Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Boulder City Hospital Snf during CMS and state inspections, most recent first.
A resident’s wall had handwritten notes posted that identified the resident as NPO and included instructions about tube feed care and the resident getting tube feed on him. An RN, CNA, and DON all confirmed the posting of resident personal information was a dignity and privacy concern and against facility policy.
A resident with severe cognitive impairment and a baseline need for two-person assist/Hoyer lift was transferred by an agency CNA without assistance, resulting in a skin tear to the left forearm. The CNA did not immediately report the injury to the LPN, and later staff interviews and video review confirmed the transfer requirement was not followed and the wound was not promptly reported.
A resident with an implanted chest port and IV antibiotics had contact precaution signage posted, but an RN drew blood from the port without a gown and repeatedly accessed the line while moving in and out of the room. Staff interviews showed confusion about contact precautions vs EBP, and the DON stated the resident should have been on EBP and that a gown should have been worn for IV line care.
The facility failed to ensure timely transmission of MDS 3.0 assessments for five residents, with data being more than 120 days late. The MDS Coordinator, working remotely, faced technical issues and lacked a designated backup, leading to delays. The Director of LTC confirmed no other staff could transmit MDS data, resulting in potential delays in resident care plans.
The facility failed to submit the quarterly PBJ data to CMS for Q1 2024 due to the MDS Coordinator's inability to access information remotely and the lack of a backup system. The Director and Chief Nursing Officer were aware of the issue.
The facility failed to complete a PASARR level two referral for a resident diagnosed with schizophrenia after admission. The social worker did not believe the referral was necessary as the resident was stable on antipsychotic medication. The medical record lacked evidence of the required referral, and the resident exhibited inappropriate behavior.
A facility failed to follow or clarify a physician's order for a resident's suprapubic catheter size, leading to the insertion of an incorrect catheter. The treatment administration record and electronic medical record contained conflicting orders, and the charge nurse confirmed the discrepancy. The facility's policy required staff to follow physician orders and not perform interventions without the required order.
The facility failed to label and date stored foods and discard expired items. An open bag of chicken tenders was found in the freezer without a label or date, and an expired container of cottage cheese was found in the refrigerator. The Dietary Manager confirmed these items should have been labeled, dated, and discarded accordingly. The facility lacked specific policies on these practices.
Inappropriate Posting of Resident Personal Information
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect when inappropriate signage containing personal information was posted on the resident’s wall. Two handwritten notes were observed in the resident’s room stating that the resident was NPO and asking staff to be careful when changing the resident because the orange cap on the tube feed kept getting lost and the resident would get tube feed all over him. An RN stated the signage should not have been posted because it contained personal information and was a dignity issue. A CNA also stated that posting a resident’s personal information was a breach of privacy and a dignity concern. The DON confirmed that having a sign posted with resident information was a dignity concern and against facility policy. The facility policy on Residents Rights stated residents have the right to privacy over personal and clinical records, including protected health information, personal care, and medical treatments.
Failure to Follow Transfer Assistance and Report Injury Promptly
Penalty
Summary
The facility failed to ensure a two-person assist was provided during a resident transfer for a resident with severe cognitive impairment and documented dependence for chair/bed-to-chair and toilet transfers requiring two or more helpers. The resident’s interim functional status assessment identified the need for two-person assistance, and staff interviews confirmed the resident routinely required a two-person assist and/or a Hoyer lift because of frailty, fearfulness, resistance during movement, and inability to assist with transfers. According to the investigation, an agency CNA transferred the resident from chair to bed without assistance on the AM shift and the resident sustained a skin tear to the left upper forearm. A skin assessment documented the wound, and facility review found there was no prior documentation or physician order for the injury when it was later discovered. Video surveillance and staff interviews were used in the investigation, and findings indicated the injury likely occurred during the transfer performed by the agency CNA. The facility also failed to ensure the resident’s injury was timely reported to the assigned licensed nurse. Staff interviews indicated the agency CNA did not immediately report the skin tear after the transfer and instead provided wound treatment outside CNA scope of practice. Nursing staff later identified the dressing on the resident’s left arm, and the injury was then assessed and reported. Interviews with the DON, Social Worker, and Risk Manager confirmed the transfer requirement was not followed and that the delayed reporting prevented prompt nursing assessment, treatment, physician notification, and implementation of interventions.
