Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Nevada State Veterans Home - Boulder City during CMS and state inspections, most recent first.
A resident with chronic Foley use and bladder dysfunction had a catheter order for a 16 Fr/10 ml Foley, but surveyors observed an 18 Fr/30 cc catheter in place. The LPN and charge nurse confirmed the mismatch, and the record lacked documentation of the NP’s catheter size and balloon amount when the catheter was changed after insertion difficulty. The charge nurse also reported the resident had burning and pain at the catheter site, and the urology note later documented a 16 Fr Foley with a 10 cc balloon.
A resident with cardiac conditions had BP meds, including carvedilol and amiodarone, administered even when BP was below the ordered hold parameters, and the DON confirmed the orders were not followed. Another resident with dementia and chronic low back pain received hydrocodone-acetaminophen for pain rated 5/10 even though the order was only for pain rated 7-10; staff confirmed the MAR showed the opioid was given below the prescribed pain scale and there was no order covering 4-6/10.
Failure to Communicate Abnormal HgbA1C Results and Complete Ordered Quarterly Diabetes Labs: A resident with dementia and diabetes had an abnormal HgbA1C result that was not documented as communicated to or addressed by the physician, and ordered quarterly HgbA1C testing was not completed. Another resident with type 2 DM and hyperglycemia also had a missed quarterly HgbA1C, with staff confirming the test should have been done but no result found in the record.
A resident with dementia, who was independent in mobility, was placed in a Broda chair and secured with a seat belt by staff without a physician's order, justification, or care plan. The chair was used to manage agitation, and the resident was unable to exit independently when reclined. Staff acted under direction from a charge nurse who threatened retaliation for noncompliance, and facility protocols for restraint use were not followed.
A resident with chronic kidney disease and other conditions experienced significant weight loss without a nutritional assessment or interventions being implemented. The facility failed to reweigh the resident as required by policy, and the attending physician was unaware of the weight loss. The resident's meal intake decreased significantly, with frequent meal refusals noted.
A resident experienced significant weight loss and poor appetite, but the LTC facility failed to notify the physician and the resident's POA. Despite a care plan to monitor for malnutrition, the resident's declining condition was not communicated, leading to a lack of timely interventions. The facility's policy required prompt notification of such changes, but this was not followed.
The facility failed to refer three residents for a PASARR Level 2 evaluation after they acquired new psychiatric diagnoses or began new psychotropic medications. The social services department was unfamiliar with the PASARR process, and no clear procedure was in place following the departure of the former medical records director. This resulted in a lack of documented referrals for necessary evaluations, as confirmed by the Social Services Supervisor and Administrator.
A resident with multiple communication challenges was not using the Dynavox device due to eye tremors, instead using alternative methods like an alphabet board and sign language. Despite this, the care plan was not updated to reflect these methods, risking inaccurate communication and inappropriate care.
A facility failed to identify a new skin impairment for a resident, who developed a pressure ulcer while in care. The resident, previously admitted with a healed stage 4 pressure ulcer, reported lying in bed all day and sometimes in excrement. The care plan included monitoring skin status, but the facility did not adhere to these interventions. The Wound Care Nurse and Charge Nurse were unaware of the new wound, which was not reported, despite facility policy requiring daily skin checks and reporting of abnormalities.
A facility failed to communicate a pharmacy recommendation for a dose reduction of Escitalopram for a resident with Alzheimer's and depression. The recommendation, made due to the resident's advanced age, was not documented in the medical record or reviewed by the physician, as confirmed by the Health Information Coordinator and Administrator.
The facility failed to ensure that the arbitration agreement in the admission contract stated that signing was not a condition for admission or care, and did not grant the right to rescind within 30 days. Interviews confirmed these deficiencies, and the facility lacked a policy on arbitration.
The facility's Arbitration Agreement did not allow for the selection of a neutral arbitrator agreed upon by both parties, nor did it provide for a venue convenient to both parties. The Home Admission Contract required disputes to be decided by the National Health Lawyers Association, without mutual agreement on the arbitrator or venue. The compliance officer acknowledged these issues and the absence of an arbitration policy.
