Boulder City Hospital SNF

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure an adequate pull string was attached to the emergency call light located in a resident's bathroom. The deficient practice had the potential to compromise resident safety and well-being in an emergency. Findings include: On 05/22/25 at 03:25 PM, an observation of the emergency call light in room [ROOM NUMBER], did not have a proper pull string (a cord which activated the device which was mounted to the wall). On 05/22/25 at 03:50 PM, the Licensed Practical Nurse (LPN) observed the emergency call light and stated the emergency call light did not have an adequate pull string to call for assistance. The LPN verbalized a resident would not be able to use the call light easily. On 05/22/25 at 03:52 PM, the Director of Nursing verbalized an emergency call light pull string must be long enough for a resident to reach in case of an emergency. On 05/22/25 at 03:53 PM, the Risk Manager stated the emergency call system should have a pull…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and document review, the facility failed to ensure employees completed mandatory dementia training, for one of 10 sampled employees (Employee 9). The deficient practice had the potential to result in an employee being unprepared to respond appropriately to the altered mentation of residents with dementia. Findings include: On 05/22/2025, at 8:52 AM, 10 employee files were reviewed with the Director of Human Resources. Employee 9 (E9) was hired on 11/15/2024 for the position of Certified Nurse Assistant. On 05/22/2025, in the morning, the Director of Human Resources revealed mandatory dementia training was to be completed within 30 days after hire. The Director of Human Resources reported the purpose of the dementia training was to prepare employees to respond appropriately to residents with altered mentation. The Director of Human Resources verbalized E9's file lacked documented evidence dementia training had been completed. The facility policy and procedure title Mandatory Training (New Hires), dated 08/30/2018, indicated the facility provided all new hires with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. The facility MDS data from the resident assessment indicated data was more than 120 days for Residents 11, 28, 27, 3, and 9. The State MDS Coordinator documented in June 2023, there was a 20% late submission for residents at the facility. On 06/07/2024 in the afternoon, the Minimum Data Set (MDS) Coordinator indicated working remotely and only coming to the facility when there was a technical issue with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. The MDS Coordinator explained being at facility once a week and was not in the facility when it was due. The MDS coordinator verbalized most of work was done remotely however, was unable to access information from remote workstation and was planning on completing the next day however became ill. The MDS coordinator revealed being the only one at the facility with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) level two referral was completed for 1 of 15 sampled residents (Resident 35). The deficient practice had the potential to deprive the resident of concern and other residents of necessary behavioral health services. Findings include: Resident 35 (R35) R35 was admitted on [DATE], with a diagnosis of schizophrenia. On 06/04/2024 in the morning, R35 was up in a wheelchair and stated had been at the facility for about 3 months. A PASARR level one document dated 01/12/2024, indicated R35 did not have dementia, mental illness (MI), intellectual disability (ID), mental retardation (MR), or any related condition (RC) and was deemed appropriate for nursing facility placement. The admission diagnoses from an acute care facility dated 01/26/2024, documented R35 had no cognitive deficits or diagnoses. The acute care facility physician progress note dated 01/28/2024,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, and document review, the facility failed to follow or clarify physician order regarding a suprapubic catheter size prior to insertion. The deficient practice had the potential to result in discomfort or inadequate drainage of the bladder. Findings include: Resident 31(R31) R31 was admitted on [DATE] with diagnoses including obstructive uropathy and severe neurocognitive deficit. On 06/04/2024 at 9:15 AM, resident was sitting in bed awake and alert. Resident indicated staff recently changed catheter. On observation the resident had suprapubic catheter inserted on right side abdomen. Dressing was soiled with yellow tinged fluid. On 06/07/2024 at 10:00 AM, a Licensed Practical Nurse (LPN) indicated all wound and any care treatments such as catheter care would be documented in the treatment book at the nurse's station. The treatment book would contain the most recent order for resident care. The treatment administration record for R31 indicated an order to change…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, document review and interview, the facility failed to ensure stored foods were labeled and dated and food items were discarded prior to the expiration date. This deficient practice posed a potential risk to safety and health standards which could lead to contamination, inadequate storage, and place residents at risk of foodborne illness. Findings include: On 06/04/2024 at 8:15 AM, an open bag of chicken tenders was stored in the walk-in freezer without a label as to what is in the bag or a date as to when the bag was opened. The