Deficiencies (last 3 years)
Deficiencies (over 3 years)
21.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
200% worse than Nevada average
Nevada average: 7.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Annual Inspection
Census: 92
Deficiencies: 5
Date: Mar 13, 2025
Visit Reason
This inspection was conducted as a State Licensure Survey in conjunction with a Federal Recertification survey from March 10, 2025 through March 13, 2025, to assess compliance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities.
Findings
The facility was found deficient in multiple areas including personnel records (TB testing, physical exams, fingerprinting/background checks), dementia training, CMS star rating posting, non-discrimination statement posting, and cultural competency training. Corrective actions and audits were planned to address these deficiencies.
Deficiencies (5)
Failure to ensure timely initial tuberculosis testing, physical examinations, and fingerprinting/background checks for sampled employees.
Failure to ensure employees completed eight hours of dementia training within 30 days of hire.
Failure to post the correct CMS star rating conspicuously in the facility and on the facility's website.
Failure to include Division contact information in the facility's non-discrimination statement posted in the facility and on the website.
Failure to ensure cultural competency training was completed within the required timeframe for sampled employees.
Report Facts
Census: 92
Sample size: 20
Deficiency severity F: 2
Deficiency severity C: 2
Deficiency severity D: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori Runyan | Administrator | Signed report and responsible for corrective actions |
| Human Resources Director | Interviewed regarding personnel records, TB testing, physical exams, background checks, dementia and cultural competency training | |
| People Culture Director | Responsible for overseeing compliance with personnel documentation and training requirements | |
| Staff Development Coordinator | Reeducated on dementia and cultural competency training requirements |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 13, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding neglect and failure to report and investigate an allegation of neglect involving Resident #60 after a fall resulting in serious bodily injury.
Complaint Details
The complaint investigation focused on neglect of Resident #60 after a fall on 11/20/2024, which resulted in a subdural hematoma and hospital transfer. The facility failed to report the neglect allegation to the State Agency and did not thoroughly investigate allegations against the former Director of Nursing who allegedly instructed staff not to send the resident to the hospital.
Findings
The facility failed to protect Resident #60 from neglect after a fall, resulting in delayed hospital transfer despite high blood pressure and head injury signs. The facility also failed to timely report the neglect allegation to the State Agency and did not thoroughly investigate allegations against the former Director of Nursing related to refusal to send the resident to the hospital.
Deficiencies (3)
Failed to protect a resident from neglect after a fall, resulting in risk of unnoticed condition changes and delayed hospital transfer.
Failed to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities.
Failed to respond appropriately to all alleged violations by not thoroughly investigating an allegation of neglect.
Report Facts
Residents sampled: 19
Blood pressure readings: 6
Time to hospital transfer: 150
Days for subdural hematoma reassessment: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unnamed Licensed Practical Nurse | Licensed Practical Nurse (LPN) | LPN involved in post-fall care and documentation; admitted not reviewing vital signs documented by CNA |
| Unnamed Certified Nursing Assistant | Certified Nursing Assistant (CNA) | CNA who assisted Resident #60 after fall and documented vital signs; raised concerns about LPN's response |
| Unnamed Physician | Physician | Physician familiar with Resident #60; ordered hospital transfer after high blood pressure and possible head strike |
| Unnamed Registered Nurse | Registered Nurse (RN) | RN who assessed Resident #60 post-fall and called physician due to injury concerns |
| Unnamed Regional Director of Quality and Clinical Services | Regional Director of Quality and Clinical Services (RDQCS) | RDQCS who provided expert statements on neglect, reporting requirements, and investigation deficiencies |
| Unnamed Executive Director | Executive Director (ED) | ED who denied reporting Resident #60's fall to the State Agency |
| Unnamed Former Director of Nursing | Former Director of Nursing (DON) | Alleged to have instructed staff not to send Resident #60 to hospital; allegations not thoroughly investigated |
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: Mar 13, 2025
Visit Reason
The inspection was conducted based on complaints and concerns regarding resident rights, medication administration, staff training, infection control, and other regulatory compliance issues at Northern Nevada State Veterans Home.
