Map showing the location of ORMSBY POST ACUTE REHABILITATION in CARSON CITY, Nevada
3050 N ORMSBY ROAD, CARSON CITY, NV, 89703

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating

Where it ranks

  • NevadaLowest tier among peers65 rated homes · average 3.1★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point1★−2.0 vs NV avg
  • StaffingCan add or remove a star3★±0.0 vs NV avg
  • Quality measuresCan add or remove a star3★−0.7 vs NV avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

  • Special Focus Facility candidateThis facility is on the CMS candidate list for the Special Focus Facility program, meaning it is among the poorest-performing facilities in its state on recent inspections.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersNV avg3.0★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover3★Above only 31% of peersNV avg3.0★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments3★Above only 25% of peersNV avg3.7★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.41hrsAbove only 29% of peersNV avg4.35Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.86hrsAbove only 49% of peersNV avg1.07Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better67%Above only 6% of peersNV avg46%RN turnover50%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$60,464Above only 9% of peersNV avg$15,465Fines · denials1 · 1
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
100citations
8inspection dates
0actual harm (G–I)
1immediate jeopardy (J–L)
Mar 27, 2025most recent

Citations by monthMar 2023 – Mar 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Mar 27, 202510 citationsCycle 1worst F · no actual harm
  1. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Apr 14, 2025
  2. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Apr 14, 2025
  3. F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.AdministrationE · patternCorrected Apr 14, 2025
  4. F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident RightsD · isolatedCorrected Apr 14, 2025
  5. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Apr 14, 2025
  6. F656Develop 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 PlanningD · isolatedCorrected Apr 14, 2025
  7. F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Apr 14, 2025
  8. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Apr 14, 2025
  9. Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Resident Assessment and Care PlanningD · isolatedCorrected Apr 14, 2025
  10. F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.AdministrationD · isolatedCorrected Apr 14, 2025
Sep 18, 20244 citationsCycle 2worst D · no actual harm
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 3, 2024
  2. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Nov 3, 2024
  3. F602Protect each resident from the wrongful use of the resident's belongings or money.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 3, 2024
  4. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Nov 3, 2024
May 29, 202441 citationsCycle 2worst J · immediate jeopardy$60,464, payment denial
  1. F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Nursing and Physician ServicesD · isolatedCorrected Jul 24, 2024
  2. Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Quality of Life and CareD · isolatedCorrected Jul 24, 2024
  3. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Jul 24, 2024
  4. Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.AdministrationE · patternCorrected Jul 24, 2024
  5. F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected Jul 24, 2024
  6. F865Have a plan that describes the process for conducting QAPI and QAA activities.AdministrationF · widespreadCorrected Jul 24, 2024
  7. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 24, 2024
  8. F602Protect each resident from the wrongful use of the resident's belongings or money.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 24, 2024
  9. F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Resident RightsD · isolatedCorrected Jul 24, 2024
  10. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Jul 24, 2024
  11. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 24, 2024
  12. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Jul 24, 2024
  13. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningE · patternCorrected Jul 24, 2024
  14. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Jul 24, 2024
  15. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Jul 24, 2024
  16. F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Jul 24, 2024
  17. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Jul 24, 2024
  18. F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Jul 24, 2024
  19. F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesD · isolatedCorrected Jul 24, 2024
  20. F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesF · widespreadCorrected Jul 24, 2024
  21. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Jul 24, 2024
  22. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Jul 24, 2024
  23. F761Ensure 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.Pharmacy ServiceE · patternCorrected Jul 24, 2024
  24. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Jul 24, 2024
  25. F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.AdministrationF · widespreadCorrected Jul 24, 2024
  26. F839Employ staff that are licensed, certified, or registered in accordance with state laws.AdministrationC · widespreadCorrected Jul 24, 2024
  27. F841Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.Nursing and Physician ServicesC · widespreadCorrected Jul 24, 2024
  28. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Jul 24, 2024
  29. F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.AdministrationD · isolatedCorrected Jul 24, 2024
  30. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Jul 24, 2024
  31. F881Implement a program that monitors antibiotic use.Infection ControlF · widespreadCorrected Jul 24, 2024
  32. F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlE · patternCorrected Jul 24, 2024
  33. F887Educate 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.Infection ControlD · isolatedCorrected Jul 24, 2024
  34. F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.AdministrationD · isolatedCorrected Jul 24, 2024
  35. F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Resident RightsE · patternCorrected Jul 24, 2024
  36. F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 24, 2024
  37. F945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.Infection ControlE · patternCorrected Jul 24, 2024
