Northern Nevada State Veterans Home

Inspectors wroteBased on observation, interview and record review, the facility failed to reasonably accommodate the documented allergy of garlic for 1 of 19 sampled residents (Resident #20). This deficient practice had the potential to cause emotional distress and/or physical harm to the resident.

Inspectors wroteBased on clinical record review, interviews, and document review, the facility failed to ensure that a resident remained free from physical and/or mental abuse for 2 of 19 sampled residents (Resident #10 and #13). This deficient practice resulted in the resident being subjected to both physical and mental abuse, causing emotional distress and posing a potential risk for physical injury and a decline in psychosocial well being.

Inspectors wroteBased on clinical record review, document review and interview, the facility failed to ensure an antibiotic medication was administered in a timely manner as ordered by the physician order for 1 of 19 sampled residents (Resident #3). This deficient practice had the potential to result in delayed treatment, worsening clinical condition, and avoidable decline in health status.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1) a handwashing station was stocked with disposable hand towels, 2) dry food was appropriately stored, and 3) food was prepared and served in a sanitary manner. These deficient practices had the potential to increase the risk of infection and foodborne illnesses in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the outside garbage receptacle area was kept free from debris. This deficient practice had the potential to result in the harborage and feeding of pests.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a dishwasher machine in 1 of 3 satellite pantries was maintained in good working order to keep dishes, utensils, and other cooking equipment properly sanitized. This deficient practice had the potential to expose residents to foodborne illnesses.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure an effective pest control program was maintained as evidenced by the presence of live ants in 1 of 6 serving kitchens in the facility. This deficient practice had the potential to contribute to ants and other pest infestations, contaminate food preparation areas, and increase the risk of foodborne illness.

Inspectors wroteBased on interview, personnel record review, and document review, the facility failed to ensure elder abuse prevention training was completed timely per facility policy for 6 of 20 sampled employees (Employees #2, #3, #4, #15, #17, and #19). This deficient practice had the potential to place all residents at risk for abuse and neglect.

Inspectors wroteBased on record review and interview, the facility failed to maintain staffing hour postings for at least 18 months as required by federal regulation. This deficient practice had the potential to impede the facility's ability to demonstrate compliance with staffing requirements and hinders transparency for regulatory review.

Inspectors wroteBased on personnel record review, interview and document review, the facility failed to ensure initial elder abuse prevention training was completed timely for 10 of 20 sampled employees (Employees #1, #5, #11, #12, #14, #15, #16, #18, #19, and #20). This deficient practice had the potential to place all residents at risk for abuse and neglect.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's right to choose to not be approached by individuals providing pet therapy when the resident had a documented allergy to animal hair and a care plan addressing the resident's desire to not be asked about receiving pet therapy was respected for 1 of 19 sampled residents (Resident #16). This deficient practice had the potential to result in the resident feeling disrespected due to the resident's requests not being honored in the facility.

Inspectors wroteBased on interview, clinical record review, and document review the facility failed to protect a resident from neglect after a fall in the facility for 1 of 19 sampled residents (Resident #60). This deficient practice placed the resident at risk for changes in condition to go unnoticed by staff and a delay in transfer to the hospital.

Inspectors wroteBased on clinical record review, interview, and document review the facility failed to ensure an allegation of neglect and a fall resulting in serious bodily injury was reported to the State Agency (SA) for 1 of 19 sampled residents (Resident #60). This deficient practice had the potential for allegations of neglect to not be investigated by the facility and/or the SA.

Inspectors wroteBased on clinical record review, interview, and document review the facility failed to ensure an allegation of neglect was thoroughly investigated for 1 of 19 sampled residents (Resident #60). This deficient practice had the potential for physical and/or emotional harm to residents due to allegations of neglect not being investigated and protections put in place to prevent future neglect.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure nurses performed the job duties as outlined in the State Board of Nursing Nurse Practice Act with safe medication administration when 1) qualified Licensed Practical Nurses (LPN) and Registered Nurses failed to verify the appropriateness of a medication order for 1 of 19 sampled residents (Resident #69) and 2) eye drops were administered with incorrect technique for 1 of 4 residents observed during medication administration (Resident #72). The deficient practice resulted in a physician order being inaccurately transcribed onto a resident's electronic health record (EMR) and medication administration record (MAR), as well as the misadministration of ordered medication.

