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Nevada State Veterans Home - Boulder City

100 Veterans Memorial Dr, Boulder City, NV 89005 · Government - State · 180 certified beds · (702) 332-6711 Medicare & Medicaid certified

Call the home — (702) 332-6711 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jan 2024Behavioral-health or dementia-care citations — no harm found (F0744, F0758)1 actual-harm citation$10,358 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2024
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $10,358 in federal fines (most recent 2024-12-06)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1631 Boulder City Pkwy · (702) 919-7505 · Call to confirm hours
Pharmacy
800 Buchanan Blvd · (702) 293-6705 · Call to confirm hours
Grocery
1008 Nevada Hwy · (702) 293-7592 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
1200 Industrial Rd · (678) 772-3986

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased19.3%12.6%15.4%worse
Long-stay residents who lose too much weight4.7%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.0%1.6%0.9%better
Long-stay residents with a urinary tract infection1.9%1.9%2.0%typical
Long-stay residents with depressive symptoms0.7%5.1%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.1%2.0%3.3%typical
Long-stay residents whose ability to walk worsened15.0%13.5%16.1%typical
Long-stay residents on antianxiety or hypnotic medication10.1%22.2%18.9%better
Long-stay residents given the seasonal flu vaccine96.8%89.6%95.3%typical
Long-stay residents with pressure ulcers4.4%5.4%4.7%typical
Long-stay residents with worsening bladder/bowel control25.4%15.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table12.6%17.1%17.1%better
Short-stay residents given the seasonal flu vaccine75.6%80.7%79.4%typical
Long-stay hospitalizations per 1,000 resident days1.391.851.67better
Long-stay outpatient ER visits per 1,000 resident days0.641.451.80better

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

9.9%U.S. median 10.7%
Went back to hospital
21.7%U.S. median 56.6%
Met the expected recovery
0.25U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 21.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 23 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.25 therapist hours per resident per day in 2026Q1 — more than 34% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.9%CMS range 6.5–14.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge21.7%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge13.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge17.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified93.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.3%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.121.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.84
RN hours/ resident / day
0.81
LPN hours/ resident / day
2.35
Aide hours/ resident / day
3.99
Total nurse hours/ resident / day
0.63
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 180 beds and averages 167.7 residents a day — about 93% occupied, or roughly 12 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.99 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.84 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.35 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.61 hrs/resident/day on weekends vs 4.15 on weekdays — 13% thinner on weekends. RN hours go from 0.92 to 0.63 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

