Nevada State Veterans Home - Boulder City

In the surveyor’s words

From the most serious findings on record at Nevada State Veterans Home - Boulder City, in the surveyor’s own words.

• Actual harm, isolatedF692Dec 6, 2024

  Based on observation, interview, record review, and document review, the facility failed to ensure: 1) A nutritional assessment was completed when significant weight loss was identified; 2) Interventions were implemented; and 3) A resident was reweighed when significant weight loss was identified, and weight was obtained monthly per policy for 1 of 30 sampled residents (Resident 139). The deficient practices had the potential to lead to further weight loss. Findings include: Resident 139 (R139) was admitted on [DATE], with diagnoses including chronic kidney disease (CKD), anemia, and malignant melanoma of the face. 1) R139's medical records lacked documented evidence nutritional assessments were completed when significant weight loss was identified. […]

• No harm, potential for more than minimal, patternF804Jan 30, 2024

  Based on observations, interviews, and document review the facility failed to ensure residents received warm and palatable meals. The deficient practice placed the residents at risk for not consuming meals to maintain appropriate nutrition needed for overall good health. Findings include: On 01/23/2024 at 8:24 AM, the dishwasher temperature was below acceptable levels with current reading of 101 degrees Fahrenheit. Temperature log was completed for dishwasher and did not reveal any previous concerns. The Dietary Manager indicated dishwasher temperature was new concern, however the service company was scheduled to be at the facility in the next several hours and would inform the service company of identified concern. […]

• No harm, potential for more than minimal, isolatedF690Feb 13, 2026

  Based on observation, interview, record review and document review, the facility failed to ensure physician orders were followed for a resident's indwelling catheter, specifically, following the correct Foley size for 1 of 34 sampled residents (Resident 177). The deficient practice had the potential to place the resident at risk for catheter-related complications such as urethral trauma and pain.Findings include:Resident 177 (R177) was admitted on [DATE], with diagnoses including neuromuscular dysfunction of the bladder and chronic Foley catheter use.On 02/10/2026 in the morning, R177 was seated in wheelchair with a covered urinary bag hanging below center of the wheelchair. […]

• No harm, potential for more than minimal, isolatedF757Feb 13, 2026

  Based on record review, observations, interviews, and document review, the facility failed to ensure:Prescribed parameters for blood pressure medications were consistently followed and the physician notified of low blood pressure readings for 1 of 34 sampled residents (Resident #2); and parameters for administering prescribed pain medication were followed for 1 of 34 sampled residents (Resident #134).These deficient practices had the potential to result in the inappropriate administration of blood pressure medication, leading to hypotension, dizziness, or falls, and the inappropriate administration of pain medication, which could have resulted in inadequate pain management.Findings include:Based on record review, observations, interviews, and document review, the facility failed to… […]

• No harm, potential for more than minimal, isolatedF773Feb 13, 2026

  Based on interview, record review and document review, the facility failed to ensure an abnormal Hemoglobin A1C (HgbA1C) was communicated to and addressed by a physician for 1 of 34 sampled residents (Resident 23) and physician orders for quarterly HgbA1C blood test were carried out for 2 of 34 sampled residents (Resident 23 and 104). The deficient practice had the potential to place the residents at risk for diabetes-related complications and delayed treatment. Findings include:Resident 23 (R23) was admitted on [DATE], with diagnoses including unspecified dementia with other behavioral disturbance and diabetes mellitus. […]