Inspectors wroteBased on personnel record review, document review, and interview, the facility failed to ensure direct care staff maintained current Cardio-Pulmonary Resuscitation (CPR) certification for 2 of 11 sampled direct care employees (Employee #11 and #12). This deficient practice could result in a negative outcome for a resident requiring CPR while awaiting the arrival of emergency medical personnel.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident received individualized activities to meet the resident's interests and need to have assistance with the use of electronic devices for 1 of 19 sampled residents (Resident #74). This deficient practice had the potential to result in a resident feeling isolated and frustrated from lack of social interaction and opportunities to pursue personalized interests.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a medication cart containing resident medications was secure and expired medications were removed from the active supply in 1 of 3 medication storage rooms and 1 of 3 medication carts reviewed for medication storage. The deficient practice could have facilitated unauthorized access to medications in the carts and had the potential for expired medications to be administered to residents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure culinary staff checked the holding temperatures for all hot foods to ensure the foods were at a safe temperature prior to beginning meal service from a satellite kitchen to residents in the [NAME]/Quail dining room during a lunch service with the potential to affect 15 of 15 residents residing on the unit and to ensure vegetables prepared for residents requiring a minced and moist diet in the Aspen/Pinion dining room were at a safe temperature prior to beginning lunch service with the potential to affect 1 of 15 residents residing on the unit. This deficient practice had the potential to result in food not held at appropriate temperatures resulting in the growth of pathogens that cause foodborne illness being served to residents.

Inspectors wroteBased on clinical record review, interview, and document review, the facility failed to ensure an electronic medical record (EMR) accurately reflected a resident's code status for 1 of 19 sampled residents (Resident #52) and physician orders were transcribed accurately into the resident's Medication Administration Record (MAR) and EMR to prevent medication errors for 1 of 19 sampled residents (Resident #69). This deficient practice had the potential for a resident's preference related to cardiopulmonary resuscitation (CPR) to not be followed and to result in a significant medication error and compromised resident safety.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure residents were offered timely pneumonia vaccines to complete the recommended pneumonia vaccine schedule for 2 of 5 residents reviewed for immunizations (Residents #21 and #22). This deficient practice had the potential to result in a resident contracting a preventable illness.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a resident was provided education on the risks and benefits of COVID-19 vaccination and a resident was offered the COVID-19 vaccine for 2 of 5 residents reviewed for immunizations (Resident #21 and #22). This deficient practice had the potential to result in residents and their representatives not being given the opportunity to make informed decisions before accepting or declining vaccination and a resident not given the opportunity to accept the vaccine and potentially prevent severe illness and hospitalization from infection with COVID-19.

Inspectors wroteBased on observation and interview, the facility failed to ensure current nursing hours were posted for 6 of 6 units in the facility. This deficient practice had the potential to result in a lack of awareness for residents and visitors regarding the number of nursing and direct care staff on duty.

Inspectors wroteBased on interview, clinical record review, and document review the facility failed to ensure a resident was not verbally abused by a Certified Nursing Assistant (CNA) when the CNA used profane language towards a resident for 1 of 5 sampled residents (Resident #2).

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to 1) submit a Facility Reported Incident (FRI) initial report with accurate and complete information, and 2) submit a final report to the State Agency (SA) within the required five-day timeframe for 1 of 5 sampled residents (Resident #1).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure the secured memory care unit did not contain potentially harmful and hazardous substances and materials for vulnerable, cognitively impaired residents for 22 of 32 residents residing in the secured unit (Residents #88, #31, #43, #22, #12, #82, #37, #52, #26, #81, #64, #40, #246, #4, #2, #5, #15, #45, #54, #63, #66, and #92). The deficient practice could result in vulnerable residents ingesting harmful and hazardous substances and materials with the potential for adverse health outcomes and hospitalization.

Inspectors wroteBased on interview, clinical record review, observation, and document review, the facility failed to ensure a resident's dignity was maintained when maintenance staff opened a resident's closed bedroom door and entered without knocking or asking permission to enter for 1 of 19 sampled residents (Resident #60).

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure the facility's abuse policy was implemented to investigate and report a resident's injury of unknown origin for potential abuse (Resident #4) and the policy included the required time frames for investigation and reporting of potential abuse. The deficient practice could result in resident's injuries of unknown origin to continue without investigation resulting in the potential for resident harm.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a resident's injury of unknown origin was reported to the State Agency (Resident #4). The deficient practice could allow injuries of unknown origin to not be investigated for potential abuse to occur and not be reported to the State Agency (SA) and/or Law Enforcement.

