Boulder City Hospital SNF

In the surveyor’s words

From the most serious findings on record at Boulder City Hospital SNF, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF640Jun 7, 2024

  Based on interview, record review, and document review the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were transmitted timely for 5 of 5 residents reviewed for Resident Assessment (Residents 11, 28, 27, 3, and 9). The deficient practice had the potential to impact resident care by also delaying the resident care plan. Findings include: The facility policy titled Assessments Periodic for Minimum Data Set (revised 10/25/2021) documented periodic assessments were conducted by the MDS Coordinator. The results of the assessments were used to create resident care plans and calculate resource utilization grouping categories used by regulators, payers, and surveyors. […]

• No harm, potential for more than minimal, widespreadF851Jun 7, 2024

  Based on interview and document review the facility failed to ensure the quarterly payroll based journal (PBJ) data was submitted to Center for Medicare and Medicaid Services (CMS). The deficient practice prevented CMS from analyzing staffing patterns and populate the staffing component of the Nursing Home Compare website. A review of the facility Certification and Survey Provider Enhanced Reporting System (CASPER) report revealed the facility failed to submit staffing data for the first quarter of 2024. On 06/04/24 at 1:28 PM, the Minimum Data Set (MDS) Coordinator indicated being the person responsible for submitting the PBJ data and was aware the PBJ data was not submitted for the first quarter of the 2024 fiscal year. […]

• No harm, potential for more than minimal, widespreadF563Oct 15, 2021

  Based on observation, interview and document review, the facility failed to ensure outdoor and indoor visitation was provided for 10 of 34 residents. Findings Include: On 10/12/2021 at 8:00 AM, There were signs on the front door entrance to the hospital indicating No visitors allowed due to COVID-19. The Long-Term Care (LTC) unit was accessed by entering the hospital waiting room area and walking through the building to the LTC unit. The LTC unit was in the back of the building and was a separate area from the hospital. The LTC unit had multiple doors to the outside and had two courtyards. One courtyard had an awning with three tables and multiple chairs. Part of the courtyard had benches located in a sunny area. The other courtyard was not blocked in. […]

• No harm, potential for more than minimal, widespreadF882Feb 11, 2021

  Based on interviews, the facility failed to provide evidence the Infection Preventionist completed specialized training in infection prevention and control. Findings include: On 02/10/2021 at 8:34 AM, the Infection Preventionist (IP) revealed being in the process of completing specialized training in infection prevention and control through the Centers of Disease Control and Prevention (CDC). The IP indicated starting the modules in the training but has not had a chance to complete the training and obtain the certificate. The IP indicated having the role of the IP in the facility since 2007. […]

• No harm, potential for more than minimal, widespreadF885Feb 11, 2021

  Based on interviews, the facility failed to ensure the residents and family members were notified of a confirmed COVID-19 case when a staff member tested positive for COVID-19. Findings include: On 02/10/2021 at 1:57 PM, the Infection Preventionist (IP) and the Director of Nursing (DON) revealed the most recent positive COVID-19 case in the facility was on 01/21/2021, when a Certified Nursing Assistant tested positive for COVID-19. The DON indicated the Activity Director was one of the staff members assigned to call the residents' family members or representatives and inform them the facility would be performing COVID-19 testing for the residents. […]