Inspection Reports for Nevada State Veterans Home – Boulder City

The inspection was conducted as a result of a Facility-Reported Incidents (FRIs) investigation at the facility on 05/01/2025, in accordance with federal regulations for long term care facilities.

Four facility-reported incidents were investigated, with one substantiated deficiency related to the improper use of physical restraints on Resident 6. The facility failed to ensure the resident was free from physical restraints without proper authorization, causing potential harm and diminished quality of life. Corrective actions and staff education were implemented to prevent recurrence.

Four facility-reported incidents were investigated; one (FRI #NV00073860) was substantiated involving improper use of physical restraints on Resident 6. The other three FRIs were unsubstantiated with no regulatory deficiencies identified.

The inspection was conducted as a Medicare Recertification Survey, Complaint and Facility-Reported Incident investigation from 12/03/2024 through 12/06/2024.

The facility had no regulatory deficiencies substantiated from complaints and incidents. However, several deficiencies were identified including failure to notify physician and family of significant weight loss, failure to complete PASARR Level 2 referrals for residents with new psychiatric diagnoses, incomplete care plans for residents with alternate communication methods, omitted medication dose due to unavailability, failure to reweigh residents after significant weight loss, failure to ensure pharmacy recommendations were reviewed by physicians, and failure to perform hand hygiene during medication administration.

The inspection was conducted as a result of a complaint and Facility Reported Incident (FRI) investigations at the Nevada State Veterans Home - Boulder City from 04/17/2024 through 04/18/2024.

One complaint was substantiated without any deficient practice identified, and seven facility reported incidents were investigated but not substantiated. No regulatory deficiencies were found during the investigation.

Complaint #NV00070687 was substantiated without deficient practice. The other seven FRIs were unsubstantiated with no regulatory deficiencies identified.

The inspection was conducted as a result of a Complaint and Facility Reported Incident investigation at Southern Nevada State Veterans Home from 10/19/2023 through 10/20/2023.

One regulatory deficiency was identified related to failure to ensure post fall protocol was implemented for one of 16 sampled residents, impacting the quality of life of the resident. The facility lacked documentation of neurological assessments and neuro checks per protocol following an unwitnessed fall.

There were four complaints and twelve Facility Reported Incidents (FRI) investigated. Several complaints and FRIs could not be verified and no regulatory deficiencies were identified for those. The substantiated complaint involved Resident 10's fall and related care.

The inspection was conducted as a result of a Medicare Recertification Survey, Complaint investigation, and Facility Reported Incidents investigation initiated on November 29, 2022 and completed on December 7, 2022.

The facility had multiple substantiated and unsubstantiated complaints and incidents investigated, including issues with consent for psychoactive medications, management of resident funds, notification of changes in resident condition, grievance handling, accuracy of assessments, development of comprehensive care plans, mobility care, and respiratory care. Deficiencies were identified in consent documentation, financial management, notification procedures, grievance follow-up, assessment accuracy, care planning, and adherence to physician orders for oxygen and equipment maintenance.

Complaint #NV00067443 was substantiated. Allegation #1 regarding funds withdrawn from trust account without consent of the Power of Attorney was substantiated. Allegation #2 regarding resident removal for a day trip while on hospice care was not substantiated.

This inspection was conducted as a state licensure survey in conjunction with a Federal Recertification survey at the Nevada State Veterans Home - Boulder City.

The facility failed to ensure that 6 of 9 sampled employees completed initial cultural competency training from a division-approved program, resulting in a regulatory deficiency related to discrimination prohibited under Nevada Revised Statutes. The facility identified an alternate approved training and plans to implement a 'train the trainer' course to ensure 100% compliance.

The inspection was conducted as a result of a facility reported incident and complaint investigation survey from 09/06/2022 through 09/07/2022, in accordance with 42 CFR Chapter IV, Part 483 - Requirements for Long Term Care Facilities.

The survey investigated 23 facility reported incidents and two complaints. Several allegations were substantiated including medication errors, failure to notify responsible parties, and abuse/neglect incidents. Some allegations related to elopement, falls, and resident-to-resident altercations were not substantiated. The facility failed to ensure residents were free from abuse and medication errors for one resident. Corrective actions and staff training plans were outlined.

The complaint investigation included allegations of elopement, falls, resident-to-resident altercations, injury of unknown origin, medication errors, failure to notify responsible parties, and abuse/neglect. Some allegations were substantiated (e.g., medication errors, failure to notify, abuse), while others were not substantiated (e.g., elopement, some falls, some altercations).

The inspection was conducted as a result of a complaint investigation involving four complaints alleging various concerns about resident care and facility practices.

The investigation found that most allegations could not be substantiated, including concerns about resident mobility, room changes, toenail care, haircuts, communication with family, and social distancing practices. One complaint regarding a resident on contact isolation walking around was substantiated with no regulatory deficiency. Another complaint about staff mask fit testing was substantiated with no regulatory deficiency. There were no regulatory deficiencies identified overall.

