Northern Nevada State Veterans Home

In the surveyor’s words

From the most serious findings on record at Northern Nevada State Veterans Home, in the surveyor’s own words.

• Actual harm, isolatedF690Feb 1, 2023

  Based on clinical record review, interview, and document review the facility failed to ensure 1 of 6 FRI sampled residents (Resident # 4) received the care required to prevent urinary retention and urethral trauma (bleeding from the urethra). Findings include: Resident #4 was admitted to the facility on [DATE], with diagnoses including neuromuscular dysfunction of the bladder, unspecified, presence of urogenital implants, and vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A physician's order dated 02/28/22, documented an order to change an indwelling Foley 16 French (Fr)/10 cubic centimeters (cc) balloon (urinary) catheter every 30 days on night shift. […]

• No harm, potential for more than minimal, widespreadF812Apr 6, 2023

  Based on observation and interview, the facility failed to ensure food items were discarded by the discard dates with the potential to affect 86 of 86 residents in the facility. Findings include: On 04/03/23 at 8:33 AM, the refrigerator contained the following items: - tray of lemon squares labeled opened on 03/27/23, discard on 04/02/23 - container of turkey gravy labeled opened on 03/30/23, discard on 04/02/23 - tray of fruit [NAME] labeled opened on 03/31/23, discard on 04/02/23 - container of cranberries labeled opened on 03/22/23, discard on 03/25/23 On 04/03/23 at 8:48 AM, the Dining Services Director verbalized the facility policy was to discard leftover food three days after the food was prepared or opened, and confirmed the aforementioned foods should have been discarded. […]

• No harm, potential for more than minimal, widespreadF585Apr 25, 2022

  Based on interview and document review, the facility failed to respond to verbally reported grievances from residents regarding consistency of staff assignments. Findings include: On 04/19/22 at 1:13 PM, during a Resident Council interview, a Resident Council member verbalized the members had asked about having the same staff assigned to a unit to improve care and the staff's knowledge of the residents. The current practice was for staff to rotate throughout the facility during the week and the staff did not have time to learn about residents individual care needs and preferences. […]

• No harm, potential for more than minimal, widespreadF757Apr 25, 2022

  Based on clinical record review, document review, and interview, the facility failed to ensure a resident did not receive a medication without proper indication for 17 of 94 residents (Resident #101,#78, #92, #102, #106, #108, #109, #77, #86, #114, #115, #119, #7, #124, #91, #82, and #22) and an antibiotic without adequate monitoring for 59 of 94 residents (Resident #71, #100, #101, #8, #78, #65, #15, #18, #102, #103, #32, #14, #26, #105, #106, #107, #28, #20, #108, #109, #110, #2, #49, #77, #112, #113, #86, #114, #59, #42, #73, #115, #116, #117, #118, #119, #72, #66, #120, #19, #56, #21, #121, #130, #122, #123, #124, #53, #125, #126, #43, #127, #6, #39, #82, #22, #128, #60, and #4). […]

• No harm, potential for more than minimal, widespreadF801Apr 25, 2022

  Based on interview and document review, the facility failed to employ a State licensed Registered Dietician (RD) either full-time, part-time or on a consultant basis to carry out functions related to nutrition services. Findings include: On [DATE] at 10:01 AM, the Administrator confirmed the facility did not have an RD either on a full-time, part-time, or a consultant basis since the week of [DATE]. The Administrator verbalized the facility had just hired a full-time RD and would be starting on [DATE]. The facility personnel rosters documented the Registered Dietitian was hired on [DATE]. On [DATE] at 12:23 PM, the Human Resources/Payroll Coordinator verbalized the position was currently filled by a Registered Dietitian from their corporate office in another state. […]