Vets home hit with 18 citations

In a recent unannounced inspection, the Southern Nevada State Veterans’ Home was cited 18 times for issues ranging from verbal abuse of a patient to failing to provide meals at an appropriate temperature, to employees not having keys to locked gates, which would be needed in the case of an emergency evacuation.

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 the abuse incident.

The documentation of deficiencies was provided by the Centers for Medicare and Medicaid Services. Note that almost all of the people who spoke to the Review for this story did so on the agreement that their names would not be used. Current employees expressed a fear of retaliation by NDVS and the current director of nursing and some former employees expressed a fear that speaking out would limit their future job options. The only person willing to have her name used was former Director of Nursing Poppy Helgren, who retired in summer of 2023.

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

The inspection was conducted in late January by surveyors from the Centers for Medicare and Medicaid Services (CMS). In an email statement, a CMS representative said:

“The health and safety of nursing home residents is a top priority of the Centers for Medicare and Medicaid Services. 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. CMS requires Medicare-certified skilled nursing facilities, commonly known as nursing homes, to meet a set of federal health and safety standards to ensure quality of care and patient safety. State survey agencies conduct nursing home health inspections. If an inspection team finds that a nursing home doesn’t meet a specific federal standard, it issues a citation.”

Surveys are conducted without prior notice.

“A survey is required to be unannounced to prevent the facility from making special preparations that would not reflect ongoing and typical operations and could potentially mask the true quality of care and the level of safety routinely provided by the facility. CMS requirements for unannounced surveys is necessary to allow surveyors to ensure the quality and safety of patients and residents,” said a CMS spokesperson.

The allegation of verbal abuse was leveled at the licensed administrator, who has run the facility since mid-2023, Steven Pavlow. It revolved around Pavlow reportedly telling a resident, “If you don’t like it here, you can leave,” when a resident expressed displeasure with certain furniture and amenities that they relied on being removed. The incident was considered serious enough that on Jan. 25 (which was after the survey began), current deputy director of NDVS, Mark McBride, opened an official investigation.

The survey reports that rather than suspend Pavlow during the investigation, he was instructed to not interact with residents while the investigation was ongoing. However, in the weeks prior to this story, current employees at the home have reported that Pavlow has not been in the facility for an extended period and that they have been told he has been put on leave. The Boulder City Review has not been able to confirm if Pavlow is or is not on leave. NDVS has refused to answer any personnel questions and referred the matter to the attorney general’s office.

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.”

Multiple other citations all revolve around employees not having, or not having ready access to, keys for locked gates that would need to be opened in the case of fire or other emergency evacuation. At least half of employees interviewed by surveyors were also unaware of the location of either the emergency food or emergency water supplies in case of an issue that requires staff and residents to shelter in place. Emergency food and water supplies are stored in two different locations within the home.

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

All of the citations issued by CMS are given a rating or grading of either D or E. Ratings are on a matrix ranging from A through M and are based on a combination of the actual or potential degree of harm and how many patients are affected. Citati0ns with a grading of A do not require the facility to file a formal plan of correction, but anything B or lower has the requirement. Citations rated A, B or C are considered as still “substantially in compliance.” Citations with a grade of F or lower indicate substandard care and may impact a facility’s ability to participate in CMS funding. Citations with a grade of D or E (which describe all 18 of the violations at SNSVH) exist in kind of a gray zone between those two poles. According to multiple sources with experience running skilled nursing facilities, “Anything worse than a C is bad.”

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

In the CMS survey, a certified nursing assistant and a registered nurse who witnessed the incident are reported to have told surveyors that they considered it 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.

Helgren said that when she was the director of nursing for the home, that position doubled as the abuse coordinator.

“Part of the director of nursing’s job description at Southern Nevada State Veterans’ Home and the policies and procedures at the home, is that the DON is the abuse coordinator,” she said. “This entails doing all reporting of abuse to the BHCQ (Bureau of Healthcare Quality and Compliance), Aging and Disability and the VA. It also involves coordinating the investigation into any abuse that has been reported. It involved substantiating or not substantiating the abuse, through a complex and detailed investigation. When I was the DON for 8-1/2 years at the home, I kept meticulous files about incidents and reported abuse and the outcomes. In addition, I kept the numbers for our Quality Assurance Performance Improvement (QAPI) Program. Each year a group from the Nevada attorney general’s office (Medicaid Fraud) came to the facility to review the Mandatory Reporters Law with all employees. It was reviewed with them that the DON (myself) was the abuse coordinator. In fact, my name, as DON, was listed on the back of our nametags, as being the abuse coordinator. Staff was also reminded that if Mandatory Reporters did not report abuse, it could lead to six months in jail and/or a $1,000 fine.”

Helgren reported that on March 18, she received confirmation from the attorney general’s office that they had received her complaint against the current director of nursing alleging that they failed to report abuse.

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.