A nurse failed to perform hand hygiene after administering an Exelon Transdermal Patch to a resident with Parkinson's and Alzheimer's, potentially leading to cross-contamination. The nurse acknowledged the oversight, which was confirmed by a Charge Nurse, as it violated the facility's hand hygiene policy.
Foley Catheter Size Did Not Match Physician Order
Penalty
Summary
The facility failed to follow physician orders for a resident with neuromuscular dysfunction of the bladder and chronic Foley catheter use. The resident was admitted with an indwelling catheter, and the physician admission order specified a 16 Fr/10 ml Foley catheter for obstructive uropathy. The resident’s MAR showed the catheter was last changed on 01/31/2026, but on 02/12/2026 the surveyor observed the resident with a catheter labeled 18 Fr/30 cc. The LPN reviewed the record and confirmed the order was for a 16 Fr/10 ml catheter, while the observed catheter was 18 Fr/30 cc. The charge nurse also confirmed signing for the catheter change on 01/31/2026, and stated the catheter had been changed by the NP because nurses were having difficulty replacing it. The medical record did not contain documentation of what Foley size or balloon amount the NP used when the catheter was changed. A physician encounter note documented difficulty with catheter insertion due to obstruction, that the provider exchanged the Foley without complications, and that the patient tolerated the exchange well. The charge nurse stated nurses should not sign for other nurses’ medication or treatment services and could not explain why the resident had an 18 Fr/30 cc Foley that did not match the physician order or the urology note from 02/06/2026, which documented a 16 Fr two-way Foley with a 10 cc balloon. The charge nurse also stated the resident reported burning and pain at the catheter site on 02/09/2026, but this was not communicated from night shift. The unit manager stated the NP inserted a Coude catheter when a regular catheter could not be inserted, but could not explain why the resident had an 18 Fr/30 cc Foley catheter.
Medication Orders Not Followed for Blood Pressure and Pain Parameters
Penalty
Summary
Prescribed parameters for blood pressure medications were not consistently followed for a resident admitted with hypertension, diastolic congestive heart failure, hypertensive chronic kidney disease, ventricular fibrillation, chronic venous hypertension, and a cardiac pacemaker. Physician orders for carvedilol 3.125 mg twice daily and amiodarone HCl 200 mg daily both directed staff to hold the medications if systolic blood pressure was below 110 mmHg or heart rate was below 60 beats per minute. The MAR for February 2026 showed the medications were administered despite blood pressure readings below the ordered hold parameters on multiple occasions. On 02/13/2026 at 2:30 PM, the DNS confirmed both medications had been given without following the prescribed holding parameters. The DNS stated nurses were expected to follow physician orders and indicated the nurses should have notified the attending physician for possible dose adjustment or discontinuation of the medication. The facility policy on Medication-Administration and Treatment stated scheduled cardiovascular medications should be held if blood pressure or pulse were outside the established parameters prescribed by the healthcare practitioner. Parameters for administering pain medication were also not followed for a resident admitted with unspecified dementia with other behavioral disturbance and radiculopathy lumbar region and lesion of sciatic nerve, with chronic lower back pain documented in a physician encounter note. Orders included acetaminophen 325 mg, two tablets every four hours as needed for mild pain, and hydrocodone-acetaminophen 5 mg-325 mg every eight hours as needed for pain rated 7-10 for 30 days. During a medication pass observation, the resident reported lower back pain rated 5/10 and an LPN administered hydrocodone-acetaminophen. Review of the MAR and interviews with nursing staff confirmed hydrocodone was given for pain ratings below the ordered 7-10 range on multiple dates, and staff stated there was no order covering pain rated 4 to 6/10.
Failure to Communicate Abnormal HgbA1C Results and Complete Ordered Quarterly Diabetes Labs
Penalty
Summary
The facility failed to ensure an abnormal HgbA1C result was communicated to and addressed by a physician for a resident with dementia and diabetes mellitus, and failed to carry out ordered quarterly HgbA1C testing for that resident. The resident had a physician order entered on 04/30/2025 for HgbA1C testing every three months, and a lab result on 05/07/2025 showed an HgbA1C of 7.0%, which the lab interpretation identified as suboptimal blood glucose control for known diabetics. The medical record did not show that this abnormal result was communicated to the physician or addressed by a provider, and subsequent quarterly HgbA1C testing was not documented as ordered. The facility also failed to complete ordered quarterly HgbA1C testing for another resident with type 2 diabetes mellitus with hyperglycemia. Admission orders required HgbA1C testing every three months if the resident was diabetic at admission, and the record showed HgbA1C results in February, May, and August 2025, but no documented HgbA1C result for November 2025. Staff interviews confirmed the quarterly test should have been completed, and the Health Information Coordinator was unable to locate the November 2025 HgbA1C laboratory result.
