Northern Nevada State Veterans Home
NORTHERN NEVADA STATE VETERANS HOME in SPARKS, NV — inspection on April 2, 2026.
Found 9 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
documented allergy of garlic for 1 of 19 sampled residents (Resident #20).
This deficient practice had
include:Resident #20Resident #20 was admitted to the facility on [DATE], with diagnoses including gastro-esophageal reflux disease without esophagitis, and muscle weakness.On 03/31/2026 at 12:57 PM, Resident #20 expressed fear of eating garlic due to concern it could result in an undignified death from colic and severe gastrointestinal distress. Resident #20 verbalized when receiving an alternate meal in place of the regular meal, the resident did not receive any side items, including dessert. Resident #20's clinical record section Allergies, dated 05/02/2025, documented Resident #20's allergens included garlic, and severe allergy type.Physician's order dated 05/05/2025, documented regular diet, regular texture, regular liquids/consistency, allergic to garlic.Resident #20's care plan dated 05/06/2025, documented Resident #20 was allergic to garlic. Be sure the food, including condiments, does not contain garlic.On 04/01/2026 at 12:30 PM, the Culinary Director explained resident allergies were documented on the tray card ticket to ensure allergies were not included in meals provided to the resident.
The Culinary Director verbalized staff reviewed the list of foods with the allergen with Resident #20.
The Culinary Director explained Resident #20 was too proud to request further accommodation with meals to ensure garlic was not present in the meal.
The Culinary Director verbalized when a dish contained garlic, staff would ask the resident for an alternative meal choice.
The Culinary Director verbalized the kitchen could not prepare a separate garlic free version of the scheduled meal option due to cost and production limitations.On 04/02/2026 at 10:00 AM, the Registered Dietician (RD) explained an alternate meal was not necessarily equal in calories to the regular meal being served.
The RD did not explain if alternate meals were equal in nutritional value.The facility policy and procedure manual titled Food Allergies, undated, documented individuals with food allergies would be provided with safe foods and fluids, and appropriate substitution to maintain health.The facility policy and procedure manual titled Resident Rights, reviewed 04/16/2025, documented the community must protect and promote the rights of all residents and ensure residents were receiving the care and services needed.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
295105 04/02/2026
Northern Nevada State Veterans Home 36 Battleborn Way Sparks, NV 89431
front of the resident's face while getting closer to the resident. Resident #13 looked away from CNA1
Nurse's (RN) witness statement dated 09/26/2025, documented the RN had received report from the
to the Director of Nursing and then had CNA1 meet with the RN and Security regarding CNA1's conduct with the residents. CNA1 was asked to surrender the employee badge and was notified CNA1 would be placed on suspension pending a formal investigation. CNA1 was then escorted from the facility property.On 03/31/2026 at 3:37 PM, the Administrator verbalized the facility investigation into the alleged abuse of Resident #10 and Resident #13 by CNA1 on 09/26/2025, was substantiated.
The Administrator explained the incident with both residents occurred at the Nurse's Station. CNA1 was suspended immediately, surrendered the employee's badge, and then terminated in response to the investigation findings.
The Administrator provided the investigation documentation, staff and resident witness statements from the investigation, a staff In-Service on abuse prevention and reporting, and a report to the Nursing Board regarding CNA1 dated 10/03/2025. On 04/02/2026 at 9:56 AM, the Human Resources Director confirmed CNA1 was terminated for resident rights violations and resident abuse on 10/10/2025.A CNA Job description signed on 8/26/2025, documented a common core role of quality of care included following all policies and procedures related to reporting and preventing abuse of vulnerable adults.
The incumbent would ensure residents received the highest quality of service in a caring, compassionate, and dignified manner which recognized the individual's needs and rights.
Residents would be assisted with activities of daily living in a manner conducive to the residents' safety and comfort.
The facility policy titled Abuse, Neglect, and Exploitation, dated 01/2023, documented it was the policy of the facility to take appropriate steps to prevent the occurrence of abuse, neglect, and misappropriation of property.
Abuse included verbal, sexual, physical and mental abuse.
Instances of abuse of all residents, irrespective of any mental or physical condition, caused physical harm, pain, or mental anguish.