3
deficiencies at the latest standard inspection (2026-02-13)
9
at the previous standard inspection (2024-12-06)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · G2024-12-06 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. R139's Weight Summary documented as follows: -12/02/2024: 145.0 lbs. (Weight loss of 15 lbs.) -10/04/2024: 160.0 lbs. -09/04/2024: 161.0 lbs. -08/02/2024: 147.0 lbs. (Weight loss of 18 lbs.) -07/01/2024: 165.0 lbs. (Weight loss of 12 lbs.) -06/07/2024: 177.0 lbs.…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. R177 indicated taking oral antibiotics for a suspected urinary tract infection and had experienced burning and pain to the catheter site the day before. R177 indicated not being certain if the night nurse replaced the catheter but the resident was relieved with the nurse's intervention. The admission minimum data set (MDS) dated [DATE],…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-13 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 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…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-13 · tag F0773 — isolated
    Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. The admission minimum data set (MDS) dated [DATE], revealed R23 was admitted with an active diagnosis of diabetes mellitus and was not receiving Insulin. A physician order dated 04/30/2025, documented to complete an HgbA1C every three months by night shift on the last day of month. Review of medical record revealed R23's HgbA1C on 05/07/2025 was 7.0 percent (%). A lab interpretation note…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-01 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure the resident who had dementia was free from physical restraints for 1 of 6 sampled residents (Resident 6). This deficient practice had the potential to cause diminished physical functioning, increased confusion, psychosocial distress, and a decline in quality of life. Findings include: Resident 6 (R6) R6 was admitted on [DATE], with diagnoses including dementia, hearing loss, and major depressive disorder. The admission Minimum Data Set, dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severely impaired cognitive status. R6 had routinely used a walker. The Nursing Progress Notes for the month of March documented multiple instances when R6 was confused, agitated, and restless. The Psychiatric Evaluation dated 03/25/2025, documented the encounter had been conducted in person. R6's safety had been assessed, and the current risk was deemed low; therefore, a safety…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-06 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 / physician extender, and the resident representative were notified when a resident experienced poor appetite and a significant weight loss for 1 of 30 sampled residents (Resident 139). The deficient practice had the potential for the physician or family to not be aware of a change in a resident's condition which could result in a delay in a resident's plan of care. Findings include: Resident 139 (R139) was admitted on [DATE], with diagnoses including chronic kidney disease (CKD), anemia, and malignant melanoma of the face. R139's census documented received hospice services from 05/16/2024 to 06/11/2024. The Director of Nursing (DON) confirmed R139 was discharged from hospice services on 07/11/2024. A Physician Order dated 05/16/2024, documented a regular diet, regular texture, and thin consistency. 1) A Care Plan initiated on 05/17/2024 documented R139's diet was provided and served as ordered. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-06 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to follow the facility policy on referring residents for a Preadmission Screening and Resident Review (PASARR) Level 2 evaluation who acquired a new diagnosis indicative of a mental illness or begin a new psychotropic medication for 3 of 30 sampled residents (Resident 72, 139, and 98). The deficient practice had the potential to place residents at risk of not being evaluated for appropriate determination of necessary behavioral health services. Findings include: 1.) Resident 72 (R72) was admitted on [DATE] and readmitted [DATE], with diagnosis including type 2 diabetes mellitus with hyperglycemia, major depressive disorder, and senile degeneration of brain. On 12/03/2024 at 9:11 AM, R72 was observed in the dining room sitting on wheelchair with eyes closed and calm. R72 did not display concerning behaviors or symptoms of distress. A Nevada PASARR Level I Identification Determination dated 08/02/2021, revealed R72 did not…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-06 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and document review, the facility failed to ensure a care plan was revised to include current communication practices for 1 of 30 sampled residents (Resident 69). The deficient practice placed the resident at risk for inaccurate communication leading to inappropriate care. Findings include: Resident 69 (R69) was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, dysarthria following unspecified cerebrovascular Disease, major depressive disorder, dysphagia, and dysphonia. On 12/03/2024 in the morning, the resident was lying in bed with a Dynavox box (a type of communication device) in the room, but it did not appear R69 was using it. R69 was only able to answer yes/no questions. On 12/04/2024 at 9:18 AM the Speech-Language Pathologist (SLP) explained R69 had a hard time vocalizing and articulating. The resident's voice was inconsistent and dysarthric (a motor speech disorder in which the muscle used for speech are weak). The SLP stated…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-06 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure an omitted dose due to drug unavailability was prevented for 1 of 30 sampled residents (Resident 255). These deficient practices could have the potential to result in adverse health outcomes including delayed healing or ineffective treatment. Findings include: Resident 255 (R255) was admitted on [DATE], with diagnosis including urinary tract infection, polyneuropathy, and chronic pain syndrome. On 12/04/2024 at 8:30 AM, R255 was observed in their room while interacted with a nurse and discussed medications refused and medications to be administered. R255 was alert and oriented and no observation concerns were identified. A Physician Order dated 11/11/2024 documented Zinc Oxide Ointment 10%, apply topically two times a day for excoriation, topical. The morning dose was to be administered at 8:00 AM. On 12/04/2024 at 8:35 AM, the nurse failed to administer Zinc Oxide Ointment 10% as ordered by the physician. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to identify a new skin impairment for 1 of 30 sampled residents (Resident 26). The deficient practice placed the resident at risk for worsening skin impairments and diminished quality of life. Findings include: Resident 26 (R26) admitted to the facility on [DATE] with diagnoses including stage 4 pressure ulcer upon admission. On 12/04/24 at 9:46 AM, R26 stated having a pressure ulcer acquired from another facility but developed one while in the current facility. R26 believed the new pressure ulcer developed because of lying in bed all day and sometimes in excrement for long periods of time. Review of R26's care plan revised on 10/09/2024 identified the following: R26 was at risk for skin breakdown, skin tears, bruising/skin discoloration and pressure ulcers related to impairment of physical mobility post total left hip surgery, refusal to be turned and repositioned, and fragile/sensitive skin. Goals included: Resident will…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-06 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 for a gradual dose reduction (GDR) was communicated to the physician for 1 of 30 sampled residents (Resident 45). The deficient practice had the potential to cause the resident to be administered a higher dose of medication than was necessary. Findings include: Resident 45 (R45) was admitted on [DATE], with diagnosis including Alzheimer's disease with late onset, dementia, and major depressive disorder. On 12/05/2024 at 7:15 AM, the resident was observed lying in bed, eyes closed, no signs and symptoms of pain or distress. A Physician Order dated 07/24/2024, documented Escitalopram Oxalate Oral Tablet 20 milligrams (mg) 1 tablet by mouth in the morning for depression/anxiety. A Psychoactive Medication Consent dated 07/25/2024, documented Escitalopram 20 mg 1 tablet by mouth in the morning, specific target behaviors depression/anxiety. Potential side effects included headache, constipation, 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2024-12-06 · tag F0847 — isolated
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to ensure 1) the arbitration agreement stated neither the resident or their representative is required to sign the agreement as a condition of admission or to receive care at the facility, and 2) the arbitration agreement explicitly grant the resident or their representative the right to rescind the agreement within 30 calendar days of signing it. The deficient practice had the potential to deny admitted residents or their representatives the right to withdraw from the agreement within the 30-day after the signature as well as to deny the resident or representative their right to resolve their dispute in the court of law. Findings include: A facility document titled .Home admission Contract, documented by signing, a resident confirmed to have received a copy of the document, and the provisions of the contract had been explained in a clear and understandable manner. The document indicated all the questions formulated by the resident had been answered. Section 10 of this contract was Arbitration. This section of the document…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-06 · tag F0848 — isolated
    Provide a neutral and fair arbitration process and agree to arbitrator and venue.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to ensure the Arbitration Agreement provided for the selection of a neutral arbitrator agreed upon by both parties; and for the selection of a venue that was convenient to both parties. The deficient practice had the potential to obstruct a resident's ability to make a well-informed decision about signing the arbitration agreement. Findings include: A facility document titled .Home admission Contract, documented by signing, a resident confirmed to have received a copy of the document, and the provisions of the contract had been explained in a clear and understandable manner. The document indicated all the questions formulated by the resident had been answered. Section 10 of this contract is Arbitration. This section of the document revealed by signing this contract, the resident or their representative agreed to have any dispute between the resident and the facility decided by arbitration administered by the National Health Lawyers Association and not a neutral arbitrator agreed upon by both parties. The arbitration section…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-06 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, document review, and interview, the facility failed to ensure a nurse performed hand hygiene after medication administration of an intradermal patch, after removing gloves and prior to administration of another resident's medication for 1 unsampled resident (Resident 113). The deficient practice had the potential for cross-contamination and the spread of infection. Finding Include: Resident 113 (R113) was admitted on [DATE] with diagnosis including Parkingson's disease without dyskinesia, Alzheimer's disease, and dementia. A