Complaint Details
The visit was complaint-related, triggered by allegations concerning resident rights violations, medication errors, staff training deficiencies, infection control lapses, and other regulatory compliance issues.
Findings
The facility was found deficient in multiple areas including failure to honor resident rights regarding pet therapy, improper medication administration and transcription errors, lack of current CPR certification for staff, inadequate individualized activities for residents, failure to post current nursing staffing information, unsecured medication storage with expired medications present, failure to ensure safe food temperatures, inaccurate resident medical records including code status and medication orders, failure to offer timely pneumonia and COVID-19 vaccinations, and untimely elder abuse prevention training for staff.
Deficiencies (11)
Failed to ensure a resident's right to choose to not be approached by pet therapy individuals despite documented allergy and care plan.
Failed to ensure nurses performed safe medication administration and accurate transcription of medication orders.
Failed to ensure direct care staff maintained current CPR certification.
Failed to provide individualized activities to meet resident's interests and needs.
Failed to post current nursing hours daily for all units.
Failed to ensure medication carts were secure and expired medications were removed from active supply.
Failed to ensure culinary staff checked and recorded holding temperatures for all hot foods prior to meal service.
Failed to ensure electronic medical records accurately reflected resident code status and medication orders were transcribed accurately.
Failed to ensure residents were offered timely pneumonia vaccines to complete recommended vaccine schedule.
Failed to provide education on COVID-19 vaccination and offer vaccine to eligible residents.
Failed to ensure timely completion of initial elder abuse prevention training for staff.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Direct care employees affected: 2
Units with missing nursing staff postings: 6
Expired medications found: 3
Residents affected: 15
Residents affected: 1
Residents affected: 2
Residents affected: 2
Employees affected: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #11 | Registered Nurse | Lacked current CPR certification and elder abuse prevention training |
| Employee #12 | RN/Infection Preventionist | Lacked current CPR certification and elder abuse prevention training |
| Employee #1 | Executive Director | Lacked documented elder abuse prevention training |
| Employee #5 | Social Services Director | Elder abuse prevention training completed late |
| Employee #14 | Licensed Practical Nurse | Elder abuse prevention training completed late |
| Employee #15 | Licensed Practical Nurse | Elder abuse prevention training completed late |
| Employee #16 | Certified Nursing Assistant | Elder abuse prevention training completed late |
| Employee #18 | Culinary Staff | Elder abuse prevention training completed late |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 6, 2024
Visit Reason
The inspection was conducted due to complaints of verbal abuse by a Certified Nursing Assistant (CNA) towards residents, and failure to timely and accurately report suspected abuse incidents to the State Agency.
Complaint Details
The complaint investigation substantiated verbal abuse by a CNA towards Resident #2. The CNA admitted to using profane language out of frustration and was terminated. The facility also failed to submit a final Facility Reported Incident (FRI) within the required timeframe for Resident #1, and the initial FRI contained inaccurate information.
Findings
The facility substantiated verbal abuse by a CNA towards Resident #2, who was called a profane word. The CNA was suspended, terminated, and reported to the State Board of Nursing. Additionally, the facility failed to submit an accurate initial Facility Reported Incident (FRI) and did not submit a final FRI within the required five-day timeframe for Resident #1.
Deficiencies (2)
Failed to protect Resident #2 from verbal abuse by a CNA who used profane language.
Failed to timely and accurately report suspected abuse incidents to the State Agency for Resident #1.
Report Facts
Residents sampled: 5
Facility Reported Incident (FRI) number: FRI #NV000072178 related to Resident #2 verbal abuse
Facility Reported Incident (FRI) number: FRI #NV00072148 related to Resident #1 reporting failure
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Employee who verbally abused Resident #2 and was terminated | |
| Regional Director of Quality and Clinical Services (RDQ) | Confirmed verbal abuse and reporting failures | |
| Director of Nursing (DON) | Escorted CNA out of the building after verbal abuse incident | |
| Administrator | Completed initial FRI with inaccurate information |
Inspection Report
Routine
Deficiencies: 17
Date: Apr 18, 2024
Visit Reason
The inspection was a routine regulatory survey to assess compliance with federal regulations for nursing home care, including resident rights, abuse prevention, care planning, medication administration, infection control, and safety.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, inadequate abuse investigation and reporting, incomplete care plans especially for oxygen therapy, medication administration errors, unsafe storage of hazardous items in memory care, incomplete staff training, and infection control lapses.
