Boulder City Hospital

“This Statement of Deficiencies was generated as a result of a Medicare Life Safety Code (LSC) recertification survey conducted at your facility on 06/25/2025 through 06/26/2025. Your facility was surveyed using the “EXISTING” Health Care Occupancy chapter of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 Edition, and NFPA 99, Health Care Facilities Code, 2012 Edition. The facility was a single-story building with a NFPA 220 construction Type II (000) and was fully equipped with an automatic fire sprinkler system. The Critical Access Hospital (CAH) was licensed for 25 medical surgical beds and 10 Prospective Payment System (PPS)-geriatric psychiatric beds. The facility was additionally licensed for 47 distinctly separated skilled nursing beds The census of the CAH at the time of the survey was 16 patients (eight medical surgical patients and seven PPS geriatric patients). The facility was equipped with a Type 1 Essential Electrical System (EES). The facility was equipped with piped in medical gas system to include oxygen and vacuum. The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigations, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The following regulatory deficiencies were identified:”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 51486 National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Section 7.1.10.1 means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergencies. Based on observation, the facility failed to ensure all egress doors were unimpeded allowing for instant and full access. Findings include: On 06/26/2025, during a tour of the facilities laboratory, observation revealed an egress door marked with signage that read “EMERGENCY EXIT ONLY, ALARM WILL SOUND”. The emergency egress door was obstructed by a black electrical pedestal fan and a hydraulic lab/specimen diagnostic machine.”

“Alcohol Based Hand Rub Dispenser (ABHR) CFR(s): NFPA 101 Alcohol Based Hand Rub Dispenser (ABHR) ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met: * Corridor is at least 6 feet wide * Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols * Dispensers shall have a minimum of 4-foot horizontal spacing * Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room * Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30 * Dispensers are not installed within 1 inch of an ignition source * Dispensers over carpeted floors are in sprinklered smoke compartments * ABHR does not exceed 95 percent alcohol * Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11) * ABHR is protected against inappropriate access 18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485 This Standard is not met as evidenced by: 51486 Based on observation, the facility failed to properly install Alcohol-Based Hand Rub (ABHR) dispensers in accordance with the requirements of NFPA 101 - 2012 edition, Section 19.3.2.6. Findings include: On June 26, 2025, during a tour of the facility’s activities office, observation revealed an ABHR dispenser located directly above and in-line with a duplex electrical receptacle.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 51486 National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems, 2010 Edition 6.2.7 Escutcheons and Cover Plates. 6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler. 6.2.7.2* Escutcheons used with recessed, flush-type, or concealed sprinklers shall be part of a listed sprinkler assembly. 6.2.7.3 Cover plates used with concealed sprinklers shall be part of the listed sprinkler assembly. National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition. 5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage (2) Corrosion (3) Physical damage (4) Loss of fluid in the glass bulb heat responsive element Based on observation, the facility failed to maintain the water-based fire protection system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, 2010 Edition and NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition. Findings include: 1. On 06/25/2025, during a tour of the facility, observation revealed the following areas contained a sprinkler head escutcheon gap greater than 1/8 of inch revealing access into interstitial spacing: a) The PPS-Geriatric Psychiatric Unit patient dining room contained an institutional style sprinkler head with annular escutcheon gapping. b) Patient room # 102 contained a pendent sprinkler head located in the restroom with annular escutcheon gapping. c) Patient room # 103 contained a pendent sprinkler head located in the restroom with annular escutcheon gapping. d) Patient room # 112 contained a pendent sprinkler head located in the restroom with annular escutcheon gapping. e) Patient room # 104 contained a pendent sprinkler head with annular escutcheon gapping. f) Activities Office contained a pendent sprinkler head above the workspace with annular escutcheon gapping. g) Laboratory “blood bank” room contained a pendent sprinkler head with annular escutcheon gapping. h) Central Supply “breakdown” room contained a pendent sprinkler head with annular escutcheon gapping. i) Emergency Department staff shower room contained a pendent sprinkler head with annular escutcheon gapping. j) Facility Dining room contained 4 pendent sprinkler heads with annular escutcheon gapping due to cut/broken drop ceiling tiles. k) X-Ray Room #1 contained two cosmetic pendent sprinkler heads with annular escutcheon gapping. l) X-Ray Room #2 contained one cosmetic pendent sprinkler head with annular escutcheon gapping. m) Radiology Technician supply room contained one pendent sprinkler head with annular escutcheon gapping. n) Janitor Closet adjacent to the on-call physician room contained one pendent sprinkler head with annular escutcheon gapping. 