Staff were supervised to identify inappropriate behaviors such as derogatory language, rough handling, and ignoring residents while giving care.FRI 2629530
295105 04/02/2026
Northern Nevada State Veterans Home 36 Battleborn Way Sparks, NV 89431
medication was administered in a timely manner as ordered by the physician order for 1 of 19 sampled
worsening clinical condition, and avoidable decline in health status.
Findings include:Resident #3 Resident #3 was admitted to the facility on [DATE], with diagnoses including type 2 diabetes mellitus with diabetic polyneuropathy, peripheral vascular disease, unspecified, embolism and thrombosis of arteries of the lower extremities, acquired absence of right leg above knee, and infection following a procedure, deep incisional surgical site, sequela. Resident #3's Care Plan dated 02/02/2026, documented surgical wound to right above the knee amputation.
Wound dehiscence with wound infection. A physician order dated 03/05/2026, documented Bactrim Double Strength Oral Tablet 800-160 milligrams (mg), give one tablet by mouth two times a day for wound infection suppressive therapy, 0800 and 2000 hours. Resident #3's Medication Administration Record dated April 2026, lacked documented evidence Bactrim Double Strength Oral Tablet was administered on April 1, 2026 at 0800 hours. On 04/01/2026 at 11:45 AM, the Licensed Practical Nurse (LPN) verbalized having administered Bactrim Double Strength Oral Tablet to Resident #3 at 11:01 AM, due to time having gotten away from the LPN.
The LPN confirmed the order for the Bactrim Double Strength Oral Tablet documented the antibiotic was to be administrated at 8:00 AM, but was not. On 04/01/2026 at 2:29 PM, the Director of Nursing (DON) confirmed the Bactrim Double Strength Oral Tablet should have been administered to Resident #3 at 8:00 AM, and verbalized having expected medications to be administered at the time documented on the order.
The facility policy titled, Medication Administration, dated 11/2024, documented all medications were to be administered as ordered by the physician.
The standard of practice for medication administration was an hour before or an hour after unless the physician order documented a specific time for administration.
295105 04/02/2026
Northern Nevada State Veterans Home 36 Battleborn Way Sparks, NV 89431
minimal harm 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
staffing hour postings from 07/2025 - 09/2025. On 03/31/2026 at 11:10 AM, the Administrator verbalized the Staff Scheduler was not retaining the staffing hour postings.
The Administrator confirmed staff postings were to be retained for 18 months.
The Administrator verbalized being unaware the Staff Scheduler was discarding the staffing hour postings at the end of every week.
The Administrator explained an in-service was provided to the Staff Scheduler for the required retention time of the staffing hour postings on 03/31/2026.
serve food in accordance with professional standards.
observation, interview, and document review, the facility failed to ensure 1) a handwashing station
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.
Findings include:Handwashing StationOn 03/30/2026 at 9:24 AM, during a tour of the Aspen Pinion Serving Kitchen, the handwashing station was not stocked with disposable hand towels.On 03/30/2026 at 9:24 AM, the Culinary Director (CD) confirmed the lack of disposable hand towels at the Aspen Pinion Serving Kitchen handwashing station and verbalized disposable hand towels should always be available at the handwashing stations.The facility policy titled, Policy and Procedure Manual - Hand Washing, dated 2021, documented handwashing facilities would be readily accessible and equipped with hot and cold running water, paper towels and/or automatic hand dryer, soap, trash cans and signage.Food StorageOn 03/30/2026 at 9:45 AM, during a tour of the Reflections Satellite Pantry, pouches of powdered fruit punch and lemonade were open and exposed to the air and other contaminants.On 03/30/2026 at 9:45 AM, the CD confirmed the observation and verbalized the powdered fruit punch and lemonade pouches should be folded and closed.The facility policy titled, Policy and Procedure Manual - Food Storage, dated 2021, documented food would be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination.
Food would be stored and handled to maintain the integrity of the packaging until ready for use.Sanitary Food PreparationOn 04/01/2026, during lunch tray line observation in the [NAME] Quail Serving Kitchen, the following events occurred:-At 12:05 PM, the Dietary Supervisor (DS) took the temperature of the soft and bite sized asparagus.
