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Nursing HomeMedicaid Investigative

Gardnerville Health & Rehabilitation Center

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

1573 South Muller Pkwy, Gardnerville, NV 8941060 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing

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6/ 10
high Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Low staffing rating (2/5 stars)
  • Above-median deficiencies (20 vs median 8.0)
  • High staff turnover (75%)
  • High RN turnover (54%)

Bottom 25% in NV · Meets national RN staffing standard · Very high staff turnover · Worst in EVERGREEN HEALTH CARE chain · No penalties on record

Source: Medicare data

What this means for your family

This facility has areas of concern that warrant careful consideration. The facility has 21 deficiencies, which is above the state average. We recommend asking the administrator directly: "How are you addressing recent staffing shortfalls?" These are not reasons to panic, but they are reasons to ask tough questions and visit in person.

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
1.02hrs
OK
Registered nurses for medical care
Total Nursing
3.53hrs
86%
All nurses + aides combined
Staff Turnover
73%
Lower is better (< 30% = good)
RN Turnover
53%
Lower is better (< 30% = good)

Total nursing hours are below minimum, though RN coverage is adequate. This may mean fewer aides for daily tasks like bathing and mobility.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
2/ 5
Better Than Avg

7

measures

Worse Than Avg

8

measures

Mixed Results

2

measures

Long-Stay Residents
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility38.7%
Worse than Avg
Here
38.7%
US
19.5%
NV
22.2%
Douglas
17.4%
😔

Residents with depression symptoms

↓ Lower is better
This Facility0.7%
Better than Avg
Here
0.7%
US
12.1%
NV
5.1%
Douglas
9.2%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🦠

Residents who got a urinary tract infection

↓ Lower is better
This Facility11.1%
Worse than Avg
Here
11.1%
US
1.6%
NV
2.0%
Douglas
2.4%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility24.1%
Worse than Avg
Here
24.1%
US
15.3%
NV
16.5%
Douglas
18.1%
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility97.6%
Better than Avg
Here
97.6%
US
95.5%
NV
89.6%
Douglas
93.5%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
93.4%
NV
92.3%
Douglas
92.9%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility95.8%
Better than Avg
Here
95.8%
US
81.8%
NV
84.6%
Douglas
80.9%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility84.7%
Better than Avg
Here
84.7%
US
79.7%
NV
80.7%
Douglas
79.7%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
1.6%
NV
1.5%
Douglas
1.7%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

21deficiencies
Well above state avg (9.4)
9 complaint-triggered

Families have filed complaint reports triggering 8 deficiencies, indicating ongoing concerns about this facility. The most recurring problems involve infection control, medication management, and care planning, with issues persisting across multiple surveys from 2023 to 2025. While all deficiencies show correction dates, the pattern of repeated violations in critical care areas suggests systemic challenges that families should carefully consider.

Mar 17, 2026Complaint
1
0600Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

May 1, 2025Routine
19
0690Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

0880Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0036Potential for harm · PatternCorrected

Emergency Preparedness Deficiencies

Establish emergency prep training and testing.

0353Potential for harm · IsolatedCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0363Potential for harm · IsolatedCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0920Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0645Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0730Potential for harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

0759Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0761Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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.

0838Potential for harm · IsolatedCorrected

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

0842Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

0867Potential for harm · IsolatedCorrected

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

0883Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

0887Potential for harm · IsolatedCorrected

Infection Control Deficiencies

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.

May 1, 2025Complaint
5
0609Potential for harm · PatternCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0603Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

0943Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

0552Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

0557Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Jun 26, 2024Routine
18
0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0880Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0223Potential for harm · IsolatedCorrected

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

0363Potential for harm · IsolatedCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0511Potential for harm · IsolatedCorrected

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

0741Potential for harm · IsolatedCorrected

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

0920Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0552Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

0678Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

0757Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

0758Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

0883Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

0887Potential for harm · IsolatedCorrected

Infection Control Deficiencies

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.

0921Potential for harm · IsolatedCorrected

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

0943Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Jun 26, 2024Complaint
1
0761Potential for harm · WidespreadCorrected

Pharmacy Service Deficiencies

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.

Aug 31, 2023Routine
27
0725Potential for harm · WidespreadCorrected

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

0881Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

0882Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

0712Potential for harm · PatternCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0920Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0656Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0223Potential for harm · IsolatedCorrected

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

0353Potential for harm · IsolatedCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0355Potential for harm · IsolatedCorrected

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

0374Potential for harm · IsolatedCorrected

Smoke Deficiencies

Install smoke barrier doors that can resist smoke for at least 20 minutes.

0511Potential for harm · IsolatedCorrected

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

0741Potential for harm · IsolatedCorrected

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

0557Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

0558Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

0657Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0730Potential for harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

0756Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

0759Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0761Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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.

0814Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

0838Potential for harm · IsolatedCorrected

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

0868Potential for harm · IsolatedCorrected

Administration Deficiencies

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

0943Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Ownership & Operations

Who Operates This Facility

Owner / Operator

Gardnerville Health & Rehabilitation Center

Organization Type

for profit

Chain Affiliation

Chain Name

Evergreen Healthcare Group

Chain Size

43 facilities nationwide

Chain avg rating: 2.5/5 · Rank 2 of 2 (Worst)

Ownership & Management

Owners

Pacific Northwest 12 Leased Operations Holdings LLC

Owner · Organization

Ch Pnw 12 Holdings LLC

Owner (parent company) · Organization

Witzcorp Pnw 12 LLC

Owner (parent company) · Organization

Herzka, Yisroel

Owner (parent company)

Yenowitz, Yitzchok

Owner (parent company)

Key personnel

Earl, StevenManaging Control - Governing BodyRiker, MichelleManaging Control - Governing BodySpielman, ShimonOfficer / DirectorYenowitz, YitzchokOfficer / DirectorCouve Financial Services LLCManager
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

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