Unauthorized Use of Physical Restraint for Resident with Dementia
Penalty
Summary
A resident with dementia, hearing loss, and major depressive disorder was admitted to the facility and was noted to be independent in bed mobility, transfers, and ambulation with a walker, but required supervision to prevent falls. The resident exhibited confusion, agitation, and restlessness, particularly in the evenings, but was assessed as low risk for safety concerns and did not require a safety plan. Despite this, staff placed the resident in a Broda chair, a specialized wheelchair, and secured the seat belt without a physician's order, justification, consent, or care plan. The decision to use the Broda chair was made by a charge nurse, who instructed certified nursing assistants to comply, and threatened staff with termination if they spoke out. Multiple staff interviews confirmed that the Broda chair was used to manage the resident's agitation and that the resident was unable to independently exit the chair when it was reclined. The Broda chair was not intended for behavioral management or fall prevention, and its use in this manner constituted a physical restraint. The facility's Director of Rehabilitation Services and other clinical staff confirmed that the Broda chair required a physician order, clinical evaluation, and monitoring, none of which were present in this case. The medical record lacked documentation of any order, justification, or care plan for the use of the Broda chair for this resident. Facility policy defined physical restraints as any device that restricted movement and could not be easily removed by the resident, and prohibited their use unless required to treat medical symptoms. The use of the Broda chair in this instance was not supported by clinical need or proper authorization, and staff education on abuse and restraint had been provided. The incident was later investigated by facility administration, but at the time of the event, required protocols and documentation were not followed.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to conduct a nutritional assessment for a resident, identified as Resident 139, who experienced significant weight loss. The resident was admitted with chronic kidney disease, anemia, and malignant melanoma. Despite a notable weight loss from July to August, no nutritional assessment was completed, and the Registered Dietitian (RD) confirmed that the weight loss was unplanned and undesirable. The RD, who started working in October, noted that the resident's body mass index (BMI) was 22, with a target goal of 25, indicating a risk for weight fluctuations. The facility's policy required nutritional assessments with any significant status change, but this was not adhered to. Interventions were not implemented for Resident 139 when significant weight loss was identified. The resident's medical records showed a lack of documented evidence of interventions, despite a decline in appetite and social engagement observed by staff and the resident's Power of Attorney (POA). The resident's meal intake decreased significantly, with frequent meal refusals noted. The RD acknowledged that no interventions, such as appetite stimulants or oral nutritional supplements, were implemented, and the attending physician was unaware of the weight loss, indicating a communication gap. The facility also failed to reweigh Resident 139 when significant weight loss was identified, as required by policy. The resident's weight was not obtained in November, and reweighs were not conducted in July and August after significant weight changes. The Nurse Manager confirmed that the process required reweighing residents for three consecutive days if weight changes were significant, but this was not done. The Charge Nurse and Unit Secretary confirmed that the resident's weight was missed in November, and the RD expressed that weight documentation was crucial for assessing nutritional status and preventing further decline.
Failure to Notify Physician and Family of Resident's Weight Loss
Penalty
Summary
The facility failed to notify a physician and the resident's representative about a significant change in a resident's condition, specifically poor appetite and significant weight loss. The resident, who had a history of chronic kidney disease, anemia, and malignant melanoma, was admitted to the facility and had been receiving hospice services before being discharged for eye surgery. Despite a care plan that included monitoring for signs of malnutrition, the resident's declining appetite and weight loss were not communicated to the physician or the resident's power of attorney (POA). Observations and interviews revealed that the resident, who was previously eating well, began showing signs of physical decline, including a lack of appetite and social engagement. The resident's meal intake dropped significantly, with frequent meal refusals and an average intake of only 0-25% of meals over a two-week period. Despite these changes, there was no documented evidence that the physician or POA were informed, which was confirmed by the Registered Dietitian and the Nurse Manager. The facility's policy required prompt notification of any significant change in a resident's condition, including weight loss, to the physician and family. However, the staff failed to adhere to this policy, as the attending physician and the POA were unaware of the resident's significant weight loss until early December. The lack of communication prevented timely interventions, such as the initiation of appetite stimulants or supplements, which could have addressed the resident's declining condition.