2. On 06/26/2025, during a tour of the facility, observation revealed the following areas contained a sprinkler head that displayed obvious signs of corrosion and were loaded with foreign material: a) Facility Dining room contained 4 pendent sprinkler heads loaded with foreign material. b) Facility Kitchen contained 10 pendent sprinkler heads loaded with foreign material. c) Facility Dish room contained 2 pendent sprinkler heads loaded with foreign material.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 51486 National Fire Protection Association (NFPA) 10, Standard for Portable Fire Extinguishers, 2010 Edition. 6.1.3 Placement. 6.1.3.8 Installation Height. 6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) should be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. 6.1.3.8.2 Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be installed so that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. 6.1.3.8.3 In no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less than 4 in. (102 mm). 7.2 Inspection. 7.2.1 Frequency. 7.2.1.1* Fire extinguishers shall be manually inspected when initially placed in service. 7.2.1.2* Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals. 7.2.2 Procedures. Periodic inspection or electronic monitoring of fire extinguishers shall include a check of at least the following items: (1) Location in designated place (2) No obstruction to access or visibility Based on observation and measurement, the facility failed to provide evidence that portable fire extinguishers were 1) properly installed to the correct height from the finished floor and 2) their visibility and physical access were unobstructed. Findings include: 1) On 06/25/2025, during a tour of the facility, observation and measurement of the fire extinguisher located on the 300-hallway near the cross-corridor doors revealed the height of the extinguisher handle was 5’2” from the floor. 2) On 06/26/2025, during a tour of the facility’s kitchen, observation revealed a mounted portable fire extinguisher near the walk-in freezer had its visibility and accessibility physically obstructed by cardboard boxes of fruit juices.”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 51486 National Fire Protection Association (NFPA) 70, National Electric Code, 2011 Edition COVERS Article 314 - Outlet, Device, Pull, and Junction Boxes; Conduit bodies; Fittings; and Handhold Enclosures 314.25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, lamp holder, or luminaire canopy, except where the installation complies with 410.24(B). 314.28(c) Pull and Junction Boxes and Conduit Bodies. (c) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where used, metal covers shall comply with the grounding requirements of 250.110. Article 314 - Outlet, Device, Pull, and Junction Boxes; Conduit bodies; Fittings; and Handhold Enclosures EXTENSION CORDS Article 590.2 All Wiring Installations. Article 590.2(A) Other Articles. Except as specifically modified in this article, all other requirements of this Code for permanent wiring shall apply to temporary wiring installations. Article 400.8 Uses Not Permitted. Unless specifically permitted in Article 400.7, flex cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure. (2) Where run through holes in walls, structural ceilings, suspended ceiling, dropped ceilings or floors. (3) Where run through doorways, windows or similar openings. (4) Where attached to building surfaces, exception to (4): Flex cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56. (5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings. (6) Where installed in raceways, except as otherwise permitted by the Code. (7) Where subject to physical damage. Based on observation, the facility failed to maintain the electrical system within the building per NFPA 70, National Electrical Code. Findings include: On 06/25/2025 and 06/26/2025, during a tour of the facility, the following electrical system deficiencies were observed: 1) The plastic housing near the grounding slot of duplex receptacles was observed to be broken in the following locations: a) (PPS)-Geriatric Psychiatric south corridor near exit door b) Social Work office c) MST Acute Care office d) 100 Hallway Nurse’s station e) Mailroom f) IT Manager’s office g) Patient room #120 h) Patient Room #121 i) IT work room #123 j) Dining Room vending machine k) Janitor’s closet in the facility kitchen 2) Use of extension cords, relocatable power taps, and cord adapters observed in the following locations: a) (PPS)-Geriatric Psychiatric patient activity room contained a microwave and traditional coffee pot plugged into relocatable power tap (RPT). b) On-Call Physician room contained a microwave, and a dorm-style refrigerator plugged into relocatable power tap (RPT).”