Four complaints were investigated. Complaint #NV00062188 with five allegations was not substantiated. Complaint #NV00060670 with three allegations was not substantiated except for one allegation about contact isolation which was substantiated with no regulatory deficiency. Complaint #NV00060686 with four allegations was substantiated with no regulatory deficiencies. Complaint #NV00063074 with two allegations was substantiated with no regulatory deficiencies.

The inspection was a focused infection control survey conducted to assess compliance with infection control and prevention regulations, specifically related to COVID-19.

The facility had 21 positive COVID-19 resident cases and nine presumptive cases at the time of inspection. The survey reviewed infection control policies, staff training, PPE use, and screening practices. No regulatory deficiencies were identified.

The inspection was conducted as a Centers for Medicare and Medicaid Services (CMS) Focused Infection Control survey to evaluate the facility's compliance with infection control and prevention requirements related to COVID-19.

The facility was found to have no regulatory deficiencies. The inspection included review of infection control policies, PPE use, staff education, and COVID-19 unit management. Adequate PPE supplies were verified and appropriate PPE use was observed among staff.

A Focused Infection Control survey was conducted to investigate regulatory compliance for Infection Control and Prevention, including policies, procedures, resident care practices, surveillance plans, visitor and staff screening, and staffing issues related to COVID-19.

The facility had dedicated units for COVID-19 positive residents and presumptive cases with appropriate PPE usage and staffing. Infection control practices, including hand hygiene, PPE use, and cleaning protocols, were observed and found effective. No regulatory deficiencies were identified during the survey.

This inspection was a Centers for Medicare and Medicaid Services (CMS) Focused Infection Control survey conducted to review the overall effectiveness of the Infection Control and Prevention Program, including policies, procedures, and practices related to COVID-19.

The facility maintained infection control practices including screening, PPE use, and staff education. There were no regulatory deficiencies identified during the survey, and no positive COVID-19 cases at the time of the survey, though eleven presumptive cases were noted.

The inspection was a Centers for Medicare and Medicaid Services (CMS) Focused Infection Control survey conducted to review the effectiveness of the Infection Control and Prevention Program, including policies, procedures, and practices related to COVID-19.

The facility maintained appropriate infection control practices including screening, use of PPE, staff education, and cleaning protocols. No regulatory deficiencies were identified during the survey.

This inspection was a Centers for Medicare and Medicaid Services (CMS) COVID-19 Focused Infection Control survey initiated on 04/28/2020 and finalized on 05/01/2020 to assess infection prevention and control practices related to COVID-19.

The facility failed to ensure staff consistently wore personal protective equipment (PPE) such as face masks at all times and residents did not consistently practice social distancing. Observations included a CNA removing a face mask after taking vitals and multiple residents not practicing social distancing in common areas. The facility provided education and implemented audits to improve compliance.

This survey was conducted as a Centers for Medicare and Medicaid Services (CMS) COVID-19 Focused Infection Control survey to assess the facility's compliance with infection prevention and control requirements.

The facility failed to ensure staff were appropriately using personal protective equipment (PPE) and residents were practicing social distancing, as evidenced by observations of staff not wearing face masks and residents not maintaining social distance.

This document is a Medicare recertification survey conducted at the Nevada State Veterans Home on 02/13/2020 to assess compliance with federal regulations for long term care facilities.

The survey found multiple deficiencies including failure to substantiate some facility reported incidents, issues with resident care such as feeding assistance, falls, abuse investigations, inaccurate assessments, improper use of medical devices, infection control lapses, and food safety violations. Corrective actions and plans of correction were submitted by the facility.

This Statement of Deficiencies was generated as a result of an Emergency Preparedness survey conducted in conjunction with a Medicare recertification survey at the facility on 2/12/2020.

There were no regulatory deficiencies identified during the survey. No further action was necessary.

This inspection was a Medicare Life Safety Code recertification survey conducted at the Nevada State Veterans Home from 02/11/2020 through 02/12/2020 to assess compliance with NFPA 101 and NFPA 99 codes.

The facility failed to follow its policy for tracking fixed and portable patient-care related electrical equipment, including nebulizers, suction units, vital sign monitors, and feeding pumps, which lacked proper identification and inspection tags. The facility also did not track manufacturer instructions for patient-care related equipment and did not inspect motorized wheelchairs considered personal possessions.

The inspection was conducted as an Emergency Preparedness survey in conjunction with a Medicare recertification survey, in accordance with 42 CFR and the State Operations Manual Appendix Z.

The facility was found to be in substantial compliance with the Emergency Preparedness program regulations. No deficiencies requiring further action were identified.

This report documents a Medicare re-certification survey conducted at the facility on 03/07/19 - 03/08/19 to assess compliance with health and safety regulations, including the National Fire Protection Association (NFPA) Life Safety Code.