Deficiencies (17)
Failure to ensure a resident's dignity was maintained when maintenance staff entered a resident's room without knocking or permission.
Failure to implement abuse policy to investigate and report a resident's injury of unknown origin within required time frames.
Failure to timely report suspected abuse and results of investigation to proper authorities.
Failure to develop a baseline care plan addressing oxygen therapy for a resident.
Failure to develop complete care plans within 7 days of assessment and ensure appropriate interventions for residents in memory care.
Failure to meet professional standards of medication administration including ensuring residents swallow medications.
Failure to ensure nursing staff were trained and certified to perform CPR.
Failure to coordinate medication orders with contracted hospice agency for a resident receiving end-of-life care.
Failure to ensure memory care unit was free from hazardous substances and materials accessible to cognitively impaired residents.
Failure to ensure safe and appropriate respiratory care including obtaining and following physician orders for oxygen therapy.
Failure to ensure monthly medication regimen reviews were completed timely for residents reviewed for unnecessary medications.
Medication administration errors with an error rate of 8%, including failure to remove lidocaine patch as ordered and improper insulin pen preparation.
Failure to ensure employee wore appropriate hair restraints in kitchen and perform hand hygiene before and after resident contact during meal service.
Failure to update facility assessment to reflect accurate and current staffing needs of the memory care unit.
Failure to implement infection prevention and control program including disinfecting insulin pen rubber seal, proper COVID-19 testing location, and removal of used COVID test from resident area.
Failure to ensure elder abuse prevention training was completed timely for staff.
Failure to ensure annual behavioral health training was completed for staff as required.
Report Facts
Medication error rate: 8
Oxygen flow rate: 4.5
Oxygen flow rate: 2
Medication regimen review delay: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #15 | Licensed Practical Nurse | Lacked documented CPR training and certification |
| John Smith | Assistant Director of Nursing | Named in medication error finding for Resident #71 |
| Director of Nursing | Provided multiple clarifications on care plans, medication administration, oxygen therapy, and infection control | |
| Human Resources Director | Confirmed deficiencies in abuse prevention and behavioral health training | |
| Dietary Services Director | Commented on hair restraint and sanitation practices in kitchen | |
| Infection Preventionist | Commented on hand hygiene and COVID test handling | |
| Registered Nurse 1 | Observed medication administration errors with insulin pen and lidocaine patch | |
| Registered Nurse 2 | Observed medication administration error with insulin pen |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Dec 28, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding inadequate physician documentation when residents were transferred to another facility and failures in care planning and treatment for sampled residents.
Complaint Details
The complaint investigation found substantiated deficiencies related to inadequate physician documentation for resident transfers, incomplete care planning, failure to provide necessary treatment for bowel obstruction, and missing physician orders for diagnostic tests and transfers.
Findings
The facility failed to ensure physician documentation included specific resident needs, facility attempts to meet those needs, and services available at receiving facilities for transferred residents. Additionally, the facility failed to update a comprehensive care plan for constipation and abdominal distention, provide appropriate treatment for a resident with bowel obstruction, and ensure physician orders were properly entered and signed.
Deficiencies (4)
Failed to ensure required physician documentation was entered when residents were transferred to another facility for 5 of 5 sampled residents.
Failed to update a Comprehensive Care Plan to include care related to constipation and abdominal distention for 1 of 5 sampled residents.
Failed to provide appropriate treatment and care to identify and treat bowel obstruction for 1 of 5 sampled residents.
Failed to ensure physician orders for an x-ray and transfer to acute care were entered and signed for 1 of 5 sampled residents.
