 → 17).

YearCitationsSerious (G–L)Worst severity that year
2023200F
2024140F
2025201G ▲
202630D

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityNevada avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)3.864.053.95top 44% in Nevada; top 46% in the U.S.
Registered Nurse hours0.950.980.69top 41% in Nevada; top 18% in the U.S.
Weekend total nurse staffing3.463.613.50top 38% in Nevada; top 44% in the U.S.
Weekend RN hours (not acuity-adjusted)0.520.870.48bottom 33% in Nevada; top 31% in the U.S.
Total nursing staff turnover (%)63.645.145.8bottom 8% in Nevada; bottom 11% in the U.S.
RN turnover (%)46.743.442.9bottom 39% in Nevada; bottom 41% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.69, RN 0.91, weekend 3.31. Staffing rating: 3/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 1/5 · long-stay residents: 1/5 · short-stay residents: 3/5

Who owns this facility

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
CH PNW 12 Holdings LLCOrganizationIndirect Ownership InterestNOT APPLICABLE08/31/2023
Herzka, YisroelIndividualIndirect Ownership InterestNOT APPLICABLE08/31/2023
Pacific Northwest 12 Leased Operations Holdings LLCOrganizationDirect Ownership InterestNOT APPLICABLE08/31/2023
Witzcorp PNW 12 LLCOrganizationIndirect Ownership InterestNOT APPLICABLE08/31/2023
Yenowitz, YitzchokIndividualIndirect Ownership InterestNOT APPLICABLE08/31/2023
Couve Financial Services LLCOrganizationOperational/Managerial ControlNOT APPLICABLE08/31/2023
Couve Financial Services LLCOrganizationADP of the SNFNOT APPLICABLE04/11/2025
Couve Healthcare Consulting LLCOrganizationOperational/Managerial ControlNOT APPLICABLE08/31/2023
Couve Healthcare Consulting LLCOrganizationADP of the SNFNOT APPLICABLE04/14/2025
Earl, StevenIndividualManaging Control - Governing BodyNOT APPLICABLE08/31/2023
Earl, StevenIndividualOperational/Managerial ControlNOT APPLICABLE08/31/2023
Earl, StevenIndividualADP of the SNFNOT APPLICABLE08/31/2023
Garcia, MelanieIndividualOperational/Managerial ControlNOT APPLICABLE08/31/2023
Garcia, MelanieIndividualADP of the SNFNOT APPLICABLE08/31/2023
PNW 12 Opco Management LLCOrganizationOperational/Managerial ControlNOT APPLICABLE08/31/2023
PNW 12 Opco Management LLCOrganizationADP of the SNFNOT APPLICABLE04/11/2025
PNW 12 SNF Consulting LLCOrganizationOperational/Managerial ControlNOT APPLICABLE08/31/2023
PNW 12 SNF Consulting LLCOrganizationADP of the SNFNOT APPLICABLE04/14/2025
Rance, AaronIndividualOperational/Managerial ControlNOT APPLICABLE08/31/2023
Rance, AaronIndividualADP of the SNFNOT APPLICABLE08/31/2023

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

Nearby facilities (within 20 miles)

FacilityDistanceCityOverallInspectionFlags
Mountain View Health and Rehabilitation13.0 miCarson City, NV★★☆☆☆2/5abuse
Barton Hospital D/P SNF13.1 miSouth Lake Tahoe, CA★★★★☆3/5
Sierra Basin Post Acute15.5 miCarson City, NV★★★★★4/5
Northstar Post Acute16.0 miCarson City, NV★☆☆☆☆1/5
Ormsby Post Acute Rehabilitation16.7 miCarson City, NV—/5abuseSFF

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Facility data as of CMS processing date 2026-08-01. CCN 295082.