Physician Order dated 09/19/2024 documented Exelon Patch 4.6 milligrams (mg), 1 patch every day transdermal. Indication diagnosis was dementia with behaviors. On 12/04/2024 at 7:44 AM, R113 was observed in the dining area. A nurse removed the existing Exelon Transdermal Patch and replaced it with a new patch. The nurse failed to perform hand hygiene after removing gloves and prior to administration of medication to another resident. On 12/04/2024 at 8:00…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-30 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. On 01/23/2024 at 8:45 AM, the Dietary Manager indicated the dishwasher would be taken out of service until further notice and meals would primarily be served in styrofoam containers until dishes could be properly cleaned and sanitized. On 01/23/2024 at 9:23 AM, Resident 24 (R24) indicated food was…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ddisputed · IDR2024-01-30 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 1 of 31 sampled residents (R155) were free from mental / verbal abuse. The deficient practice resulted in potential psychosocial harm for the resident. Findings include: A review of the Abuse Neglect and Exploitation policy revised 03/15/2017, documented verbal abuse was described as oral, written, or gestured language toward a resident that was derogatory or disparaging. This was without regard to the resident's ability to see, hear, or comprehend such language. Mental abuse included but was not limited to statements or actions that humiliate, harass, and threats of punishment of deprivation. A review of the Civility Pledge posted throughout the facility documented staff will: - Hold themselves responsible for their words, thoughts, and actions - Speak in a civil manner to others, even if they do not agree with what is being communicated - Respectfully point out uncivil behavior from others. - Genuinely attempt to listen to and understand…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-30 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to develop a baseline care plan within 48 hours of admission for a resident using a brace (a medical device used to prevent unwanted movement in a joint), for 1 of 31 sampled residents (Resident 141). The deficient practice had the potential to delay or prevent the provision of needed care to the resident, which could result in adverse mental or physical outcomes for the resident. Findings include: Resident 141 (R141) R141 was admitted on [DATE] with diagnoses including fracture of the lower end of the right femur (thigh bone). On 01/23/24 at 10:12 AM, R141 was supine in bed and answered questions appropriately. R141 reported being confined to bed most of the time. The resident recalled undergoing surgery for a thigh bone fracture occurring just above the right knee, with implanted hardware. R141 reported following surgery a brace had been applied to the right leg, and the resident had subsequently been transferred from 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-30 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure a comprehensive care plan for post-traumatic stress disorder (PTSD) was developed for 1 of 31 sampled residents (Resident 149). The deficient practice had the potential for the resident not receiving person-centered care and services. Findings include: Resident 149 (R149) R149 was admitted on [DATE], with diagnoses including post-traumatic stress disorder (chronic) and anxiety disorder. The admission Summary Nurse's Notes dated 12/13/2023, documented R149 had helicopter-triggered PTSD. R149's admission Minimum Data Set (MDS) dated [DATE], documented the resident's active diagnoses including PTSD and anxiety disorder. R149's medical record lacked documented evidence a comprehensive care plan for the resident's PTSD was developed. On 01/30/2024 at 12:45 PM, the MDS Coordinator confirmed the findings and revealed R149's MDS admission assessment was completed on 12/26/2023. The MDS Coordinator explained the comprehensive care plan…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-30 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to obtain a physician order or to assess a brace (a medical device used to prevent unwanted movement in a joint), for 1 of 31 sampled residents (Resident 141). The deficient practices had the potential to result in damage to the resident's affected joint, and/or impaired circulation and resultant tissue damage to the extremity. Findings include: Resident 141 (R141) R141 was admitted on [DATE] with diagnoses including fracture of the lower end of the right femur (thigh bone). On 01/23/24 at 10:12 AM, R141 was supine in bed and answered questions appropriately. R141 reported being confined to bed most of the time. The resident recalled undergoing surgery for a thigh bone fracture occurring just above the right knee, with implanted hardware. R141 reported following surgery a brace had been applied to the right leg, and the resident had subsequently been transferred from the hospital to the nursing facility still wearing 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-30 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to 1) develop and implement a person-centered care plan to support dementia care needs and 2) develop individualized interventions related to symptoms of dementia for 1 of 31 sampled residents (R117). Findings include: Resident 117 (R117) R177 was admitted on [DATE] with diagnoses including dementia, major depressive disorder, and post-traumatic stress disorder. On 01/24/2024 at 9:41 AM, R177's medical record lacked documented evidence of a care plan or individualized interventions for dementia. A review of the most recent Minimum Data Set (MDS) section I documented R177 was coded with an active diagnosis of dementia. On 01/25/2024 at 9:41 AM, the MDS Manager Coordinator verbalized R117 