“Draperies, Curtains, and Loosely Hanging Fabr CFR(s): NFPA 101 Draperies, Curtains, and Loosely Hanging Fabrics Draperies, curtains including cubicle curtains and loosely hanging fabric or films shall be in accordance with 10.3.1. Excluding curtains and draperies: at showers and baths; on windows in patient sleeping room located in sprinklered compartments; and in non-patient sleeping rooms in sprinklered compartments where individual drapery or curtain panels do not exceed 48 square feet or total area does not exceed 20 percent of the wall. 18.7.5.1, 18.3.5.11, 19.7.5.1, 19.3.5.11, 10.3.1 This Standard is not met as evidenced by: 51486 Based on observation and interview, the facility failed to ensure all draperies within patient care areas were compliant with National Fire Protection Association (NFPA) 701. Findings include: On 06/26/2025, a tour of the Physical Therapy (PT) suite revealed six loose hanging panoramic synthetic draperies physically attached to the 2’x4’ light fixtures located above within the drop ceiling tiles. The draperies did not contain a NFPA 701 label indicating flame retardant. During an interview, the Director of Plant Operations indicated the facility could not produce flame spread or flame-retardant documentation for the draperies attached to the lighting fixtures.”

“Combustible Decorations CFR(s): NFPA 101 Combustible Decorations Combustible decorations shall be prohibited unless one of the following is met: o Flame retardant or treated with approved fire-retardant coating that is listed and labeled for product. o Decorations meet NFPA 701. o Decorations exhibit heat release less than 100 kilowatts in accordance with NFPA 289. o Decorations, such as photographs, paintings and other art are attached to the walls, ceilings and non-fire-rated doors in accordance with 18.7.5.6(4) or 19.7.5.6(4). o The decorations in existing occupancies are in such limited quantities that a hazard of fire development or spread is not present. 19.7.5.6 This Standard is not met as evidenced by: 51486 Based on observation and interview, the facility failed to ensure combustible decorations were flame retardant or treated with an approved fire-retardant coating that was listed and labeled for the product and that such quantity was limited in that a hazard of fire development or spread were not present. Findings include: On 06/25/2026, during a tour of the Prospective Payment System (PPS)-Geriatric Psychiatric Unit, observation revealed a quantity of decorative stringed crate paper streamers, globes, and flags attached to the ceilings. The combustible decorations were attached to walls and ceilings throughout the resident dining room and administrative offices at the nurse’s station in such a quantity as to pose a hazard of fire development aiding in subsequent spread. The facility failed to produce flame retardant documentation records. During an interview, the Director of Plant Operations indicated the facility did not have documentation specific to flame retardant and/or flame spread levels for combustible decorations.”