Report Facts
Residents sampled: 5
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Reviewed Physician Discharge Summaries and confirmed deficiencies in documentation and orders |
| Administrator | Facility Administrator | Confirmed lack of adequate physician documentation and orders |
| Licensed Practical Nurse | LPN | Nurse for Resident #4 who recalled resident's condition prior to EMS arrival |
| Registered Nurse | RN/Unit Supervisor | Confirmed resident's condition and assisted with hospital transfer |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 12, 2023
Visit Reason
The inspection was conducted due to allegations of staff to resident verbal abuse and possible financial exploitation involving two residents at the Northern Nevada State Veterans Home.
Complaint Details
The complaint involved allegations of verbal abuse by the Business Office Manager towards Resident #6 and possible financial exploitation of Resident #1 by a family member. The facility did not complete or submit required FRIs to the state agency for these allegations.
Findings
The facility failed to prevent verbal abuse by an employee towards Resident #6 and did not complete or submit required Facility Reported Incidents (FRIs) to the state agency for allegations of verbal abuse and exploitation involving Residents #6 and #1. The Business Office Manager received on-the-spot abuse training following the incident.
Deficiencies (2)
Failed to ensure a resident was not verbally abused by an employee for 1 of 7 sampled residents (Resident #6).
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities for allegations involving Residents #6 and #1.
Report Facts
Residents sampled: 7
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Named in verbal abuse finding and received on-the-spot abuse training | |
| Social Worker Director | Provided explanation of abuse reporting and assisted with reporting exploitation | |
| Administrator | Instructed Business Office Manager not to speak to Resident #6 and confirmed failure to submit FRIs |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 30, 2023
Visit Reason
The inspection was conducted to investigate complaints related to resident dignity, abuse, neglect, and supervision failures at Northern Nevada State Veterans Home.
Complaint Details
The complaint investigation involved allegations of a CNA laughing at a resident who fell in the shower, resident-to-resident physical abuse incidents involving Residents #2, #3, #4, and #5, and failure to follow post-fall protocols and supervision requirements after a resident fall.
Findings
The facility failed to maintain a resident's dignity when a CNA laughed at a resident who fell in the shower, failed to prevent resident-to-resident physical abuse involving three residents, and did not follow post-fall protocols or provide adequate supervision after a resident fell in the shower.
Deficiencies (3)
Failed to ensure a resident's dignity was maintained when a resident fell in the shower and a CNA laughed at the resident.
Failed to prevent resident-to-resident physical abuse for 3 residents.
Failed to ensure post fall protocol was followed and supervision was provided when a resident fell.
Report Facts
Facility Reported Incident (FRI) residents: 15
Residents affected by dignity deficiency: 1
Residents affected by physical abuse deficiency: 3
Residents affected by post fall protocol deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA#1) | Named in dignity and fall supervision findings for laughing at resident and leaving resident on floor | |
| Licensed Practical Nurse (LPN) | Verbalized concerns about CNA attitude and fall supervision | |
| Registered Nurse (RN#1) | Interviewed regarding resident fall and transfer issues | |
| Abuse Coordinator | Provided information on resident-to-resident abuse incidents |
Inspection Report
Routine
Deficiencies: 11
Date: Apr 6, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations at Northern Nevada State Veterans Home.
Findings
The facility was found deficient in multiple areas including dignity in resident care language, care planning for urinary catheters, medication administration practices, wound care communication, bowel and bladder care programs, respiratory care, food safety, protection of resident health information, vaccination policies, and staff training on elder abuse.
Deficiencies (11)
Staff referred to residents needing assistance with eating as feeders, which was a dignity concern.
Failure to develop and implement a care plan for a urinary catheter for Resident #23.
Registered Nurse failed to adhere to standards of nursing practice when administering medications to Resident #51, including pouring medications into the resident's mouth while lying flat.
Failure to communicate identification of a new wound and obtain treatment orders for Resident #66's ingrown toenail.
Failure to implement a bowel and bladder program for Resident #78 despite assessment indicating candidacy.
Failure to obtain physician's order for care, maintenance, and monitoring of a urinary catheter for Resident #23.
Failure to follow physician's order for oxygen therapy for Resident #1; oxygen was administered at 3.5 LPM instead of ordered 4.0 LPM.
