Nevada State Veterans Home - Boulder City

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.