required assistance with activities of daily living due to a compression fracture, was at risk for falls due to history, and had a hearing deficit. Potential for mood problems manifested as difficulty falling asleep and lethargy. The MDS Manager Coordinator confirmed R117…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-30 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure the physician's orders for the administration of medications were clarified and the manufacturer's instructions for the administration of Lidoderm Patch 5% (Lidocaine) was followed for 1 of 31 sampled residents (Resident 69). The deficient practice had the potential for a medication error and the resident's adverse reactions from the medication. Findings include: Resident 69 (R69) R69 was admitted on [DATE], with diagnoses including generalized anxiety disorder and chronic pain syndrome. The physician's order dated 01/09/2023, documented Buspirone Hydrochloride (HCl) Tablet 30 milligram (mg) by mouth every night shift related to generalized anxiety disorder, give at 6:00 PM. R69's Medication Administration Record (MAR) for January 2024, documented Buspirone HCl Tablet 30 mg was scheduled to be given at 10:00 PM. The physician's order dated 03/09/2023, documented Buspirone HCl Tablet 15 mg by mouth two times a day for anxiety…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-30 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and document review the facility failed to ensure psychotropic medications administered as needed was not prescribed for more than 14 days without rationale from the prescribing physician for 2 of 31 sampled residents (Resident 23 and 52). The deficient practice had the potential for unnecessary use of medications. Findings include: The facility policy titled Psychoactive Medication (revised 07/21/2017) documented psychoactive medications include anxiolytic/antianxiety, antipsychotic, and sedative/hypnotic drugs. The consultant pharmacist will review the medication regimen at least monthly and more often if needed based on resident status. Resident 23 (R23) R23 was admitted on [DATE] with diagnoses including anxiety disorder and Alzheimer's disease with late onset. A physician order dated 12/13/2023, documented Hydroxyzine HCL to give 1 tablet by mouth as needed for anxiety. R23's medical record lacked documented evidence of an end date of 14 days for use of as needed…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-30 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure transmission-based precautions (TBP) were followed, when 1) a staff member lacked appropriate personal protection equipment (PPE) prior to contact with residents on droplet isolation precautions; did not use and dispose of an N95 respirator in accordance with droplet isolation procedures; and 2) lacked appropriate PPE while cleaning a room recently vacated by residents on droplet isolation precautions and 3) staff did not post easily visible signs listing the required PPE adjacent to the rooms of residents on droplet precautions; and did not place a receptacle for disposing of used N95 respirators outside of room doors in accordance with their facility procedure. The deficient practices separately or in aggregate had the potential to allow the transmission of disease-causing organisms from infected residents to uninfected residents and/or staff, with potential for serious adverse outcomes. Findings include: 1. Inappropriate PPE On…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure post fall protocol was implemented for 1 of 16 sampled residents (Resident 10). The deficient practice had the potential for inaccurate assessment and monitoring following a fall, impacting the quality of life of the resident. Findings include: Resident 10 (R10) R10 was admitted on [DATE] with diagnoses including unspecified dementia, type II diabetes mellitus, difficulty walking, and history of falls. A Brief Interview for Mental Status (BIMS) documented R10 had a score of 5, which indicated severe impairment. A progress note dated 08/02/2023, documented R10 was found lying on the floor between the beds. R10 did not recall how the fall occurred and was noted wearing regular socks. Neurological (neuro) check started with initial vital signs as follows: temperature 97.7 degrees Fahrenheit, pulse 77 beats per minute, respirations 28 breaths per minute, blood pressure 163/78, oxygen saturation 94 percent room air, and blood sugar…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$10,358 in federal fines across 1 penalty.

  • $10,358 — penalty dated 2024-12-06

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleShareSince
STATE OF NEVADAOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 09/24/2002
BALTAZAR-DODGE, KATEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/11/2024
DORAN, SUSANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/08/2012
FULLER, JENNIFERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/13/2024
JORGENSON, CRAIGIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2004

CMS files one row per role, so the 11 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$31.9M
Net patient revenuemost recent cost report
+19.7%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 23%Medicare 3%Other / private 73%

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$439per resident / day
operating cost
$13,349per month
≈ monthly operating cost
$547per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NV

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Nevada Medicaid page.

Typical monthly cost in Nevada
$11,786/mo
Nursing home (semi-private)
$14,463/mo
Nursing home (private)
$6,241/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 295081. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-13, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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