The facility was found to have multiple deficiencies related to fire safety and life safety code compliance, including issues with delayed egress locking arrangements, sprinkler system maintenance, fire pump testing, corridor door latching, smoke barrier construction, electrical systems, and gas equipment storage. Corrective actions and audits were planned to address these deficiencies.

This report documents a Medicare Recertification survey conducted from February 26, 2019 through March 1, 2019, including investigation of three complaints and a review of facility compliance with federal regulations for long term care facilities.

The survey found multiple deficiencies related to transfer and discharge documentation, care plan timing and revision, quality of care including wound care and medication management, accident prevention, bowel and bladder incontinence care, tube feeding management, infection control, and medication labeling and storage. Some complaints were substantiated while others were not.

Three complaints were investigated: Complaint #NV00055511 was not substantiated; Complaint #NV00056210 was substantiated involving denial of resident readmission and staff searching resident belongings; Complaint #NV00056282 was not substantiated.

The inspection was conducted as a complaint investigation regarding an allegation that the facility was not sending appropriate discharge letters to the Long Term Care Ombudsman Program.

The complaint was not substantiated and no regulatory deficiencies were identified during the investigation. Interviews and record reviews were conducted with relevant staff.

Complaint #NV00051895 alleged the facility was not sending appropriate discharge letters to the Long Term Care Ombudsman Program; this allegation was not substantiated.

This inspection was conducted as a re-licensure Medicare certification and Emergency Preparedness survey, including a Medicare Life Safety Code survey, to assess compliance with state and federal regulations.

The facility was found to be in substantial compliance with Emergency Preparedness regulations. However, deficiencies were identified related to the maintenance and testing of the sprinkler system, corridor doors not resisting smoke passage, smoke barrier construction, and electrical panelboard labeling. Corrective actions and plans of correction were submitted and accepted.

The inspection was conducted as an annual Medicare Recertification Survey from December 11, 2017 through December 19, 2017, to assess compliance with federal regulations for long term care facilities.

The survey identified several regulatory deficiencies related to residents' rights to be free from physical restraints, accuracy of assessments, food safety requirements, and proper disposal of garbage and refuse. Specific issues included failure to complete quarterly assessments for restraints, inaccurate coding of resident status, improper thawing and storage of food, and an unclean dumpster area.

The inspection was conducted as a result of a complaint investigation involving three complaints with multiple allegations related to resident care and facility practices.

The investigation included observations, interviews, and record reviews related to the complaints. None of the allegations in the three complaints were substantiated, and no regulatory deficiencies were identified.

Three complaints were investigated: Complaint #NV00050651 with four allegations, Complaint #NV00050760 with two allegations, and Complaint #NV00050724 with four allegations. None of the allegations were substantiated.

The inspection was conducted as a complaint investigation triggered by two complaints regarding the facility's care practices, including monitoring of a resident's weight and administration of medications.

The investigation substantiated two complaints: failure to monitor a resident's weight per physician's order and failure to ensure appropriate documentation of medication administration. Several other allegations were not substantiated.

Two complaints were investigated. Complaint #NV00047813 was substantiated regarding failure to monitor a resident's weight. Complaint #NV00049309 was substantiated regarding medication administration documentation. Other allegations including incomplete nursing assistant tasks, inappropriate laboratory services, unavailable medical equipment, water availability, and incontinence care were not substantiated.

The inspection was conducted as a result of two complaint investigations regarding the facility's monitoring of a resident's weight and the appropriate documentation of medication administration.

The facility was found to have substantiated deficiencies related to failure to monitor a resident's weight per physician's orders and failure to ensure appropriate documentation of medication administration. Several other allegations were investigated but not substantiated.

Two complaints were investigated. Complaint #NV00047813 was substantiated regarding failure to monitor a resident's weight. Complaint #NV00049309 was substantiated regarding failure to ensure appropriate documentation of medication administration. Other allegations related to CNA task completion, laboratory services, medical equipment, water availability, and incontinence/skin care were not substantiated.

The inspection was conducted as a complaint investigation survey triggered by complaint #NV00048188 alleging that a Certified Nursing Assistant (CNA) pushed a resident while providing care.

The allegation against the CNA could not be substantiated; however, other deficiencies related to investigation and reporting of abuse allegations were identified. The facility failed to ensure thorough investigation of alleged abuse and proper handling of the complaint.

Complaint #NV00048188 alleged that a CNA pushed a resident while providing care. The allegation was not substantiated. The investigation included observations, interviews with staff and residents, and clinical record reviews. The CNA was placed on administrative leave and returned to work after the allegation was found unsubstantiated. The facility failed to ensure the alleged violation was thoroughly investigated.

The inspection was conducted as a complaint investigation triggered by an allegation that a Certified Nursing Assistant (CNA) pushed a resident while providing care.