Failure to Refer Residents for PASARR Level 2 Evaluation
Penalty
Summary
The facility failed to adhere to its policy on referring residents for a Preadmission Screening and Resident Review (PASARR) Level 2 evaluation for residents who acquired new diagnoses indicative of mental illness or began new psychotropic medications. This deficiency was identified in three residents. Resident 72 was admitted with diagnoses including type 2 diabetes mellitus, major depressive disorder, and senile degeneration of the brain. Despite new diagnoses of anxiety disorder, major depressive disorder, and post-traumatic stress disorder, there was no documented evidence of a referral for a PASARR Level 2 evaluation. The social workers involved were unfamiliar with the PASARR Level 2 evaluation process, and the Social Services Supervisor confirmed the lack of referral documentation. Resident 139, admitted with chronic kidney disease, heart disease, and PTSD, also lacked documented evidence of a referral for a new level of care assessment or a PASARR Level 2 evaluation after a new psychiatric diagnosis was identified. The Social Services Supervisor confirmed the absence of such documentation. Similarly, Resident 98, with diagnoses including Parkinson's disease, major depressive disorder, and PTSD, was not referred for a PASARR Level 2 evaluation despite new psychiatric diagnoses and the initiation of psychoactive medication. The Administrator acknowledged that residents with new psychiatric illnesses met the criteria for a PASARR Level 2 referral but deferred to social services for the process. The facility's PASARR and Level of Care Screening policy required PASARR screenings to be completed prior to admission and for residents with new diagnoses indicative of mental illness or those beginning new psychotropic medications. However, the social services department was not well-versed in the PASARR process, and no clear process had been developed for identifying and referring residents for PASARR Level 2 evaluations since the departure of the former medical records director. The Administrator confirmed that no residents had been referred for new level of care assessments or PASARR Level 2 evaluations since the former director's departure, indicating a lapse in the facility's compliance with its own policy.
Failure to Update Communication Care Plan
Penalty
Summary
The facility failed to revise the care plan for a resident with multiple communication challenges, including multiple sclerosis, dysarthria following a cerebrovascular disease, major depressive disorder, dysphagia, and dysphonia. The resident was observed not using the Dynavox communication device due to difficulties with eye gaze technology caused by eye tremors. Instead, the resident effectively communicated using alternative methods such as an alphabet communication board, finger spelling via sign language, and responding to yes/no questions. However, these methods were not documented in the resident's care plan, which only included the use of the Dynavox device. The Speech-Language Pathologist and the RN Unit Manager both acknowledged the resident's communication difficulties and the use of alternative communication methods. Despite this, the care plan was not updated to reflect these changes, which is a requirement according to the facility's policy. The policy mandates that care plans be updated as changes in resident status occur, but not less than every 92 days. The failure to update the care plan with the resident's current communication practices placed the resident at risk for inaccurate communication and inappropriate care.
Failure to Identify and Report New Skin Impairment
Penalty
Summary
The facility failed to identify a new skin impairment for a resident, placing them at risk for worsening skin impairments and diminished quality of life. The resident, who was admitted with a stage 4 pressure ulcer that had healed, reported developing a new pressure ulcer while in the current facility. The resident attributed this to lying in bed all day and sometimes being in excrement for long periods. The care plan for the resident, revised earlier, identified the resident as being at risk for skin breakdown and included interventions such as monitoring and documenting any changes in skin status. However, the facility did not adhere to these interventions effectively. On observation, the resident's CNA revealed two dressings on the resident's buttock, with one dressing covering a reddened area with broken skin. The Wound Care Nurse (WCN) and the Charge Nurse were unaware of this new wound, as it had not been reported. The WCN confirmed the wound appeared to be moisture-associated skin damage with a high likelihood of developing into a pressure ulcer. The facility's policy required daily head-to-toe skin checks and reporting of any abnormal skin findings, but these procedures were not followed, leading to the deficiency.