Failure to discard food items by discard dates, risking food safety for all residents.
Failure to safeguard resident-identifiable information; computer terminal left unattended displaying PHI of Resident #60.
Failure to ensure education and offer pneumococcal vaccination to Residents #32 and #3, including lack of documented declination.
Failure to ensure timely elder abuse training for Employees #1 and #6.
Report Facts
Residents affected: 16
Residents affected: 8
Medication tablets administered: 8
Oxygen liters per minute ordered: 4
Oxygen liters per minute administered: 3.5
Food discard dates missed: 4
Employees sampled: 20
Employees with late or missing abuse training: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Administrator | Completed elder abuse training 27 days late |
| Employee #6 | Registered Dietician | Lacked documented evidence of initial and annual elder abuse training |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 6, 2023
Visit Reason
The inspection was conducted following a complaint regarding improper medication administration to Resident #51, specifically concerning the method of administering evening medications.
Complaint Details
The complaint investigation was substantiated based on interviews, clinical record review, and document review. Resident #51 reported being administered medications while lying flat and nearly choking. The Director of Nursing confirmed the nurse did not follow proper medication administration procedures.
Findings
The facility failed to ensure a Registered Nurse adhered to nursing standards when administering medications to Resident #51, who was given multiple medications while lying flat in bed with the medications poured directly into the resident's mouth, contrary to facility policy and standard nursing practice.
Deficiencies (1)
Failure to ensure a Registered Nurse adhered to standards of nursing practice when preparing and administering medications to Resident #51, including pouring multiple medications directly into the resident's mouth while lying flat in bed.
Report Facts
Medication tablets administered: 8
Sampled residents: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Conducted interview with the night shift RN and confirmed the medication administration process was not followed. | |
| Registered Nurse (RN) | Administered medications improperly to Resident #51 by pouring medications directly into the resident's mouth while lying flat. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Feb 1, 2023
Visit Reason
The inspection was conducted based on Facility Reported Incidents (FRI) involving allegations of abuse, neglect, misappropriation of resident property, and failure to provide appropriate care to residents.
Complaint Details
The complaint investigation involved six Facility Reported Incidents (FRI) concerning abuse, neglect, misappropriation of property, and failure to provide adequate care. The investigation substantiated abuse and neglect involving Residents #2, #3, and #4, including physical/verbal abuse, failure to monitor urinary output leading to harm, and misappropriation of property.
Findings
The facility failed to protect residents from physical and verbal abuse, ensure proper monitoring and care to prevent urinary retention and urethral trauma, prevent misappropriation of resident property, and update care plans accordingly. Specific incidents involved abuse by a Licensed Practical Nurse, neglect in monitoring urinary output leading to harm, and failure to update care plans after adverse events.
Deficiencies (5)
Failed to protect Resident #3 from physical and verbal abuse by a Licensed Practical Nurse who used profanity and slapped the resident's hand.
Failed to ensure Resident #4 received necessary services to prevent neglect resulting in urinary retention and urethral trauma.
Failed to ensure a nurse did not take Resident #2's personal property (Wi-Fi booster device).
Failed to update Resident #4's care plan to include interventions to monitor and prevent recurrence of urinary retention and urethral trauma.
Failed to provide appropriate care to Resident #4 to prevent urinary retention and urethral trauma, resulting in actual harm.
Report Facts
Facility Reported Incidents (FRI) sampled residents: 6
Resident #4 urinary retention volume: 275
Resident #2 reimbursement amount: 199
Resident #2 purchase amount: 119.99
Catheter balloon size: 16
Catheter balloon volume: 30
Urinary catheter change frequency: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN1) | Accused Resident #3 of pulling out gastric tube, used profanity, and slapped resident's hand | |
| Licensed Practical Nurse (LPN2) | Relieved LPN1 and confirmed LPN1's abusive behavior towards Resident #3 | |
| Administrator | Confirmed incidents involving LPN1 and Resident #3, and acknowledged reimbursement to Resident #2 | |
| Director of Nursing (DON) | Confirmed neglect and failure to monitor Resident #4's urinary output, and failure to update care plan |
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