Ormsby Post Acute Rehabilitation, Carson City, Nevada

88
Citations from health inspectionsNevada average: 33 a home: 1
Residents harmed or put in dangerNevada average: 0.5 a home: $60,464
Fines from the federal governmentNevada average: $13,952 a home: No rating given
Overall rating in starsNevada average: 3.1

The figures come from Medicare Care Compare files released October 8, 2026 by CMS, the federal Medicare agency. The citations span each home's three most recent inspection cycles plus their complaint visits, going back to March 2017 at the earliest; the fines span about three years, beginning September 2023. Browse the CMS files

Seven inspection visits produced 88 citations. Residents were in immediate danger in one finding. Federal fines came to $60,464 (one fine). Once, Medicare stopped paying for new admissions.

This home is a Special Focus Facility. Homes that have done poorly on past inspections are put on this list by CMS, and they get extra attention.

The CMS abuse icon is shown for this home. Care Compare adds it after a citation for abuse or neglect. Either a resident was harmed recently, or harm could have resulted over two inspections in a row.

Are you worried about the way someone was treated at this home?

Call 1-833-892-8135Calls go to a law firm that advertises on Nursing Home Violations.

Quick Look at the Record

The home's overall star rating: No rating is given while the home stays on the Special Focus list
Rating for health inspections: No rating is given while the home stays on the Special Focus list
Rating for staffing: No rating is given while the home stays on the Special Focus list
Rating for quality of care: No rating is given while the home stays on the Special Focus list
Nurse time for each resident: 2.81 hours each dayThe Nevada average is 4.34 hours
Time from registered nurses: 0.76 hours each dayThe Nevada average is 1.12 hours
Nursing staff who left during one year: 58%against the Nevada average of 45.1%
Beds that are certified: 120
Ownership: Limited Liability company (for profit)
Chain: Evergreen Healthcare Group, with 43 homes
Street address: 3050 N Ormsby Road, Carson City, Nevada 89703
County: Carson City

Each inspection's citations

Every citation marks a federal rule inspectors found broken, along with its seriousness and the number of residents affected.

25 citations dated May 14, 2026

F943 Staff Training on Abuse, Neglect, and Dementia: risk of harm, no one found hurt, one or a few residents.
F908 Keep Essential Equipment Working Safely: risk of harm, no one found hurt, one or a few residents.
F880 Infection Prevention and Control: risk of harm, no one found hurt, a pattern, several residents.
F868 Quality Group Membership and Quarterly Meetings: risk of harm, no one found hurt, one or a few residents.
F865 Written Quality Improvement Plan: risk of harm, no one found hurt, one or a few residents.
F849 Arrange Hospice Care When Needed: risk of harm, no one found hurt, one or a few residents.
F838 Facility Wide Assessment of Needed Resources: risk of harm, no one found hurt, one or a few residents.
F814 Dispose of Garbage Properly: risk of harm, no one found hurt, one or a few residents.
F812 Food Storage and Kitchen Safety: risk of harm, no one found hurt, widespread.
F805 Food Prepared to Meet Individual Needs: risk of harm, no one found hurt, one or a few residents.
F800 Nutritious, Tasty, Balanced Meals: risk of harm, no one found hurt, one or a few residents.
F761 Labeling and Locking Up Medicines: risk of harm, no one found hurt, one or a few residents.
F730 Review Nurse Aide Performance and Training: risk of harm, no one found hurt, one or a few residents.
F699 Trauma Informed and Culturally Respectful Care: risk of harm, no one found hurt, one or a few residents.
F697 Pain Management: risk of harm, no one found hurt, one or a few residents.
F684 Quality of Care: risk of harm, no one found hurt, one or a few residents.
F678 CPR and Basic Life Support: risk of harm, no one found hurt, one or a few residents.
F656 A Complete Care Plan: risk of harm, no one found hurt, one or a few residents.
F610 Investigating Abuse Allegations: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F600 Freedom From Abuse and Neglect: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F582 Notice of Medicare and Medicaid Coverage and Costs: minimal risk to residents, a pattern, several residents.
F561 Respect Resident Choices and Self Determination: risk of harm, no one found hurt, one or a few residents.
F558 Meeting Residents' Needs and Preferences: risk of harm, no one found hurt, one or a few residents.
F552 Keep Residents Informed About Health and Care: risk of harm, no one found hurt, one or a few residents.
F550 Dignity and Resident Rights: risk of harm, no one found hurt, one or a few residents.

Two citations dated March 26, 2026

F610 Investigating Abuse Allegations: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F600 Freedom From Abuse and Neglect: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.

10 citations dated March 27, 2025

F940 Effective Staff Training Program: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F849 Arrange Hospice Care When Needed: risk of harm, no one found hurt, a pattern, several residents.
F842 Medical Records and Privacy: risk of harm, no one found hurt, one or a few residents.
F812 Food Storage and Kitchen Safety: risk of harm, no one found hurt, widespread.
F761 Labeling and Locking Up Medicines: risk of harm, no one found hurt, one or a few residents.
F757 Unnecessary Drugs: risk of harm, no one found hurt, one or a few residents.
F656 A Complete Care Plan: risk of harm, no one found hurt, one or a few residents.
F641 Accurate Resident Assessments: risk of harm, no one found hurt, one or a few residents.
F640 Send Assessment Data to State on Time: risk of harm, no one found hurt, one or a few residents.
F582 Notice of Medicare and Medicaid Coverage and Costs: risk of harm, no one found hurt, one or a few residents.