“EQUIPMENT, SUPPLIES, AND MEDICATION CFR(s): Equipment, supplies, and medication used in treating emergency cases are kept at the CAH and are readily available for treating emergency cases. The items available must include the following: This Standard is not met as evidenced by: 25418 Based on observation, interview, and policy review, the facility failed to ensure supplies stocked in areas readily available for use were not expired. This deficient practice had the potential to allow expired items to be used, creating an unsafe procedure. Findings include: Review of the facility policy titled, “Environmental Safety Inspection” with a review date of 11/03/2023, revealed, “Environmental Safety Inspection, Purpose: To provide a standardized work procedure for the consistency and safety of the work environment regarding safety compliance issues. Completion of Form, Policy: Each Department Manager or designee to complete the Environmental Safety Inspection form (Attachment A) ... Review of Attachment A: Environmental Safety Inspection reviewed 11/03/2023 ...32. Did you find any expired supplies...” During a tour of the Radiology Department on 06/18/2025 at 10:49 AM, in the Cardiac Stress room there was a basket with the following items: - Saline filled syringes with four dated 02/28/24, one dated 03//31/24, one dated 10/31/24, one dated 12/31/24, and three dated 01/31/24. - Two Intravenous Secure Sets dated 05/31/24. - One Primary Plum Set dated 04/01/22. During an interview on 06/18/2025 at 10:55 AM, Radiology Technician stated inventory was conducted monthly and the room was not used that much. The Radiology Technician verified there had not been an inventory check in the room. During an interview on 06/18/2025 at 11:00 AM, the Risk Management (RM) stated the expired supplies should have been found during the monthly environmental rounds. During an observation on 06/18/2025 at 2:00 PM in Emergency Room (ER) while in ER bed/room 4 there was a reagent tube out separate from the vaginal exam kit, which expired on 02/03/2021 and two complete “Xpert” swab vaginal specimen collection kits expired; one on 05/31/2025 and one on 03/31/2025. During an interview and observation on 06/18/2025 at 2:00 PM, an ER Registered Nurse (RN) confirmed the above emergency supplies had expired.”

“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. This Standard is not met as evidenced by: 25418 Based on interview, observation, and policy review, the hospital failed to ensure supplies and equipment used in treating emergency cases had not expired in 3 emergency rooms (ER) observed. The failure to ensure equipment and supplies had not gone past their manufacturers beyond use date/expiration dates places ER patients at risk, for products that might be no longer safe or effective for use. Findings include: During the tour of the ER on 06/18/2025 between 1:30 PM and 2:00 PM the following expired or unlabeled ER supplies were identified: 1. In ER Room 1 identified as their isolation room: a. A set of pediatric defibrillator pads “Zoll Defib Pads/Pediatric” expired on 12/04/2024. b. Three packages in a drawer of ECG (electrocardiogram) pads [used in an emergency to assess cardiac/heart rhythm] expired 01/17/2025. During an interview on 06/18/2025 at 1:45 PM, an ER Registered Nurse (RN) confirmed the above emergency supplies had expired. The RN stated the staff go through the ER supplies monthly. 2. In ER Room 4: a. Three Neo-Tee T Piece Resuscitator mask and tubing expiration date of 09/26/2023 b. “Supra-pubic Introducer Foley Catheter Set” did not have a manufacturer’s expiration, the directions for use (DFU) indicated the content was good until it was opened. The package was discolored and the glue seal that kept the package content sterile was peeling back and the corner curled back. 3. In ER Room 5: a. A facility homemade “Trach (tracheotomy) Kit” contained, “Ready Prep Povidone Iodine 10% Solution that expired 01/2025, silk sutures that expired 04/30/2025, a 10-gauge angiocath expired 02/31/2025, and a disposable scalpel expired 11/2022. b. two suction canisters, one on the adult emergency crash cart and one of the pediatric crash carts expired 02/01/2021. Review of the hospital policy titled, “Environmental Safety Inspection” dated 11/03/2023 revealed, “Environmental Safety Inspection Purpose: To provide a standardized work procedure for the consistency and safety of the work environment regarding safety compliance issues. ... Attachment An Environmental Safety Inspection: ... Did you find any expired supplies?””