Inspectors wroteBased on clinical record review, document review, and interview, the facility failed to ensure a baseline care plan was developed to address the care and interventions for oxygen therapy for 1 of 19 sampled residents (Resident #295). The deficient practice could result in a negative outcome for the resident if staff were not aware of the resident's chronic oxygen status.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure the Comprehensive Care Plan was updated to include the care and interventions for oxygen therapy for 1 of 19 sampled residents (Resident #145) and the care plan interventions were appropriate for 3 of 32 residents residing in the specialized care unit (memory care) (Residents #9, #56, and #67).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to meet professional standards of medication administration for 1 of 19 sampled residents (Resident #71).

Inspectors wroteBased on personnel record review, document review, and interview, the facility failed to ensure nursing staff were trained and certified to perform Cardio-Pulmonary Resuscitation (CPR) in the event of a resident cardiac arrest for 1 of 4 sampled licensed nurses (Employee #15). The deficient practice could result in a negative outcome for a resident in cardiac arrest while awaiting the arrival of emergency medical personnel.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a resident's medication orders were coordinated with the contracted hospice agency providing the resident with end-of-life care for 1 of 19 sampled residents (Resident #26). The deficient practice could result in Resident #26 not receiving the correct medications for managing symptoms of the resident's terminal diagnosis.

Inspectors wroteBased on observation, clinical record review, interview and document review, the facility failed to obtain and/or follow a physician's order for respiratory care for 2 of 19 sampled residents (Resident #145 and #295).

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure Monthly Medication Reviews (MMR) were completed monthly for 2 of 5 residents reviewed for unnecessary medications (Resident #66 and #51).

Inspectors wroteBased on observation, interview, clinical record review and document review the facility failed to ensure medication was administered with an error rate of less than 5 percent (%). There were 25 opportunities and two medication errors. The medication error rate was 8%.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure an employee wore the appropriate hair restraints when working in the kitchen and hand hygeine was performed before and after resident contact during a lunch service. The deficient practice could impact the sanitary conditions of the working area for preparing resident food and meals and the potential to cause the spread of communicable disease to residents in the facility.

Inspectors wroteBased on observation, interview, and document review the Quality Assessment and Assurance (QAA) Committee failed to identify the lack of timely training (see Tag F678, F943, and F949).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure the rubber seal on an insulin pen was disinfected with alcohol prior to inserting a needle, COVID-19 testing was performed in an appropriate area, and a used COVID-19 test was not left in a resident area. The deficient practices have the potential to cause the spread of communicable disease to residents in the facility.

Inspectors wroteBased on personnel record review, document review and interview, the facility failed to ensure elder abuse prevention training was completed timely for 3 of 20 sampled employees (Employee #4, #7, and #9).

Inspectors wroteBased on personnel record review, interview, and document review, the facility failed to ensure annual behavioral health training was completed for 6 of 20 sampled employees (Employee #1, #2, #3, #7, #9, and #12).

Inspectors wroteBased on interview and document review, the facility failed to ensure the Facility Assessment (FA) was updated to reflect accurate and current staffing needs of the facility's special care unit (memory care).

Inspectors wroteBased on clinical record review, interview, and document review the facility failed to ensure required documentation was entered into the clinical record by a physician when residents were transferred to another facility for 5 of 5 sampled residents (Residents #1, #2, #3, #4, and #5).

Inspectors wroteBased on observation, clinical record review, interview, and document review the facility failed to ensure a Comprehensive Care Plan was updated to include a care plan related to constipation and abdominal distention for 1 of 5 sampled residents (Resident #4)

Inspectors wroteBased on record review, interview, and policy review the facility failed to ensure quality of care was provided for 1 of 5 sampled residents (Resident #4) by failing to ensure a resident with ongoing abdominal distention and pain received the care and treatment necessary to identify and treat a bowel obstruction.

Inspectors wroteBased on observation, clinical record review, interview, and document review the facility failed to ensure a physician's order for an x-ray and a physician's order to transfer a resident to an acute care emergency room were entered into the residents clinical record and signed by the physician for 1 of 5 sampled residents (Resident #4).

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a resident was not verbally abused by an employee for 1 of 7 sampled residents (Resident #6).

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a Facility Reported Incident (FRI) was completed and submitted to the state agency for an allegation of staff to resident verbal abuse for 1 of 7 sampled residents (Resident #6) and for an allegation of exploitation for 1 of 7 sampled residents (Resident #1).