The allegation of abuse (pushing and rough handling during care) by the CNA was not substantiated. However, the facility failed to thoroughly investigate the allegation as required, including not interviewing other residents or staff and not providing education or guidance to the CNA before returning to work. Several residents described the CNA as rough and using a loud voice during care.

Complaint #NV00048188 alleged that a CNA pushed a resident while providing care. The allegation was not substantiated. The investigation included observations, interviews with staff and residents, and record reviews. The facility did not complete a thorough investigation as required by policy and regulation.

The inspection was conducted as a Medicare recertification survey from November 29, 2016 through December 2, 2016, including investigation of one substantiated complaint (#NV00047538) related to an allegation of abuse.

The facility was found to have failed in timely reporting and investigating an allegation of abuse involving Resident #25, failure to ensure a fall prevention plan related to bed rails, medication error rates exceeding 5%, and failure to ensure proper food service sanitary practices. The complaint was substantiated and corrective actions were planned.

Complaint #NV00047538 was substantiated. The allegation involved an incident of abuse reported on 10/5/16 and substantiated by 10/10/16. The facility failed to report the incident timely and follow policy. Resident #25 was involved in the abuse allegation and was discharged on 10/6/16.

This document reports the results of a Medicare Recertification Life Safety Code Survey conducted at the Nevada State Veterans Home on 11/29/2016.

The facility was surveyed using the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19. No deficiencies were cited during this survey.

The inspection was conducted as a construction standards survey to evaluate compliance with the 2015 Edition of the National Fire Protection Association (NFPA) 101 Life Safety Code and 2006 AIA Guidelines for the Design and Construction of Health Care Facilities.

The facility was found to be in substantial compliance concerning the construction project involving renovation of the therapy courtyard and installation of a weatherized motor vehicle for transfer training.

The inspection was conducted as a result of a complaint investigation regarding allegations about resident care and feeding practices.

The investigation included observations, interviews, and record reviews, and concluded that the complaint allegations could not be substantiated. No regulatory deficiencies were identified and no further action was necessary.

Complaint #NV 00045075 involved four allegations related to resident feeding and hydration practices, all of which were found to be unsubstantiated.

Annual Medicare recertification survey conducted from 2016-01-05 through 2016-01-08 to assess compliance with federal regulations for long term care facilities.

The facility was found deficient in multiple areas including failure to properly report an allegation of abuse, failure to honor resident bathing preferences, failure to follow wound clinic recommendations, failure to secure treatment carts, failure to monitor nutritional status and weight changes, improper maintenance of PICC and central lines, failure to clarify oxygen orders, and inadequate monitoring of psychoactive medications.

The inspection was conducted as a Life Safety Code (LSC) survey to assess compliance with fire safety standards at the Nevada State Veterans Home.

The facility was found deficient in maintaining automatic sprinkler systems, with one sprinkler head having a non-functioning frangible bulb and four sprinkler heads covered with lint and dust. Additionally, one Alcohol Based Hand Rub (ABHR) dispenser was improperly installed over an ignition source, posing a safety hazard.

This report documents the annual Medicare recertification survey conducted at the facility from January 5, 2016 through January 8, 2016, to assess compliance with federal regulations for long term care facilities.

The survey identified multiple deficiencies related to abuse/neglect policies, resident self-determination, provision of care and services, wound care, accident hazards, nutrition status, treatment and care for special needs, drug regimen, and monitoring of psychotropic medications. The facility failed to properly report an alleged abuse incident within required timeframes and had several care and documentation deficiencies.

The inspection was conducted as a result of a complaint investigation initiated on 2/5/15 regarding an allegation that a former employee was given computer access to view resident information.

The complaint was investigated through interviews and record reviews, and it was determined that the complaint could not be substantiated. No regulatory deficiencies were identified and no further action was necessary.

Complaint #NV00041365 contained one allegation that a former employee was given computer access to view resident information. The complaint was not substantiated after investigation.

The inspection was conducted as a Life Safety Code (LSC) survey to assess compliance with fire safety standards at the facility.

The facility failed to ensure that one sprinkler head had a functioning frangible bulb and four sprinkler heads were free of foreign material, affecting two of ten smoke compartments. Additionally, an Alcohol Based Hand Rub dispenser was improperly installed directly above a duplex electrical outlet, posing a safety risk.

This inspection was a Medicare recertification survey conducted from December 2 through December 5, 2014, including one substantiated complaint investigation regarding medication administration.

The facility was found deficient in multiple areas including failure to administer medication per physician's orders, unsecured medication cart and lancets, failure to maintain nutritional status and care plans for weight changes, expired medications not disposed, and a partially closed sprinkler system valve causing an Immediate Jeopardy.

Complaint #NV00041356 was substantiated. The allegation that a resident did not receive medications per physician's orders was confirmed.

The inspection was conducted as a Life Safety Code (LSC) survey to assess compliance with fire safety regulations, specifically related to the sprinkler system.