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 25418 Based on observation, interview, record review, and policy review, the facility failed to follow facility policy for 1. open date on food products, 2. allowing personal beverages in the work area in the kitchen, 3. employee background checks, and 4. for infection control practices. This deficient practice had the potential to allow practices to occur without following facility policy. Findings include: 1. Review of the facility policy titled, “Storing Open Packages” dated 06/18/2024 revealed, “Purpose: To provide secure and properly labeled foods. . . Seal baggie and write the opened date and identify product. . .” During a tour of the kitchen on 06/18/2025 at 11:18 AM, the following items were found to be open and not dated: - In the freezer an open bag of chicken fingers and an open bag of meatballs. - On the bread rack was an unsealed bag of hotdog buns. - Over the food prep table were several bottles of Worcestershire sauce and vinegar. - Above the three compartments sink several containers of spices such as rubbed sage, ground pepper, tenderizer seasoned, rotisserie chicken spice, allspice, Mexican sage, and sugar. During an interview on 06/18/2025 at 11:32 AM, the Dietary Manager revealed staff should label an item with the open date once an item was opened 2. Review of the ServSafe guidelines presented by the facility as a policy with a date of 08/12/2022 revealed, “While general ServSafe guidelines outline proper food storage practices, specifically addressing employee food and beverages, they emphasize storing them in designated food-storage areas, separate from food intended for customers. Away from walls and at least six inches (15 centimeters) off the floor. ln a manner that prevents cross-contamination.” During a tour of the dishwashing area in the kitchen on 06/18/2025 at 12:00 PM, a drink was sitting on the shelf above the clean area of the dish room. The Dietary Manager stated the drink belonged to an employee. During an interview on 06/18/2025 at 12:00 PM, the Dietary Manager provided an email from a Health Inspector that indicated beverages must be covered and stored below work/preparation areas. 3. Review of the facility policy titled, “Hiring Procedures”, reviewed 10/17/2024 revealed, “Policy: To facilitate the hiring of competent staff and to ensure consistency throughout the Hospital, a summary of policy requirements and appropriate forms have been developed to assist supervisor, managers, and director in this process. . . Applicant Background Investigation. Verify all licensure and certification requirements for position. Human Resources will verify the last seven (7) years employment history. For written verifications, applicants sign authorization. . .” Review of staff files provided by the facility revealed Registered Nurse (RN)32 was hired on 03/13/2013. There was no current background check. Review of staff file for RN35 revealed the date of hire of 08/07/2023. There was no current background check. During an interview on 06/20/2025 at 10:00 AM, the Human Resources Director revealed the background checks for RN32 and RN35 were not completed. 4. On 06/20/2025 at 7:41 AM, an Operating Room (OR) Registered Nurse (RN) started an intravenous (IV) catheter for Patient 13 in the pre-operative (pre-op) bay. The RN placed the needle used to insert the catheter into the plastic “IV start package” lying on the tray table, instead of in the sharp container on the wall behind P13’s gurney. After removing the gloves, the RN picked up the used needle with bare hands, removed it from the plastic “IV start package,” and laid the used needle directly onto the patient’s tray table. After discarding the other supplies, the RN picked up the needle and discarded the used insertion needle in the sharp’s box located on the wall behind another patient’s pre-op bay. During an interview on 06/20/2025 at 7:41 AM, the OR Manager revealed the nurse should not have handled a used needle with bare hands. Review of the hospital’s policy titled “Hand Hygiene Program” dated 04/11/2025 revealed, “Gloves should be donned whenever there is a possibility of contact with the patient’s blood or body fluids, mucous membranes or non-intact skin and when manipulating or handling potentially contaminated patient care equipment and/or environmental surfaces Wearing gloves protects both the patient and the heath care workers.” On 06/20/25 at 8:31 AM, a Certified Registered Nurse Anesthetist (CRNA) was observed opening two new vials of medication (later identified as Propofol and 1% Lidocaine) without cleaning the septum, inserted a needle, and drew up the medication. Then without cleaning the intravenous (IV) port CRNA inserted the medication into the IV port for administration. During an interview 06/20/2025 at 9:15 AM, the CRNA was not aware that a new vial needed to be cleaned after opening or the IV port needed to be cleaned prior to administering a medication. Review of the hospital policy titled, “Safe Medication Practices” dated 06/17/25 revealed “Use aseptic techniques to avoid contamination of sterile injection equipment and medications. (Cleanse all puncture ports, IV connections prior to use.)””

