Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 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 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.
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.
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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) |
|---|---|---|---|---|
| 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 | — | 0 | 0 |
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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 August 2026) and official state health department websites.