SPARKS, NV - Federal inspectors identified multiple deficiencies at Northern Nevada State Veterans Home during a March 2025 survey, including improper medication administration techniques, expired medications in active supply, and lapses in food safety protocols that affected resident care and safety.
Medication Administration and Storage Failures
Inspectors documented several critical issues with medication handling that compromised resident safety. During observations on March 12, 2025, staff left a medication cart unlocked in the Tahoe/Truckee unit while five residents sat in the immediate vicinity. The registered nurse (RN) who returned to the cart confirmed it had been left unsecured, acknowledging that residents could have accessed medications intended for others.
Further inspection of medication storage areas revealed expired medications stored alongside active supplies. In the Pinion/Aspen unit medication cart, surveyors found Docusate Sodium stool softener capsules that expired in December 2024 and seven tablets of Ondansetron 4 mg with an expiration date of December 3, 2024. The accompanying RN confirmed these medications should have been removed and destroyed using the facility's drug disposal system before reaching their expiration dates.
The medication storage room on the same unit contained additional expired items: an intravenous solution bag of five percent Dextrose that expired in November 2024, and a vial of Tuberculin Purified Protein Derivative (Tubersol) that had been opened on January 28, 2025. According to manufacturer guidelines, Tubersol must be discarded within 30 days of opening, yet the vial remained in the refrigerator well past this timeframe.
The Director of Nursing explained that administering expired medications could reduce therapeutic effectiveness or potentially cause adverse reactions in residents. The facility's own policy required immediate removal and proper disposal of any medications past their expiration date.
Improper Eye Medication Technique Observed
Inspectors observed incorrect administration of eye drops to a resident with dementia who had been prescribed Artificial Tears three times daily for dry eye. On March 12, 2025, at 9:04 AM, a licensed practical nurse (LPN) administered the medication without pulling down the resident's lower eyelid as required by proper technique. As a result, a portion of the medication fell onto the resident's skin below the eye rather than into the eye itself. The resident was handed a tissue and wiped away the medication.
The Director of Nursing emphasized that correct eye drop administration requires specific steps: performing hand hygiene, opening the medication, ensuring the eye is free from discharge, holding the lower eyelid down, and then instilling the drop. When eye drops are administered without proper technique, residents may receive less than the prescribed dose, reducing medication effectiveness. Additionally, improper administration increases infection risk.
The facility's own policy for eye medication instillation, dating from April 2008, specified that residents should tilt their head backward while staff draw down the lower eyelid, have the resident look upward, and drop medication into the pouch of the lower lid at three to five-minute intervals.
Medical Record Discrepancies Created Safety Risks
Surveyors identified serious inconsistencies in how resident preferences for life-sustaining treatment were documented. For one resident admitted with dementia-related diagnoses, the electronic medical record indicated "full treatment CPR" status as of March 13, 2025. However, the resident's signed Physician Orders for Life-Sustaining Treatment (POLST) form from an earlier date clearly specified "do not resuscitate" with selective treatment only.
When an RN reviewed the record, she confirmed the mismatch between the electronic system and the signed POLST document. The Director of Nursing acknowledged that the code status in the electronic medical record had been updated several days late, creating a period when staff might not have honored the resident's actual wishes in a medical emergency.
Such discrepancies can have profound consequences. Emergency responders and nursing staff rely on immediately accessible code status information to make split-second decisions during medical crises. When electronic records don't match legal advance directive documents, staff may perform unwanted resuscitation attempts or withhold desired interventions.
Another medication order error involved Spironolactone, a medication prescribed for heart failure. The electronic medical record and medication administration records showed instructions to hold the medication if the resident's heart rate dropped below 60 beats per minute. However, the original physician order contained no such parameter. Spironolactone, a potassium-sparing diuretic, does not typically require pulse rate monitoring before administration—unlike medications that directly affect heart rate such as beta-blockers or certain calcium channel blockers.