The facility failed to maintain the sprinkler system in reliable working condition due to a partially closed main control valve, which posed an immediate jeopardy that was abated the same day. Corrective actions included re-educating staff, locking valves to prevent unauthorized access, and ongoing monitoring by qualified contractors.

The inspection was conducted as a Life Safety Code survey to assess compliance with fire safety standards, specifically focusing on the facility's automatic sprinkler system.

An Immediate Jeopardy was identified due to the sprinkler system not being maintained in reliable working condition caused by a partially closed main control valve. The deficiency was corrected the same day by fully opening the valve.

This inspection was a Medicare recertification survey conducted from December 2, 2014 through December 5, 2014, including investigation of one substantiated complaint.

The facility was found to have multiple deficiencies including failure to administer medications as ordered, unsecured medication cart and unattended lancets, inadequate nutritional status monitoring, and improper disposal of expired medications. One complaint was substantiated regarding medication administration.

Complaint #NV00041356 was substantiated. The allegation that a resident did not receive medications per physician's orders was confirmed.

The inspection was conducted as a result of a complaint investigation initiated on July 24, 2014, involving allegations about resident intimidation by a volunteer's dog and medication administration issues.

The investigation found one complaint unsubstantiated regarding the volunteer's dog, and another complaint substantiated related to failure to administer medications as ordered for 2 of 3 sampled residents. Additional deficiencies included failure to receive medications timely and inaccurate documentation in a resident's record.

Complaint #NV00039849 was investigated and unsubstantiated regarding residents being frightened by a volunteer's dog. Complaint #NV00039873 was investigated and substantiated related to medication administration failures.

The inspection was conducted as a result of complaint investigations (#NV00039849 and #NV00039873) regarding allegations involving resident intimidation by a volunteer's dog and failure to receive medications as ordered.

Complaint #NV00039849 was unsubstantiated, while complaint #NV00039873 was substantiated, revealing failures in medication administration and pharmaceutical services for sampled residents, including missed medications and inaccurate documentation.

Complaint #NV00039849 was investigated and unsubstantiated involving resident intimidation by a volunteer's dog. Complaint #NV00039873 was investigated and substantiated involving failure to administer medications as ordered.

The inspection was conducted as a result of a complaint investigation regarding an allegation that a resident was discharged to the hospital and unjustly denied re-admission.

The complaint investigation included review of 5 closed records, interviews with the Director of Social Services, review of a self-report on resident-to-resident altercation, and policies on bed hold notice and transfer discharge. The complaint was not substantiated and no further action was necessary.

Complaint #NV00039086 contained one allegation that a resident was discharged to the hospital and unjustly denied re-admission. The complaint could not be substantiated.

The inspection was conducted as a result of a Medicare complaint investigation initiated by the Division of Public and Behavioral Health on January 30, 2014, to investigate one complaint containing four allegations related to admission, transfer and discharge rights, food sufficiency, medication administration, and incontinence care.

The investigation substantiated the allegation regarding admission, transfer, and discharge rights related to the facility's bed-hold policy, finding that the facility failed to properly inform a resident and family about the bed-hold policy. Other allegations regarding insufficient food, medication administration, and incontinence care were not substantiated.

Complaint # NV00038063 contained four allegations: 1) Admission, transfer & discharge rights substantiated; 2) Insufficient food not substantiated; 3) Medications not administered properly not substantiated; 4) Improper incontinence care not substantiated.

The inspection was conducted as a Medicare complaint investigation initiated by the Division of Public and Behavioral Health on January 30, 2014, based on Complaint #NV00038063 which contained four allegations regarding admission, transfer & discharge rights, insufficient food, medication administration, and incontinence care.

The investigation substantiated the allegation regarding admission, transfer, and discharge rights related to the facility's bed hold policy for one resident. The other allegations regarding insufficient food, medication administration, and incontinence care were not substantiated. A regulatory deficiency was identified for failing to properly inform a resident and family about the bed hold policy upon transfer.

Complaint #NV00038063 contained four allegations: 1) Admission, transfer & discharge rights substantiated; 2) Insufficient food not substantiated; 3) Medications not administered properly not substantiated; 4) Improper incontinence care not substantiated.

This Statement of Deficiencies was generated as a result of the Medicare recertification survey conducted at the facility from 12/17/13 through 12/20/13, in accordance with 42 CFR Chapter IV, Part 483 - Requirements for Long Term Care Facilities.

The survey identified multiple deficiencies including failure to properly check gastrostomy tube placement prior to medication administration, failure to follow medication administration parameters, inadequate supervision of a resident on frequent observation, medication errors exceeding 5%, incomplete medication documentation, and inadequate staff training for emergency fire procedures.

This document is a Statement of Deficiencies generated as a result of the Medicare recertification survey conducted from 12/17/13 through 12/20/13 at the facility, in accordance with 42 CFR Chapter IV, Part 483 - Requirements for Long Term Care Facilities.