The thermometer indicated the asparagus was 132 degrees Fahrenheit (F).-At 12:05 PM, the DS verbalized the asparagus was under the appropriate temperature and should be sent back to the primary kitchen to be reheated to 140 F.
The DS may also manually chop a portion of the regular diet asparagus to meet the needs of residents requiring a soft and bite sized diet.-At 12:12 PM, the DS took a knife out of the DS's pocket and washed the knife with hand soap in the handwashing sink.
The DS plated a dish of bite sized chicken, rice, a minced and moist roll and four asparagus shoots.
The DS used the knife to cut the asparagus shoots on the plate.On 04/01/2026 at 12:29 PM, the DS verbalized the DS always kept a personal knife on hand in case a knife was needed to prepare or serve food.
The DS confirmed the DS took a personal knife out the DS's pocket and explained the DS washed the knife in the handwashing sink before using the knife to prepare resident food.
The DS verbalized the DS should have gotten a clean and disinfected knife from the pantry as it was important utensils were properly sanitized.On 04/01/2026 at 1:03 PM, the CD explained it was important food preparation surfaces, utensils and kitchenware were sanitized to prevent the spread of disease.The facility policy titled, Policy and Procedure Manual - Cleaning Dishes/Dish Machine, dated 2021, documented all flatware, serving dishes, and cookware would be cleaned, rinsed and sanitized after each use.
Dishes should be rinsed in the sink using hot soapy water if needed.
Pots and pans should be scrubbed with a non-metallic scouring pad, when necessary, washed and rinsed using the three-sink method.
295105 04/02/2026
Northern Nevada State Veterans Home 36 Battleborn Way Sparks, NV 89431
in the harborage and feeding of pests.
Findings include:On 03/30/2026 at 8:56 AM, the outside
boxes to the rear and right sides of the receptacle.The Culinary Director (CD) was present and verbalized the receptacle area was managed by facility maintenance; however, all staff were responsible for ensuring the receptacle area was kept clean and free of debris.
The CD confirmed the condition of the garbage receptacle area.On 04/02/2026 at 12:09 PM, the Plant Operations Director (maintenance) explained all staff were responsible for ensuring the receptacle area remained clean and free of debris.
The Plant Operations Director verbalized the importance of keeping the receptacle area clean was to prevent rodents in the facility.The facility policy titled, Policy and Procedure Manual - Waste Disposal, dated 2021, documented trash would be deposited into a sealed container outside the premises.
295105 04/02/2026
Northern Nevada State Veterans Home 36 Battleborn Way Sparks, NV 89431
other cooking equipment properly sanitized.
This deficient practice had the potential to expose
Reflections satellite pantry, the Culinary Director (CD) started a cycle on the dishwasher. A colorless transparent liquid seeped out from underneath the dishwasher into a puddle in front of the dishwasher. At the end of the cycle, the CD wiped a chlorine test strip on the door of the dishwasher.
The test strip lacked a change of color.
The CD wiped another chlorine test strip on the dishwasher door.
The chlorine test strip did not change color.
The CD started a second cycle on the dishwasher.
At the end of the cycle, the CD used three chlorine test strips: one on the dishwasher door, one on the dish rack, and one in the water pooling at the bottom of the dishwasher.
The test strips did not change color.
Water seeped out from underneath the dishwasher to the front and right side of the dishwasher.The CD verbalized the dishwasher was a low temperature dishwasher with chemical sanitization.
The CD explained the dishwashers used chlorine bleach.
When tested, the chlorine testing strip should turn purple to indicate the ideal chlorine sanitizer concentration of 100 parts per million (ppm).
The CD confirmed the observations and explained the chlorine test strips indicated a chemical concentration of zero ppm.
The CD confirmed no sanitizing agent was being delivered to the dishwasher.
The CD explained it was important dishes were properly washed and sanitized to prevent the spread of viruses and bacteria.
The CD was previously unaware of the dishwasher seepage and sanitizer concentration.The facility policy titled, Policy and Procedure Manual - Cleaning Dishes/Dish Machine, dated 2021, documented all flatware, serving dishes, and cookware would be cleaned, rinsed and sanitized after each use.