  38. F946Provide training in compliance and ethics.AdministrationF · widespreadCorrected Jul 24, 2024
  39. F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.AdministrationE · patternCorrected Jul 24, 2024
  40. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationJ · isolatedCorrected Jul 24, 2024
  41. F656Develop 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 PlanningD · isolatedCorrected Jul 24, 2024
Feb 16, 20245 citationsCycle 2worst D · no actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Mar 11, 2024
  2. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Mar 11, 2024
  3. F656Develop 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 PlanningD · isolatedCorrected Mar 11, 2024
  4. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 11, 2024
  5. F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected Mar 11, 2024
Oct 16, 20231 citationCycle 3worst D · no actual harm
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Oct 30, 2023
Jul 5, 202333 citationsCycle 3worst F · no actual harm
  1. F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.AdministrationD · isolatedCorrected Aug 15, 2023
  2. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 29, 2023
  3. Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.AdministrationE · patternCorrected Aug 15, 2023
  4. F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.AdministrationF · widespreadCorrected Aug 15, 2023
  5. F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Resident RightsE · patternCorrected Aug 15, 2023
  6. F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 15, 2023
  7. F945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.Infection ControlE · patternCorrected Aug 15, 2023
  8. F946Provide training in compliance and ethics.AdministrationE · patternCorrected Aug 15, 2023
  9. F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician ServicesD · isolatedCorrected Aug 15, 2023
  10. F838Conduct 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.AdministrationF · widespreadCorrected Aug 15, 2023
  11. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningF · widespreadCorrected Aug 15, 2023
  12. F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationD · isolatedCorrected Aug 15, 2023
  13. F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected Aug 15, 2023
  14. F887Educate 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.Infection ControlD · isolatedCorrected Aug 15, 2023
  15. F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.AdministrationE · patternCorrected Aug 15, 2023
  16. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Aug 15, 2023
  17. F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected Jul 29, 2023
  18. F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident RightsD · isolatedCorrected Jul 29, 2023
  19. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Aug 15, 2023
  20. F584Honor 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.Resident RightsE · patternCorrected Jul 29, 2023
  21. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Jul 29, 2023
  22. F656Develop 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 PlanningD · isolatedCorrected Jul 29, 2023
  23. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Sep 7, 2023
  24. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Aug 15, 2023
  25. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Jul 29, 2023
  26. F679Provide activities to meet all resident's needs.Quality of Life and CareD · isolatedCorrected Jul 29, 2023
  27. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Jul 29, 2023
  28. F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesF · widespreadCorrected Aug 15, 2023
  29. F758Implement 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.Pharmacy ServiceD · isolatedCorrected Aug 15, 2023
  30. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Aug 15, 2023
  31. F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Aug 15, 2023
  32. F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.AdministrationF · widespreadCorrected Aug 15, 2023
  33. F837Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.AdministrationC · widespreadCorrected Aug 15, 2023
Apr 27, 20231 citationCycle 3worst D · no actual harm
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 8, 2023
Mar 1, 20235 citationsCycle 3worst D · no actual harm
  1. F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected Mar 31, 2023
  2. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 31, 2023
  3. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Mar 31, 2023
  4. F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Mar 31, 2023
  5. F839Employ staff that are licensed, certified, or registered in accordance with state laws.AdministrationD · isolatedCorrected Mar 31, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.41hrsAbove only 29% of peers−0.94 vs NV avg
  • Registered nursesRN hours only0.86hrsAbove only 49% of peers−0.21 vs NV avg
  • Licensed practical nursesLPN hours0.72hrs
  • Nurse aidesCNA hours1.83hrs
  • Weekend nursingAll staff on Saturdays and Sundays2.80hrs
  • Nevada average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better67%Above only 6% of peersNV avg 46%
  • RN turnoverRegistered nurses only50%Not ranked by CMS
  • Administrators who leftIn the past year1Leadership changed
  • Occupancy120 certified beds · ~87 residents a day72%Above only 11% of peersNV avg 85%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $60,464In fines
  • 1Fine
  • 1Payment denial
  • $15,465NV avg in fines
Above only 9% of peersFewer fines than 9% of rated homes in Nevada

Actions on record

  1. May 29, 2024Civil money penalty$60,464
  2. May 29, 2024Denial of payment for new admissionsfrom Jul 18, 2024

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
Empres Operated by Evergreen42 facilities in the chain2.4★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Indirect owners (5%+)
  • Ch Pacific Northwest Holdings LLC
  • Witzcorp Global LLC
Operational or managerial control
  • Couve Financial Services LLC
  • Couve Healthcare Consulting LLC
  • Nevada SNF Consulting LLC
  • Ormsby SNF Operations LLC
  • Pacific Northwest Opco Management LLC
  • Steven Earl
  • Antoine Goodie
  • Harold Perlman
  • +5 more

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 295067 · 3050 N ORMSBY ROAD, CARSON CITY, NV, 89703.
  • Percentiles compare this facility with every rated nursing home in Nevada and Carson City County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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