The facility was found deficient in multiple areas including failure to properly check gastrostomy tube placement prior to medication administration, failure to follow established parameters for medication administration, failure to ensure supervision and accident prevention, failure to ensure drug regimens are free from unnecessary drugs, failure to maintain medication error rates below 5%, failure to maintain complete and accurate clinical records, failure to train staff on emergency procedures, and failure to ensure fire safety compliance.

The inspection was conducted as a Life Safety Code (LSC) survey to assess compliance with fire safety and life safety standards at the facility.

The survey identified multiple deficiencies related to fire alarm system accessibility, sprinkler system obstructions, and improper installation of alcohol-based hand rub dispensers near ignition sources. Corrective actions and monitoring plans were outlined for each deficiency.

This Life Safety Code survey was conducted to assess compliance with fire safety and related regulations at the Nevada State Veterans Home.

The survey identified multiple deficiencies including obstructed manual fire alarm pull stations, a sprinkler head obstructed by a television, and an alcohol-based hand-rub dispenser installed too close to an ignition source.

The visit was a follow-up Medicare survey conducted at the facility to assess compliance with 42 CFR Chapter IV Part 483 Requirements for Long Term Care Facilities and NAC 449: Skilled Nursing Facilities.

No issues or deficiencies were identified during the follow-up survey of the facility.

This survey was conducted as a State Licensure construction standards survey in accordance with Nevada Administrative Code, Chapter 449, Facilities for Skilled Nursing, focusing on remodeling and construction compliance.

No deficiencies were identified during this life safety code survey related to the remodeling of the front lobby walls, borders, and fireplace with Eldorado rock installation.

The visit was a follow-up Medicare survey combined with a complaint investigation conducted at the facility on 8/9/13, focusing on allegations of lack of protective supervision and untimely administration of pain medications.

Two complaints were investigated; one regarding lack of protective supervision was substantiated, while the other regarding untimely pain medication administration was unsubstantiated. The facility failed to ensure adequate supervision to prevent accidents for one resident, resulting in injury due to exposure to excessive heat. The facility's corrective actions and policies were reviewed and found to be insufficiently implemented at the time of the investigation.

Two complaints were investigated: Complaint #NV00036305 regarding lack of protective supervision was substantiated; Complaint #NV00036224 regarding untimely administration of pain medications was unsubstantiated.

The inspection was conducted as a follow-up Medicare survey and complaint investigation triggered by two complaints: one regarding lack of protective supervision and another regarding untimely administration of pain medications.

The facility was found to have failed in providing adequate supervision to prevent accidents for one resident, resulting in heat stroke and blistering due to prolonged exposure to extreme heat. The complaint regarding untimely administration of pain medications was not substantiated. The facility lacked sufficient policies and implementation regarding monitoring residents during excessive heat conditions.

Complaint #NV00036305 was substantiated regarding lack of protective supervision. Complaint #NV00036224 regarding untimely administration of pain medications and delayed response to shortness of breath was not substantiated.

This complaint investigation was initiated due to a Medicare complaint involving allegations of resident abuse, medication errors, failure to follow physician orders, and failure to notify family and physicians of changes or injuries.

The investigation substantiated multiple deficiencies including abuse by a visitor, failure to obtain consent for medication administration, failure to notify family and physician after falls, incomplete neurological assessments, failure to investigate injuries of unknown origin, and incomplete clinical documentation and care planning.

Complaint # NV00035502 was substantiated. Allegations included resident-to-resident injury, visitor abuse of residents, medication administration without consent, failure to notify family and physician of falls and injuries, and failure to investigate injuries of unknown origin.

This inspection was conducted as a result of a Medicare complaint investigation initiated by the Nevada State Health Division on May 31, 2013, concerning allegations of resident abuse and medication errors.

The complaint was substantiated with multiple deficiencies noted including failure to prevent resident abuse by visitors, failure to obtain consent for medication administration, failure to notify family and physician of resident falls, failure to investigate injuries of unknown origin, and failure to maintain accurate and complete clinical records.

Complaint # NV00035502 contained three allegations: 1) Resident pushed another resident resulting in injury; 2) Resident struck by a family member who also struck another resident during a visit; 3) Resident received medication without family permission. All allegations were substantiated.

Annual Medicare Recertification survey conducted from 2012-11-27 through 2012-12-04, including an Extended Survey on 2012-12-11.

The survey identified multiple regulatory deficiencies including failure to notify physician and family timely of resident condition changes, inadequate abuse screening and training for contracted employees, failure to maintain residents' dignity, failure to provide timely treatment for hyponatremia, unsafe hot water temperatures, incomplete physician visit documentation, pharmaceutical service deficiencies including inaccurate medication orders and documentation, infection control lapses, incomplete and inaccurate resident records, and failure to maintain employee records with required tuberculosis testing and background checks.