Dish machines must automatically dispense detergents and sanitizers.
295105 04/02/2026
Northern Nevada State Veterans Home 36 Battleborn Way Sparks, NV 89431
program was maintained as evidenced by the presence of live ants in 1 of 6 serving kitchens in the
contaminate food preparation areas, and increase the risk of foodborne illness.
Findings include:On 03/30/2026 at 10:40 AM, during a tour of the facility's serving kitchens and in the presence of the Culinary Director, several ants were present on the floor of the Pyramid [NAME] Unit serving kitchen near the door to the satellite pantry and around the garbage bin.The Culinary Director confirmed the observation and explained being aware of ants present in the facility approximately one year prior; however, the Culinary Director believed the problem had been resolved.
The Culinary Director verbalized when ants were identified, the Culinary Director would set out bait traps and disinfect the area to ensure the kitchen environment was insect free. On 04/02/2026 at 12:09 PM, the Plant Operations Director explained the facility was contracted with a pest control company for monthly services to prevent and address rodents, insects and other pests.
The Plant Operations Director verbalized being made aware of the ants in the Pyramid [NAME] Unit serving kitchen that day.
The Plant Operations Director explained when made aware of insects in the facility, the Plant Operations Director would reach out to the pest control company, the facility would be sprayed with insect repellant, and bait traps would be placed.A document titled, Industrial-Commercial-Institutional Pest Control Service Agreement, dated 03/12/2025, documented the facility would receive services for roaches, ants, silverfish, fire ants, rats, and mice.The facility policy titled, Policy and Procedure Manual - Pest Control, dated 2021, documented a pest control contractor would provide routine preventative treatments at prescheduled appointed times and if a pest situation was reported, the contractor would be notified and may be requested to make an unscheduled visit to address concerns.
295105 04/02/2026
Northern Nevada State Veterans Home 36 Battleborn Way Sparks, NV 89431
report abuse, neglect, and exploitation.
abuse prevention training was completed timely per facility policy for 6 of 20 sampled employees
residents at risk for abuse and neglect.
Findings include:Employee #2Employee #2 was hired as the Director of Nursing on 02/09/2026.Employee #2's personnel record documented initial abuse training completed on 02/15/2026, six days after hire.Employee #3Employee #3 was hired as the Activity Director on 05/13/2025.Employee #3's personnel record documented initial abuse training completed on 08/07/2025, nearly three months after hire.Employee #4Employee #4 was hired as the Registered Dietician on 07/13/2025.Employee #4's personnel record lacked documented evidence that initial abuse training was completed.Employee #15Employee #15 was hired as a Licensed Practical Nurse on 06/24/2025.Employee #15's personnel record documented initial abuse training completed on 07/22/2025, almost one month after hire.Employee #17Employee #17 was hired as a Certified Nursing Assistant on 04/22/2025.Employee #17's personnel record documented initial abuse training completed on 06/12/2025, more than seven weeks after hire.Employee #19Employee #19 was hired as a Dietary Aide on 09/09/2025.Employee #19's personnel record documented initial abuse training completed on 10/07/2025, nearly one month after hire.On 04/01/2026 at 12:03 PM, the Human Resources Director explained all staff in the facility were required to complete abuse training upon hire at the facility and annually thereafter.
The Human Resources Director confirmed Employee #2, #3, #4, #15, #17, and #19, had not completed abuse training timely.The facility policy titled Abuse, Neglect, and Exploitation, suspected Crimes, last revised August 2025, documented all employees were to be trained during orientation to the facility on issues related to abuse prohibition practices and annually thereafter.
The practices would detail appropriate interventions to deal with aggressive or catastrophic reactions of residents, how staff should report knowledge related to allegations of abuse without fear of reprisal, how to recognize sings of burnout, frustration, and stress that may lead to abuse, and what constitutes abuse, neglect, injuries of unknown origin, and misappropriation of resident property.
295105 04/02/2026
Northern Nevada State Veterans Home 36 Battleborn Way Sparks, NV 89431
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SPARKS, NV, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from NORTHERN NEVADA STATE VETERANS HOME or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.