Failure to Communicate Pharmacy Recommendation for Dose Reduction
Penalty
Summary
The facility failed to ensure that a pharmacy recommendation for a gradual dose reduction (GDR) of Escitalopram was communicated to the physician for a resident diagnosed with Alzheimer's disease, dementia, and major depressive disorder. The resident was observed without signs of distress, and a physician order indicated a daily dose of 20 mg of Escitalopram for depression and anxiety. However, the medical record lacked documentation of the pharmacy's recommendation for a dose reduction to 10 mg due to the resident's advanced age, which was made between September 1 and September 23, 2024. The Health Information Coordinator confirmed that the medical record did not contain the pharmacy's recommendation, and the section for the physician's review and signature was blank. The Administrator acknowledged that the recommendation was not reviewed by the physician as it was not found in the designated binder. A Nurse Manager also confirmed the absence of documentation showing that the recommendation was provided to the physician. The facility's policy required that such recommendations be reported to the director of nursing and the attending physician, and copies should be part of the resident's permanent medical record.
Deficiency in Arbitration Agreement Disclosure
Penalty
Summary
The facility failed to ensure that the arbitration agreement within the admission contract clearly stated that signing the agreement was not a condition for admission or continued care. Additionally, the agreement did not explicitly grant residents or their representatives the right to rescind the arbitration agreement within 30 days of signing. This deficiency was identified through interviews and document reviews, which revealed that the arbitration section of the contract lacked documentation indicating that residents or their representatives were not required to sign it as a condition of admission or care. Furthermore, there was no evidence that the agreement could be revoked within the specified timeframe. Interviews with facility staff, including the administrative assistant in admissions and the compliance officer, confirmed these deficiencies. The administrative assistant noted that the admissions agreement, including the arbitration clause, was sent to prospective residents or their representatives a few days before admission. However, the compliance officer acknowledged that the arbitration section did not inform residents or their representatives of their right to rescind the agreement within 30 days. Additionally, the facility lacked a policy regarding arbitration, and all current residents had a signed contract on file, indicating a systemic issue with the admission process.
Arbitration Agreement Lacks Neutral Arbitrator and Venue Selection
Penalty
Summary
The facility failed to ensure that the Arbitration Agreement allowed for the selection of a neutral arbitrator agreed upon by both parties and for the selection of a venue convenient to both parties. The Home Admission Contract, which residents sign to confirm receipt and understanding, included an arbitration section that mandated disputes be decided by the National Health Lawyers Association, rather than a mutually agreed-upon neutral arbitrator. Additionally, the contract did not provide for a venue selection that was convenient for both parties. On review, the compliance officer acknowledged these deficiencies and confirmed that the facility lacked a policy for arbitration.
Failure to Perform Hand Hygiene After Medication Administration
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed by a nurse after administering medication to a resident, which had the potential for cross-contamination and the spread of infection. Resident 113, who was admitted with diagnoses including Parkinson's disease without dyskinesia, Alzheimer's disease, and dementia, was observed in the dining area when a nurse removed an existing Exelon Transdermal Patch and replaced it with a new one. The nurse did not perform hand hygiene after removing gloves and before administering medication to another resident. This was acknowledged by the nurse and a Charge Nurse, both confirming that hand hygiene should have been completed after medication administration and glove removal, as per the facility's Infection Prevention and Control Policy and Procedure Hand Hygiene dated 11/17/2010.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 385 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Boulder City Hospital Snf | 1.7 mi | ★★★★★ | 0 | 0 |
| Mountain View Care Center | 2.2 mi | ★★★★★ | 22 | 0 |
| Henderson Health And Rehabilitation | 8.1 mi | ★★★★★ | 2 | 0 |
| Tlc Care Center | 11.7 mi | ★★★★★ | 6 | 0 |
| Coronado Ridge Skilled Nursing & Rehabilitation Ce | 13.6 mi | ★★★★★ | 20 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Nevada State Veterans Home - Boulder City.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.