Improper Isolation Signage and PPE Use During Central Line Blood Draw
Penalty
Summary
The facility failed to ensure appropriate isolation precaution signage was used and appropriate PPE was worn while blood was obtained from a central IV line access for one resident. The resident was admitted with diagnoses including a UTI and had an implanted port on the right upper chest with a transparent dressing and IV antibiotic medication infusing during observation. On 05/06/2026, contact precautions signage was posted at the room door, and PPE supplies were available in the bin except for a mask. A RN was observed drawing blood from the resident’s chest IV port without a gown, going in and out of the room while continuing the procedure, repeatedly accessing the port, filling multiple blood collection vials directly from the port, and flushing the port at the end of the procedure. During interviews, the RN stated the resident was on contact isolation precautions due to a body fluids infection and said a gown had not been worn because the resident had not been turned or repositioned. A CN stated that when a resident is on contact isolation, a gown should be worn and gloves and a mask are required depending on the precautions, but was uncertain why the resident was on isolation and acknowledged there was no order in place. The CN could not differentiate between EBP and contact precautions or transmission-based precautions. Another RN stated EBP and TBP precautions are the same and that gloves and a mask should have been used upon entering the room. The DON stated the resident should have been on EBP rather than contact precautions and that a gown should have been worn when caring for the resident’s IV line. The facility policy identified central lines as a high-contact resident care activity requiring gown and gloves under EBP.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) 3.0 assessments were transmitted timely for five residents. The MDS Coordinator, who worked remotely and only visited the facility when there were technical issues, was responsible for notifying the interdisciplinary team of assessment timeframes and developing a calendar for assessment completion. However, the MDS data for the residents were more than 120 days late, and the State MDS Coordinator documented a 20% late submission rate for residents at the facility. The MDS Coordinator acknowledged that the process of completing resident assessments without direct contact and relying on notes could lead to inaccurate or outdated information. Additionally, there was no designated backup for the MDS Coordinator in case of unavailability, further contributing to the delays in transmitting MDS data. The Director of Long Term Care confirmed that no other staff member, including themselves, had access to transmit MDS data as required. The Director had to contact the MDS Coordinator on several occasions to correct inaccurate data on resident assessments. The facility's policy indicated that periodic assessments were conducted by the MDS Coordinator, and the results were used to create resident care plans and calculate resource utilization grouping categories. The lack of timely transmission of MDS data had the potential to impact resident care by delaying the resident care plan.
Failure to Submit PBJ Data for Q1 2024
Penalty
Summary
The facility failed to ensure the quarterly payroll-based journal (PBJ) data was submitted to the Centers for Medicare and Medicaid Services (CMS) for the first quarter of 2024. This deficiency was identified through interviews and document reviews. The Minimum Data Set (MDS) Coordinator, who was responsible for submitting the PBJ data, acknowledged that the data was not submitted. The MDS Coordinator explained that they were only at the facility once a week and were unable to access the necessary information from their remote workstation. The Coordinator planned to complete the submission the next day but became ill. Additionally, the MDS Coordinator was the only staff member with access to the reporting system, and the Chief Nursing Officer was aware of the failure to submit the data. The Director of Long-Term Care (Director), who started their position in March 2024, was also aware that the PBJ data was not submitted for the first quarter of 2024. The Director indicated that there was no backup system in place if the MDS Coordinator was unable to complete the submission. The MDS Coordinator had been working remotely since December 2023 and only came to the facility when technical difficulties arose at their remote workstation. This lack of a backup system and reliance on a single individual for the submission process led to the failure to submit the required PBJ data to CMS.
Failure to Complete PASARR Level Two Referral for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASARR) level two referral was completed for one resident diagnosed with schizophrenia. The resident was admitted with a PASARR level one document indicating no mental illness, intellectual disability, or related condition. However, after admission, the resident was diagnosed with schizophrenia and placed on antipsychotic medication. Despite this, the social worker did not complete a PASARR level two referral, believing it was unnecessary because the resident was stable on medication and not receiving psychiatric services. The deficiency was identified through observation, interview, record review, and document review. The social worker confirmed the PASARR level one was completed before the schizophrenia diagnosis and acknowledged the responsibility for completing PASARR requests. Additionally, the medical record lacked evidence of a PASARR level two referral, and the resident exhibited inappropriate behavior, such as masturbating while staff provided care. The facility's policy mandates a PASARR level two screening for residents with mental illness or related conditions, which was not followed in this case.
Failure to Follow Physician Order for Suprapubic Catheter Size
Penalty
Summary
The facility failed to follow or clarify the physician's order regarding the size of a suprapubic catheter for a resident with obstructive uropathy and severe neurocognitive deficit. The resident was observed with a suprapubic catheter that did not match the physician's order, which specified an 18 French catheter with a 5 mL balloon to be changed every two weeks. Instead, the resident had a 16 French catheter with a 10 mL balloon inserted. The discrepancy was confirmed by the charge nurse, who indicated that the nurse responsible for the catheter change should have followed the physician's order or clarified it if the correct size was not available. The treatment administration record and the electronic medical record contained conflicting orders for the catheter size and change frequency. The facility's policy required staff to follow physician orders and not perform any intervention without the required order. The charge nurse confirmed that the correct catheter supplies were available in the clean utility or could be obtained from the hospital central supply. The failure to follow the physician's order or clarify it led to the insertion of an incorrect catheter size, which was against the facility's policies and procedures for catheter care and physician order execution.
Failure to Label and Date Stored Foods
Penalty
Summary
The facility failed to ensure stored foods were labeled and dated and food items were discarded prior to the expiration date. During an observation, an open bag of chicken tenders was found in the walk-in freezer without a label or date. The Dietary Manager confirmed that the bag should have been labeled and dated before being placed back in the freezer. Additionally, a container of cottage cheese with an expired date was found in the walk-in refrigerator. The Dietary Manager acknowledged that the item should have been discarded and explained that staff are supposed to check expiration dates when new shipments are received. The facility did not have specific policies on labeling, dating, or handling expired foods.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Boulder City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mountain View Care Center | 0.6 mi | ★★★★★ | 22 | 0 |
| Nevada State Veterans Home - Boulder City | 1.7 mi | ★★★★★ | 13 | 0 |
| Henderson Health And Rehabilitation | 9.3 mi | ★★★★★ | 5 | 0 |
| Tlc Care Center | 13.2 mi | ★★★★★ | 11 | 0 |
| Oasis Nursing & Rehab Of Green Valley | 15.2 mi | ★★★★★ | 4 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.