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. This Standard is not met as evidenced by: 25418 Based on observation, interviews, review of direction for use (DFU), and policy review, the hospital failed to ensure that it had clear directions in the policy for safe medication practices that included multi-dose medication bottles identified in the Emergency Room (ER). The failure had the potential for staff to give emergency medications that were no longer safe or effective for use. During an observation in the ER on 06/18/2025 at 2:35 PM the following was identified in the ER medication room: a. An opened and partially used bottle of Diphenhydramine Hydrochloride (HCI) (Benadryl) used as a common antihistamine to address allergic reactions had a label placed on the bottle indicating the product had a new expiration date of “05/13.” There was no month/date/year, and the label was a sticker, not a pharmacy label that would include the date opened and the date to be discarded. b. An opened and partially used bottle of Lidocaine HCI a local anesthetic used to numb the mucous membranes of the mouth and/or throat, had no label to indicate who opened it, what date it was opened, or what the new expiration date was after it was opened. During an interview and observation on 06/18/2025 at 2:35 PM, the ER RN confirmed the above emergency medications. The RN confirmed that the label on the Diphenhydramine HCI was a generic label that did not come from the pharmacy and confirmed the label did not include the month/day/year or when it was opened. The RN could not confirm if 05/13 was the month and day or the month and year. The RN was not sure what the hospital policy required or what the manufacturer’s DFU was once the bottle was opened. The RN was not sure of the beyond use date after the liquid medications identified above were opened. During an interview on 06/19/2025 at 9:00 AM, the Pharmacy Manager stated the policy required updating and did not include bottled medication. The Pharmacy Manager confirmed the Pharmacy Department needed review and revise the medication policies. The Pharmacy Manager confirmed that each department did have pharmacy labels and should be using them. The current policy required the date a multi-dose medication was opened and the date it would expire. Review of the hospital policy titled “Safe Medication Practices” dated 06/17/25 revealed, it did not include bottled medication. The policy addressed vials that indicated “Label multi-dose vials with dates when opened and discard ...””

“RECORDS SYSTEM CFR(s): The records are legible, complete, accurately documented, readily accessible, and systematically organized. This Standard is not met as evidenced by: 25418 Based on record review, interview, and policy review, the hospital failed to ensure five of 21 medical records were legible, complete, and accurately documented for patients (Patient (P) 9, P10, P11, P12, and P5). The failure to have legible, complete, and accurate medical records had the potential for inaccurate or incomplete care and treatment. Findings include: 1. During an interview 06/18/2025 at 11:15 AM, the Chief Nursing Officer (CNO) 1 confirmed the Geriatric Psychiatric Distinct Part Unit (DPU) admission packet was not legible and would bring a clean copy. CNO confirmed that admissions were done on the specific unit, and the Geriatric Psychiatric DPU would do their admissions of the unit. During an interview on 06/18/2025 at 11:32 AM, the Swing Bed Program Manager brought in another Geriatric Psychiatric DPU’s admission packet. During a tour of the Geriatric Psychiatric DPU, a copy of the admission packet was requested and pulled from the drawer by a Registered Nurse (RN). During an interview on 06/18/2025 at 2:45 PM, the RN confirmed that several forms within the admission packet had been scanned and copied and were not legible. During an interview on 06/18/2025 at 2:50 PM, the Geriatric Psychiatric Director confirmed that the Geriatric Psychiatric DPU admission packets contained forms that were not legible, and the Patient Rights did not include all the psychiatric patient’s “Patient Rights.” Review of the medical record confirmed the admission documents identified above for P9, P10, P11, and P12 were not legible. 