The Director of Nursing explained that during the facility's change of ownership, physician orders were transcribed from the previous electronic system to the current one, and some orders were transcribed inaccurately. This created a situation where nurses might inappropriately withhold a prescribed heart failure medication based on incorrect parameters, potentially compromising the resident's cardiac management.
Food Safety Violations Detected During Meal Service
Inspectors observed multiple food temperature violations during lunch service on March 12, 2025, that created potential foodborne illness risks. In the Sage/Quail satellite kitchen serving 15 residents, culinary staff began plating meals before checking all hot food temperatures. When the Dietary Manager arrived and completed temperature checks, mechanical soft fish registered at only 128 degrees Fahrenheit—well below the required 135-degree minimum for safe hot food holding.
Food safety standards require hot foods to be held at 135 degrees Fahrenheit or above to prevent bacterial growth. Temperatures between 41 and 135 degrees Fahrenheit fall within the "danger zone" where pathogens multiply rapidly. The mechanical soft fish was pulled from service and reheated to a safe temperature.
In the Aspen/Pinion dining area, vegetables prepared for residents requiring minced and moist texture-modified diets initially measured 132 degrees Fahrenheit during the pre-service check—below the safe holding temperature. The culinary staff member placed these vegetables on the hot holding table intending to recheck the temperature before serving. However, at 12:13 PM, the staff member placed a serving of these vegetables on a plate and handed it to dining room staff without rechecking the temperature. When finally measured at 12:15 PM, the vegetables had dropped to 125 degrees Fahrenheit.
The Dietary Manager confirmed that when food temperatures fall below safe levels, items should be removed from the serving line and reheated to 165 degrees Fahrenheit for at least 15 seconds before being served to residents. Residents in long-term care facilities often have compromised immune systems, making them particularly vulnerable to foodborne pathogens that proliferate when temperature controls fail.
Staffing and CPR Certification Gaps
The facility failed to maintain current cardiopulmonary resuscitation certification for two registered nurses providing direct resident care. One RN's personnel file contained no documentation of CPR training or certification. A second RN who served as the Infection Preventionist had a CPR certification that expired prior to the survey date.
Both positions' job descriptions explicitly listed CPR certification as a minimum requirement. The facility's own assessment document stated that licensed nurses and certified nursing assistants must maintain current CPR certification. The Human Resources Director confirmed that CPR certification was required for all direct care staff and acknowledged the two employees lacked current credentials.
In long-term care settings, residents experience medical emergencies requiring immediate intervention before emergency medical services arrive. Staff members with current CPR training can provide critical life-saving measures during these crucial minutes, potentially preventing death or minimizing brain damage from oxygen deprivation.
Additional Issues Identified
Inspectors found the facility failed to post current daily nursing staff levels for three consecutive days. Postings displayed throughout the six-unit facility were dated March 7, 2025, when surveyors arrived on March 10. The Staffing Coordinator, responsible for posting Monday through Friday, and the RN responsible for weekend postings both confirmed they had not updated the information for March 8 or 9. These postings provide transparency to residents and families about the number of licensed nurses and direct care staff on duty each shift.
The activities program failed to provide individualized engagement for a resident with post-traumatic stress disorder and major depressive disorder who preferred not to attend group activities. The resident reported feeling very depressed and wanting help learning to use a smartphone and tablet that family had provided. The resident needed assistance answering calls and accessing video streaming applications. Documentation showed only one self-directed activity recorded in the previous 14 days, despite the resident's care plan calling for alternate activities the resident could do alone. The Interim Activities Director acknowledged staff should have been checking in with the resident daily to provide socialization and assistance with personal interests, confirming the activities program could have helped the resident learn to use the electronic devices.
The violations identified during this inspection reflect systemic issues with medication safety protocols, food service procedures, medical record accuracy, and individualized care delivery that required immediate corrective action to ensure resident safety and well-being.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Northern Nevada State Veterans Home from 2025-03-13 including all violations, facility responses, and corrective action plans.
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