The inspection was conducted as a complaint investigation based on allegations that the facility did not notify a resident's responsible party of a change in condition and did not properly assess one of three sampled residents.

The investigation found that one allegation was substantiated regarding improper assessment of a resident, while other allegations about notification and overmedication were not substantiated. Deficiencies included failure to appropriately assess residents and failure to provide necessary care and services to attain or maintain the highest practicable well-being.

Complaint #NV00033498 alleged failure to notify a resident's responsible party of a change in condition; this was not substantiated. Complaint #NV00033493 alleged failure to notify a resident's responsible party, overmedication, and inappropriate placement on a Legal 2000 involuntary hold; the notification and overmedication allegations were not substantiated, but the inappropriate placement allegation was substantiated.

The inspection was conducted as a complaint investigation based on allegations including failure to notify a resident's responsible party of a change in condition, improper assessment of a resident, overmedication, and inappropriate use of an involuntary hold (Legal 2000).

The investigation substantiated that one resident was inappropriately placed on a Legal 2000 involuntary hold despite having dementia and no history of mental illness, and that one resident was not appropriately assessed by a licensed nurse after a suspected injury, resulting in a fractured femur. Other allegations such as failure to notify responsible parties and overmedication were not substantiated.

Complaint #NV00033498 alleged failure to notify a resident's responsible party of a change in condition (not substantiated) and improper assessment of a resident (substantiated). Complaint #NV00033493 alleged failure to notify responsible party (not substantiated), overmedication (not substantiated), and inappropriate use of Legal 2000 involuntary hold (substantiated).

The inspection was conducted as a result of a Medicare complaint investigation at Nevada State Veterans Home on 07/06/2012, with the survey completed on 07/09/2012. The investigation focused on complaints alleging failure to provide proper assessment and implementation of the Plan of Care for sampled residents.

The investigation substantiated that the facility failed to notify the physician timely of a resident's change in condition and did not implement the Plan of Care for another resident. Deficiencies were found related to injury/decline in condition and failure to provide care and services for highest well-being, including inadequate fall risk management and monitoring.

Complaint NV00032240 alleged failure to prevent a fall and provide proper assessment; this was substantiated. Complaint NV00031846 alleged failure to implement the Plan of Care; this was substantiated.

The inspection was conducted as a Medicare complaint investigation triggered by allegations regarding fall prevention measures, timely physician notification of condition changes, and implementation of the Plan of Care for sampled residents.

The investigation substantiated that the facility failed to notify the physician timely of a resident's elevated blood pressure after a fall and did not fully implement the Plan of Care for another resident. One complaint about fall prevention measures was not substantiated.

The complaint investigation addressed two main allegations: 1) The facility did not take appropriate measures to prevent a fall and did not provide proper assessment (not substantiated). 2) The facility failed to notify the physician timely of a change in condition and failed to implement the Plan of Care for sampled residents (both substantiated).

This inspection was conducted as an annual Medicare Recertification survey in accordance with 42 CFR Chapter IV Part 483 for States and Long Term Care Facilities.

The facility was found deficient in multiple areas including failure to ensure resident privacy, inaccurate documentation of medication administration, failure to provide appropriate assistive devices during transfers, inconsistent carbohydrate diet servings, unsanitary kitchen conditions, and inadequate staff response to fire alarms.

The inspection was conducted as a Life Safety Code (LSC) survey to assess compliance with fire safety standards, including the proper identification and placement of fire extinguishers, cooking facility fire safety, vegetation management, and electrical wiring safety.

The facility failed to provide conspicuous markers for portable fire extinguishers, lacked proper placards for fire extinguishers in the cooking area, failed to thin and prune shrubbery adjacent to the building, and did not ensure all electrical junction boxes were properly covered. These deficiencies posed potential risks to residents and staff.

The inspection was conducted as a Life Safety Code (LSC) survey to assess compliance with fire safety and related building safety standards at the Nevada State Veterans Home.

The facility was found deficient in several areas including lack of conspicuous markers for fire extinguisher locations, absence of required placards for kitchen fire extinguishers, failure to thin and prune vegetation near the building increasing fire risk, and missing covers on electrical junction boxes posing fire hazards.

The inspection was conducted as an annual Medicare Recertification survey in accordance with 42 CFR Chapter IV Part 483 for States and Long Term Care Facilities, conducted from 1/9/11 to 1/12/12.

The facility was found deficient in multiple areas including personal privacy/confidentiality of records, provision of care and services, free of accident hazards, menus meeting resident needs, food procurement and sanitary conditions, and emergency procedures/drills. Specific deficiencies involved breaches of resident privacy, inaccurate documentation of medication administration, unsafe use of equipment, inconsistent dietary practices, and failure to respond properly to fire alarms.

