Gardnerville Health & Rehabilitation Center
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
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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
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 2026Total 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
7
measures
8
measures
2
measures
Residents on anti-anxiety or sleep medication
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents who got a urinary tract infection
Residents whose walking got worse
Residents vaccinated for the flu
Residents vaccinated for pneumonia
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
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, 2026Complaint1
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, 2025Routine19
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.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Emergency Preparedness Deficiencies
Establish emergency prep training and testing.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
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.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
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.
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.
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.
Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
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, 2025Complaint5
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
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.
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Resident Rights Deficiencies
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Jun 26, 2024Routine18
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
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.
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
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.
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
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.
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
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.
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
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.
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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, 2024Complaint1
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, 2023Routine27
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.
Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Infection Control Deficiencies
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
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.
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.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Resident Rights Deficiencies
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
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.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
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.
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
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.
Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
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.
Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
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
Gardnerville Health & Rehabilitation Center
for profit
Chain Affiliation
Evergreen Healthcare Group
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
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
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Medicare data downloads
Original nursing home datasets
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