Four citations dated Sept. 18, 2024

F757 Unnecessary Drugs: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F658 Care That Meets Professional Standards: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F602 Protect Residents' Money and Belongings From Misuse: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F600 Freedom From Abuse and Neglect: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.

41 citations dated May 29, 2024

F949 Behavioral Health Training for Staff: risk of harm, no one found hurt, a pattern, several residents.
F946 Compliance and Ethics Training: risk of harm, no one found hurt, widespread.
F945 Infection Control Training for Staff: risk of harm, no one found hurt, a pattern, several residents.
F944 Staff Training on Quality Improvement Program: risk of harm, no one found hurt, a pattern, several residents.
F943 Staff Training on Abuse, Neglect, and Dementia: risk of harm, no one found hurt, one or a few residents.
F942 Staff Training on Resident Rights: risk of harm, no one found hurt, a pattern, several residents.
F941 Communication Training for Direct Care Staff: risk of harm, no one found hurt, one or a few residents.
F887 Coronavirus Vaccine Education, Offering, and Records: risk of harm, no one found hurt, one or a few residents.
F883 Flu and Pneumonia Vaccines: risk of harm, no one found hurt, a pattern, several residents.
F881 Antibiotic Use Monitoring Program: risk of harm, no one found hurt, widespread.
F880 Infection Prevention and Control: risk of harm, no one found hurt, one or a few residents.
F865 Written Quality Improvement Plan: risk of harm, no one found hurt, widespread.
F851 Submit Accurate Staffing Data to Federal Government: risk of harm, no one found hurt, one or a few residents.
F842 Medical Records and Privacy: risk of harm, no one found hurt, one or a few residents.
F841 Physician Medical Director: minimal risk to residents, widespread.
F839 Properly Licensed Staff: minimal risk to residents, widespread.
F835 Run the Facility Effectively: risk of harm, no one found hurt, widespread.
F812 Food Storage and Kitchen Safety: risk of harm, no one found hurt, widespread.
F761 Labeling and Locking Up Medicines: risk of harm, no one found hurt, a pattern, several residents.
F759 Medication Error Rate of 5 Percent or More: risk of harm, no one found hurt, one or a few residents.
F755 Pharmacy Services: risk of harm, no one found hurt, one or a few residents.
F726 Nurses and Aides Have Needed Skills: risk of harm, no one found hurt, widespread.
F725 Enough Nursing Staff: risk of harm, no one found hurt, one or a few residents.
F712 Face to Face Doctor Visits: risk of harm, no one found hurt, one or a few residents.
F698 Dialysis Care: risk of harm, no one found hurt, one or a few residents.
F695 Breathing and Oxygen Care: risk of harm, no one found hurt, one or a few residents.
F691 Proper Care for Surgical Bowel or Bladder Openings: risk of harm, no one found hurt, one or a few residents.
F686 Pressure Ulcer (Bedsore) Care: risk of harm, no one found hurt, one or a few residents.
F684 Quality of Care: risk of harm, no one found hurt, one or a few residents.
F678 CPR and Basic Life Support: risk of harm, no one found hurt, one or a few residents.
F677 Help With Daily Living: risk of harm, no one found hurt, one or a few residents.
F658 Care That Meets Professional Standards: risk of harm, no one found hurt, a pattern, several residents.
F657 Updating the Care Plan on Time: risk of harm, no one found hurt, one or a few residents.
F656 A Complete Care Plan: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F622 Valid Reasons and Paperwork for Transfer or Discharge: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F610 Investigating Abuse Allegations: immediate danger to residents, one or a few residents, found on a complaint visit.
F609 Reporting Suspected Abuse: risk of harm, no one found hurt, one or a few residents.
F602 Protect Residents' Money and Belongings From Misuse: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F600 Freedom From Abuse and Neglect: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F558 Meeting Residents' Needs and Preferences: risk of harm, no one found hurt, one or a few residents.
F552 Keep Residents Informed About Health and Care: risk of harm, no one found hurt, one or a few residents.

Five citations dated Feb. 16, 2024

F689 Accident Hazards and Supervision: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F657 Updating the Care Plan on Time: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F656 A Complete Care Plan: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F600 Freedom From Abuse and Neglect: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F552 Keep Residents Informed About Health and Care: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.

One citation dated Oct. 16, 2023

F600 Freedom From Abuse and Neglect: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.

Payment Denials and Fines

Date	Penalty	Amount
May 29, 2024	Fine	$60,464
May 29, 2024	Payment denial for new admissions	six days

Ownership and Management of the Home

The CMS ownership file names no owner or operator for this home.

The CMS Care Compare files, updated every month, provide provider information, health deficiencies, penalties, and ownership. The CMS certification number is 295067. Other homes in Nevada.