Nevada veterans home cited by feds for health, safety violations

The Southern Nevada State Veterans Home in Boulder City received 18 health and safety citations in a recent inspection by the federal Centers for Medicare and Medicaid Services.

A report from the regulator said the citations included verbal abuse of a patient, meals being served at inappropriate temperatures and a failure to provide keys to employees to unlock gates that would be needed in the case of an emergency evacuation, among other violations.

“The health and safety of nursing home residents is a top priority of the Centers for Medicare and Medicaid Services,” an agency spokesperson said in an emailed statement. “The agency remains committed to ensuring that any violations to our health and safety standards are addressed, and we are committed to continuing to partner with states to address performance concerns.”

In addition, at least three former employees have been interviewed by the Nevada State Capital Police for a criminal investigation, and the former director of nursing has filed a complaint with the state attorney general alleging that the current director of nursing failed to follow the law in regard to reporting of an abuse incident.

Multiple requests for confirmation have been made to the Nevada Department of Veterans Services, the Nevada state attorney general and Gov. Joe Lombardo. Those requests have been refused.

In an email statement, Elizabeth Ray, communications director for Gov. Joe Lombardo, and John Sadler, who holds the same position for Attorney General Aaron Ford said, “As NDVS has communicated repeatedly, they will share the CMS report findings with the public once the report is verified and finalized. NDVS cannot respond to unsubstantiated claims and incomplete documents, nor can NDVS, the office of the attorney general, or the office of the governor offer comment on specific personnel issues.”

‘You can leave’

The allegation of verbal abuse was leveled at an administrator who reportedly told a resident, “If you don’t like it here, you can leave,” when a resident complained about the removal of furniture and amenities they relied upon.

The incident was considered serious enough that the deputy director of the Nevada Department of Veterans Services opened an official investigation into the incident.

In the Centers for Medicare and Medicaid Services survey, a certified nursing assistant and a registered nurse who witnessed the incident told surveyors that they considered the remarks as abusive but did not report any further because the designated abuse coordinator for the home was present during the incident. The abuse coordinator reportedly told surveyors that they saw the incident as “not the best thing to say” but not abusive.

Poppy Helgren, who retired as director of nursing at the home in 2023, said she filed a complaint against the current director of nursing for failing to report the abuse and received confirmation from the attorney general’s office it had been received. She said employees are mandatory reporters and could face fines or jail time for failure to report abuse.

While interviewing officers from the Capital Police were not specific about the nature of their investigation, three of the people who have confirmed their interviews said the detectives appeared to be focused on allegations of time theft and failure to report in the case of the abuse incident.

Nearly all the employees spoke with a reporter on the agreement that their names not be used out of fear of retaliation or limitation of future job options.

Correction plan required

Other citations revolve around employees lacking or lacking ready access to keys for locked gates that would need to be opened in the case of fire or other emergency evacuations. At least half of employees interviewed by surveyors were unaware of the location of emergency food or emergency water supplies in case staff and residents had to shelter in place.

Another area of concern involved psychotropic drugs being dispensed on an “as needed” basis with no end date. Regulations state that such orders for these types of drugs be limited to 14 days.

Citations are rated on a descending scale from A to M, with A being the least serious and anything rated B or lower requiring a formal plan of correction from the facility, and ratings of F or lower may impact the facility’s ability to receive Medicare or Medicaid funding.

All the citations issued by inspectors at the Southern Nevada State Veterans Home were rated D or E, according to the report.

In almost every response to questions regarding issues at the home, NDVS has pointed to their five-star rating from CMS. None of the sources for this story expected that rating to hold after this survey. CMS noted that those ratings are based on survey results over the past 36 months and that changes to the rating may be delayed for several months after a survey is completed.