Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sierra Basin Post Acute during CMS and state inspections, most recent first.
The facility did not ensure that staff completed elder abuse prevention training before interacting with residents. Eight employees, including the Administrator, Director of Rehabilitation, RN, LPNs, CNA, Dietary Aide, and Housekeeper, began working with residents before completing the required training. This was contrary to the facility's policy, which mandates training upon hire, annually, and as needed.
A facility failed to provide written notification of transfer to a resident and their representative, as required. The resident, with serious health conditions, was transferred to an ER due to breathing difficulties and admitted to a hospital. The facility's Director of Nursing confirmed the removal of the notification requirement from their checklist, and no transfer policy was provided to the surveyor.
A resident was transferred to a hospital without receiving the required written notification of the bed hold policy, as confirmed by the DON. The facility's policy required informing residents and/or their representatives of the bed hold provision upon admission and before hospital transfer, but this was not followed.
During a fire drill, the facility's fire alarm system failed to sound in the front part of the building, including the therapy gym and dining areas, despite emergency strobe lights activating. Staff members, including a COTA and the Dietary Director, confirmed they did not hear the alarm, although they saw the strobe lights. The Maintenance Director was unaware of the issue, and the Director of Rehabilitation noted that five residents were in the therapy gym at the time.
A resident admitted for PT rehabilitation did not receive the prescribed frequency of PT sessions due to staffing issues after the facility switched PT service providers. The resident, who was recovering from a fracture, was supposed to receive PT five times a week, but received fewer sessions due to the PT Director's leave of absence and difficulties in finding coverage.
Failure to Train Staff on Elder Abuse Prevention Before Resident Interaction
Penalty
Summary
The facility failed to ensure that staff were trained on the prevention of elder abuse before engaging with residents, as evidenced by the personnel records of 8 out of 20 sampled employees. These employees, including the Administrator, Director of Rehabilitation, Registered Nurse, Licensed Practical Nurses, Certified Nursing Assistant, Dietary Aide, and Housekeeper, did not complete their required elder abuse training until after they had already started working with residents. The training was supposed to be completed upon hire, annually, and as needed, but the records show that the training was delayed for all these employees. The facility's policy, titled 'Abuse Neglect, Exploitation and Misappropriation Prevention Program,' revised in April 2021, mandates that staff orientation and training include topics such as abuse prevention, identification, and reporting of abuse. However, the Administrator confirmed that the initial elder abuse training for the mentioned employees was not completed before they began their duties with residents, indicating a lapse in adherence to the facility's policy and training requirements.
Failure to Provide Written Notification of Transfer
Penalty
Summary
The facility failed to provide written notification of transfer or discharge to a resident and their representative, which is a requirement for ensuring that residents and their representatives are informed of the reasons for such actions. This deficiency was identified during a review of the clinical records and interviews with facility staff. The resident in question was admitted to the facility with serious health conditions, including hypertensive heart disease with heart failure and acute respiratory failure. On a specific date, the resident was transferred to an emergency room due to difficulty breathing and acute hypoxia, and subsequently admitted to a hospital. The clinical records for the resident did not contain any documented evidence that written notification of the transfer or discharge was provided to the resident or their representative. During an interview, the Director of Nursing confirmed that the facility had removed the requirement for notification of transfer to a hospital from their transfer checklist. Additionally, the facility was unable to provide a policy related to facility transfers when requested by the surveyor, further indicating a lapse in following proper procedures for resident transfers.
Failure to Notify Resident of Bed Hold Policy
Penalty
Summary
The facility failed to provide a bed hold policy notification to a resident and/or the resident's representative upon transfer to an acute care hospital. This deficiency was identified during a review of the clinical records and interviews with facility staff. The resident, who had been admitted to the facility with diagnoses including hypertensive heart disease with heart failure and acute on chronic systolic heart failure, was transferred to the hospital due to difficulty breathing and acute hypoxia. However, there was no documented evidence that the resident or their representative received written notification of the right to exercise a bed hold provision at the time of transfer. The Director of Nursing confirmed that the facility did not provide the required notification when the resident was transferred to the hospital. The facility's policy, revised in October 2022, stated that residents and/or their representatives should be informed in writing of the bed hold provision upon admission and again before transfer to a hospital. In cases of emergency transfer, the second notice was to be provided within 24 hours. Despite this policy, the notification was omitted from the transfer checklist, leading to the oversight.
Fire Alarm System Failure During Drill
Penalty
Summary
The facility failed to ensure that the fire alarm system functioned properly during a fire drill, as the alarm did not sound in the front part of the building, including critical areas such as the front lobby, staff administrative offices, resident therapy gym, private dining room, and the resident dining room. This issue was identified during a fire drill conducted on January 14, 2025, at 1:28 PM, when the fire alarm was activated at a nurse's station. Although emergency strobe lights were activated throughout the facility, the absence of an audible alarm in these areas was confirmed through observations and interviews with staff members. The Maintenance Director was unaware of the malfunction and expressed that the expectation was for the alarm to sound throughout the entire building. Interviews with a Certified Occupational Therapist Assistant (COTA) and the Dietary Director confirmed that they did not hear the alarm in their respective areas during the drill, although they noticed the strobe lights. The Director of Rehabilitation noted that there were five residents in the therapy gym at the time of the drill. The facility's policy, revised in July 2021, emphasized the importance of keeping residents, staff, and visitors safe during such events, highlighting the significance of the deficiency.
Failure to Provide Prescribed Physical Therapy Due to Staffing Issues
Penalty
Summary
The facility failed to provide physical therapy (PT) services as per the physician's order for a resident who was admitted with a fracture of the superior rim of the left pubis. The physician's order specified PT evaluation and treatment five times a week for eight weeks, starting shortly after admission. However, the resident's comprehensive care plan did not reflect the frequency of treatments as ordered by the physician. The resident expressed concern about not receiving PT for several days due to a lack of PT staff, which was confirmed by both a registered nurse and a physical therapist. The facility had recently transitioned to a new company for PT services, which led to staffing issues. The Director of Nursing (DON) confirmed that the PT Director, who was also a treating therapist, took a leave of absence, and the facility struggled to find coverage. As a result, the resident received fewer PT sessions than prescribed, with only four sessions in one week and just one session in another week, instead of the required five sessions per week. This discrepancy was acknowledged by the DON as being due to staffing challenges.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Carson City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ormsby Post Acute Rehabilitation | 1.3 mi | — | 2 | 0 |
| Northstar Post Acute | 1.7 mi | — | 42 | 0 |
| Mountain View Health And Rehabilitation | 2.5 mi | — | 22 | 0 |
| Gardnerville Health & Rehabilitation Center | 15.5 mi | — | 1 | 0 |
| Life Care Center Of Reno | 19 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.