The inspection was conducted as a result of a complaint investigation regarding allegations of improper use of restraints and concerns about dignity and privacy during care of a resident.

The allegation regarding restraints was not substantiated, but the allegation concerning dignity and privacy during resident care was substantiated. Additionally, an unrelated deficiency in infection control was identified.

Complaint #NV00027680 alleged improper use of restraints and lack of dignity and privacy during care. The restraint allegation was not substantiated; the dignity and privacy allegation was substantiated.

The inspection was conducted as a complaint investigation based on allegations concerning possible improper use of restraints, and dignity and privacy during care of a resident.

The allegation regarding improper use of restraints was not substantiated, but the allegation regarding dignity and privacy during resident care was substantiated for 2 of 4 residents. Additionally, an unrelated deficiency in infection control was identified related to failure to implement appropriate infection control measures and clean equipment between resident uses.

Complaint #NV00027680 alleged possible improper use of restraints and issues with dignity and privacy during care. The restraint allegation was not substantiated; the dignity and privacy allegation was substantiated.

This document is a Statement of Deficiencies generated as a result of a Medicare Life Safety Code (LSC) survey conducted at the Nevada State Veterans Home - Boulder City on January 11, 2011.

The facility was surveyed for compliance with the 2000 Edition of the National Fire Protection Association's (NFPA) 101 Life Safety Code. Multiple deficiencies were identified related to corridor door impediments, exit access and exit door design, storage blocking egress, fire drill compliance, smoking regulations, medical gas system alarms, electrical wiring, and emergency generator transfer switch timing.

This inspection was conducted as the annual Medicare recertification survey at the Nevada State Veterans Home - Boulder City from 1/4/11 through 1/11/11 in accordance with 42 CFR Chapter IV Part 483 Requirements for Long Term Care Facilities.

The survey identified multiple deficiencies related to residents' rights, informed consent, use of physical restraints, dignity and respect, development of comprehensive care plans, medication error rates, drug records, infection control, and clinical record accuracy. The facility failed to ensure residents' rights were protected, care plans were properly followed, medication errors were minimized, and infection control procedures were adequately implemented.

The Health Division is imposing sanctions on the Nevada State Veterans Home - Boulder City due to deficiencies found during a prior survey conducted on November 10, 2009.

The report notifies the facility of sanctions based on the severity and scope of deficiencies, specifically citing a deficiency at TAG Z230 with a severity level of three and a scope level of two or less. The Plan of Correction submitted on January 27, 2010, was reviewed and accepted.

The inspection was conducted as a State licensure Construction standards compliance survey during the facility's Annual Life Safety Code recertification on 11/12/09 and 11/13/09.

The survey focused on the facility's newly added flooring and walls to their Mariner Unit (Alzheimer Unit). No regulatory deficiencies were identified.

This report documents the results of a State licensure survey conducted from November 3, 2009 through November 10, 2009, concurrently with the Medicare recertification survey, to assess compliance with Nevada Administrative Code for Skilled Nursing Facilities.

The facility failed to provide adequate protective supervision for Resident #25, resulting in a fall with injury. The resident had multiple cognitive impairments and behavioral issues, and despite monitoring and interventions, suffered injuries including fractured ribs and a head laceration.

The inspection was a State licensure survey conducted concurrently with the Medicare recertification survey from November 3, 2009 through November 10, 2009, to assess compliance with Nevada Administrative Code for Skilled Nursing Facilities.

The facility failed to ensure that one resident (#25) was given the protective supervision needed to prevent an accident with injury. The resident experienced a fall resulting in head injury and other physical harm. A Plan of Correction was required to address the deficiencies and prevent recurrence.

The inspection was conducted as a result of a complaint investigation regarding failure to notify the attending physician following two external dental consultations for Resident #1.

The facility failed to ensure the attending physician was notified after two separate dental consultations for Resident #1, which resulted in a lack of timely medical intervention. Resident #1 experienced a decline in health following dental procedures and eventually expired. The facility's policy required notification and transcription of new orders, but this was not followed.

The complaint investigation (CPT # NV00020237) was substantiated with deficiencies related to failure to notify the attending physician after two dental consultations for Resident #1.

This inspection was conducted as the annual Medicare re-certification survey of the facility.

The facility failed to ensure that physical restraints used as enablers were properly assessed, care planned, and ordered by a physician for one resident. Specifically, a Velcro strap used to secure a resident's feet to a wheelchair lacked physician order and care plan documentation.

The inspection was conducted as part of the annual Medicare re-certification survey at the facility from 11/18/08 to 11/21/08.

The facility failed to ensure that physical restraints were properly assessed, care planned, and ordered by a physician for 1 of 25 sampled residents. Specifically, Resident #3 was found to have a Velcro strap used as a restraint without proper physician orders or care plan documentation.

9PXI21

9PXI21

EP_poc.pdf

EP_poc.pdf

LSC_poc.pdf

NFQZ21