2. Review of the medical record revealed P11 was admitted on 06/10/2024 for depression and suicidal thoughts and was a current inpatient. P11’s medical record failed to have an admission psychiatric evaluation, and the cranial nerve assessment was not completed upon admission. During an interview of 06/19/2025 at 10:00 AM, Geriatric Psychiatric Manager confirmed the psychiatric evaluation should have been done as a part of the patient’s admission on 06/10/2025 and the cranial nerve assessment should have been completed by the hospitalist and was not. 3. Review of P10 was admitted 01/26/2025 for agitation and anxiety, there was no cranial nerve assessment performed as a part of the admission assessment. During an interview on 06/20/2025 at 10:15 AM, Geriatric Psychiatric Manager confirmed that P10’s admission assessment failed to include the cranial nerve assessment. During an interview on 06/20/2025 at 1:40 PM, Geriatric Psychiatric Manager and the Geriatric Psychiatric Director confirmed the admission cranial nerve assessment was to be completed by the Hospitalists. Geriatric Psychiatric Manager and the Geriatric Psychiatric Director confirmed that for P10 and P11 the admission cranial nerve assessment should have been done but was not. 4.Review of P5’s electronic medical record (EMR) revealed an admission date of 06/13/2025 with a diagnosis of debility for rehab. Further review of the chart revealed there was no history and physical assessment. During an interview on 06/20/2025 at 9:41 AM, the House Supervisor said there should be a history and physical assessment one within 24 hours of admission. Review of the admission packet for the Geriatric Psychiatric Distinct Part Unit (DPU) revealed the patient rights were incomplete and did not include the patient rights specific to psychiatric patients. The Geriatric Psychiatric DPU ‘s admission packet had been scanned and copied 11 of the 24 documents multiple times that the wording was illegible on the following forms in the admission packet: “Patient Rights” “Authorization For the Release of Patient Information” The “Boulder City Lay Caregiver Designation Form” “Gender Identity and Expression, Sexual Orientation Questionnaire” “Video Acknowledgement and Consent to Video Monitoring” “Tele Psychiatry Consent” “Consent to Participate in the Pet Therapy Program” “Important Message from Medicare” “Acknowledgement of Patient Information Medical Psychiatric Advanced Directives” “Crisrs Prevention Plan” “Interdisciplinary Treatment Plan” Review of the Medical Staff Rule and Regulations approved by the Medical Executive Committee on 12/02/2024 and approved by the Governing Board on 01/09/2025 revealed, “The attending physician shall be responsible for the preparation of a complete medical record for each patient. This record shall include: ... Personal & Social History, ... History of Present Illness, Physical Examination, ... A complete history & physical examination in all cases shall be completed within twenty-four (24) hours of an acute care admission. ... Inpatient Psychiatric Hospital Services: Admission: All medical records, including progress notes and treatment plans, shall be legible, complete. ... Psychiatric Evaluation: Each patient shall receive a psychiatric evaluation that must: (1) be completed within 60 hours of admission (2) Include a medical history (3) Contain a record of mental status (4) Note the onset of illness and the circumstances leading to admission (5) Describe attitudes and behavior (6) Estimate intellectual functioning, memory functioning, and orientation and (7) Include a descriptive inventory of the patient’s assets.””