Dietary Manager explained the open bagged item should have been dated as to when the bag was opened and labeled before placing the opened bag back in the freezer. The Dietary Manager had the staff label and date the bag during the survey. The Dietary Manager was able to determine when the bag was opened by the menu details. On 06/04/2024 at 8:17 AM, a container of cottage cheese was stored in the walk-in refrigerator with an expiration date of 05/31/2024. The Dietary Manager explained the item should have been discarded. The Dietary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure admission and weekly skin assessments were completed in accordance with the facility's wound care protocol for 3 of 12 sampled residents (Residents #17, #23 and #32). The failure resulted in a delay in treatment interventions which potentially placed the residents at risk for worsened or infected wounds. Findings include: Resident #17 (R17) R17 was admitted on [DATE] and readmitted on [DATE], with diagnoses including multiple sclerosis and chronic debility. On 04/18/2023 at 9:35 AM, R17 laid awake and alert in a bariatric specialty mattress. The resident reported being a longtime resident of the facility but recently returned from the hospital. The resident indicated having a stage three pressure ulcer in the sacral area which was identified and treated by hospital staff. The resident indicated no one in the facility had examined the resident's pressure ulcer since R17's readmission on the evening of 04/17/2023, nor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure a physician order was obtained for the insertion of a peripherally inserted central catheter (PICC) line, and care orders were transcribed for 1 of 12 sampled residents (Resident 32). The failure to obtain a physician's order before inserting the PICC line and to manage the PICC line insertion site could potentially lead to serious medical complications for the resident which may include infections, bleeding, nerve damage, or life-threatening events. Findings include: R32 was admitted on [DATE], with diagnoses including dementia and debility. The Brief Interview of Mental Status dated 02/23/2023, documented a score of 6/15, which means R32's cognitive status was severely impaired. The Informed Consent for Procedure Administration of Anesthetic and/or the Rendering of Other Medical Services dated 04/07/2023, documented the procedure Peripherally Inserted Central Catheter (PICC) Line was consented to by a family…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and document reviews, the facility failed to ensure the Oxygen (O2) orders were followed and parameters were clarified for 2 out of 12 sampled residents (Residents 32 and 9). The failure to follow O2 orders and clarify parameters could have potentially led to serious health complications, such as hypoxia (O2 deficiency) and hyperoxia (excess O2 supply), organ damage, cognitive impairment, and death. Findings include: A facility policy titled Procedure for Administering Oxygen by Cannula revised 05/21/2023, documented to verify the order. Adjust the flowmeter as ordered. Resident 9 (R9) R9 was admitted on [DATE], with diagnoses including cerebrovascular accident and myocardial infarction. The Brief Interview of Mental Status dated 03/13/2023, documented a score of 15/15, indicating R9's cognitive status was intact. The Minimum Data Set, dated [DATE], documented R9 was receiving Oxygen therapy. On 04/18/2023 at 09:55 AM, R9 was lying in bed with the head of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure a pharmacy recommendation which was approved and signed by a physician for a resident's psychiatric evaluation was carried out for 1 of 12 sampled residents (Resident #23). The failure potentially delayed a re-evaluation of the resident's medication regimen which was essential in maintaining the highest practicable mental, physical, and psychosocial well-being of the resident. Findings include: Resident #23 (R23) R23 was admitted on [DATE], with diagnoses including major depressive disorder and anxiety disorder. A Pharmacy note to attending physician or prescriber dated 03/07/2023, documented Resident #23 is receiving multiple psychotropic agents and due for psychiatric follow up. The document contained a physician/prescriber response dated 03/21/2023 which read, Agreed. Psychiatric consult pending. The medical record lacked documented evidence the physician order for psychiatric consult was entered into R23's medical record and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure there was a documented indication for use for psychotropic medications orders for 1 of 12 sampled residents (Resident #23). The failure potentially placed the resident at risk for receiving unnecessary medications. Findings include: Resident #23 (R23) R23 was admitted on [DATE], with diagnoses including major depressive disorder and anxiety disorder. The Psychotropics/Antipsychotics Use policy revised 09/02/2015, documented the resident's entire medication regimen would be managed and monitored to achieve the following goals: to achieve the highest practicable mental, physical, and psychosocial well-being in collaboration with the attending physician and facility staff. Each resident would receive only those medications, in doses and for the duration clinically indicated to treat the resident's assessed conditions. Prior to initiating an antipsychotic medication, the physician would complete the antipsychotic diagnosis form and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.