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 25418 Based on observations, interviews, and policy reviews, the hospital failed to ensure adherence to the policies and procedures for infection prevention and control including surveillance, for two of six inpatient and outpatient services (Operating Room (OR) and inpatient/swing bed). The failure to follow the hospital infection control program and policies and procedures placed patients at risk for cross contamination. Findings include: 1. On 06/20/2025 at 7:41 AM, an Operating Room (OR) Registered Nurse (RN) started an intravenous (IV) catheter for patient (P) 13 in the pre-operative (pre-op) bay. The RN placed the needle used to insert the catheter into the plastic “IV start package” lying on the tray table, instead of in the sharp container on the wall behind P13’s gurney. After removing the gloves, the RN picked up the used needle with bare hands, removed it from the plastic “IV start package,” and laid the used needle directly onto the patient’s tray table. After discarding the other supplies, the RN picked up the needle and discarded the used insertion needle in the sharp’s box located on the wall behind another patient’s pre-op bay. During an interview on 06/20/2025 at 7:41 AM, the OR Manager revealed the nurse should not have handled a used needle with bare hands. Review of the hospital policy titled “Hand Hygiene Program” dated 04/11/25 revealed, “To provide guidelines for the prevention of the spread of infection by removing potentially pathogenic organisms through hand washing and the use of alcohol-based hand sanitizers. To outline nail care expectations and care that reduce the transmission of bacteria. ... Gloves should be donned whenever there is a possibility of contact with the patient’s blood or body fluids, mucous membranes or non-intact skin and when manipulating or handling potentially contaminated patient care equipment and/or environmental surfaces. Wearing gloves protects both the patient and the heath care workers.” Review of the facility’s policy titled, “How to Use the Glucometer” review 05/29/24 revealed, “. . . Maintenance and storage . . . the monitor must be visibly wet and allowed to sit 5 minutes then wipe down with a dry cloth. . . “ 2. During an observation on 06/20/2025 at 8:00 AM, a Registered Nurse (RN) was observed to leave a random patients’ room and set the glucometer on the cabinet without a barrier. The RN proceeded to spray down the glucometer. The RN got a cloth and wiped the glucometer. During an interview on 06/20/2025 at 8:10 AM, the RN stated, “there should have been a barrier placed down and then spray it and leave for three minutes.” During an interview on 06/20/2025 at 8:15 AM, the House Supervisor stated, “There should have been a barrier placed down, and the glucometer placed on top, The RN should have sprayed it and let it stay wet and not wiped it down.””

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 21794 Based on observations, interview, and document review, the facility failed to provide a medical screening exam and treatment for 1 of 20 patients (Patient #5). The failure to provide a medical screening exam and treatment for this patient had the potential to place the patient at increased risk of harm or illness. Findings include: Patient #5 (P5) Documented in a facility post-event internal investigation, P5 and spouse entered into the facility’s Emergency Department’s (ED) Waiting Room on 05/29/2024 at 11:17 PM. Upon entrance, the spouse of P5 approached the ED Registration Window and provided identification cards and was informed by the Admitting Clerk that medical imaging was not available. A review of the ED Central Log for the month of May 2024, revealed there was no documented evidence P5 was registered during the late evening of 05/29/2024. A telephonic interview with the ED provider on 11/06/2023 at 9:30 am, revealed at the time P5 was in the ED waiting room between the hours of 11:17 PM and 11:29 PM on 05/29/2024, the ED provider was located in the physician breakroom asleep. The ED provider confirmed not being alerted of the patient’s arrival by the RN. The ED provider only became aware of the patient’s presence onsite when awakened by the local Fire Chief after midnight on 05/30/2024, accusing the ED provider of not evaluating P5. In a telephonic interview with the ED Registered Nurse (RN) on 11/06/2024 at 11:06 am, the ED RN acknowledged not placing eyes on P5 while in the waiting room, and only spoke to the spouse of P5 as they were exiting the ED at 11:29 pm on 05/29/2024. In a face-to-face interview with the Admitting Clerk during the afternoon of 11/06/2024, the Admitting Clerk confirmed telling the spouse of P5, imaging was not available and did not register P5 upon arrival to the ED. In the facility’s internal investigation conducted by Risk Management, it was documented in the report that medical imaging was operational as of 10:15 PM, the evening of 05/29/2024. On 11/07/2024, a review of the camera footage for 05/29/2024 between P5’s arrival at 11:17 PM and departure time of 11:29 PM, P5 remained in the ED waiting room. During the brief stay P5 appeared restless, observed initially sitting in the chair upon arrival then kneeling on the floor hunched over. There was no observable evidence P5 was brought back to the ED from the waiting room and provided a medical screening evaluation (MSE). Complaint #NV00071832”