Alexander "sandy" Nininger State Veterans Nursing

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This was observed during 3 of 3 visits conducted in the Main Kitchen.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to: 1. Follow the approved menu for the lunch meal served to the residents on 05/18/26 with the potential to affect 63 residents with orders for regular texture foods. 2. Failed to provide all the menu items for 1 of 1 resident observed during the breakfast meal on 05/19/26. (Resident #65) 3. Failed to provide all the menu items for 1 of 1 resident observed during the lunch meal on 05/19/26. (Resident #43) 4. Failed to serve the correct portion size for residents on 05/20/26 with the potential to affect 7 residents with orders for bite sized consistency.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide pureed foods in a form to meet the needs of a total of 17 residents with orders for pureed foods.

Inspectors wroteBased on Interview and record review, the facility failed to obtain informed consent for the use of Psychoactive medications for 1 of 4 residents reviewed for Dementia Care, Resident #98.

Inspectors wroteBased on interview and record review, the facility failed to ensure accuracy of diagnoses included on the PASARR (Preadmission screening and record review) for individuals with a mental disorder, for 3 of 4 residents reviewed (Residents #33, #34, and #7).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to develop and implement a care plan with measurable goals and interventions for 1 of 5 residents reviewed for Behavior, Resident #7; and failed to follow care plan interventions for 1 of 2 residents reviewed for falls, Resident #65.

Inspectors wroteBased on observations, interviews and record review, the facility failed to investigate and update interventions to care plans to prevent additional falls for 1 of 2 residents reviewed for falls (Residents #65).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide care and services to meet the needs and prevent re-traumatizing of 2 of 5 residents reviewed for Behavior, (Residents #7, and #9).

Inspectors wroteBased on interview, and record review, the facility failed to document behavior monitoring for 1 of 4 residents reviewed for Dementia Care, (Resident #98).

Inspectors wroteBased on review of policy and procedure, interview and record review, the facility failed to 1) accurately document, assess and report a resident's change in skin condition and; 2) ensure appropriate notification of the resident's representative of a change in the resident's condition for 1 of 2 sampled residents reviewed, Resident #1.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to address a significant weight loss in a timely manner, failed to provide adequate nutritional supplements to prevent further significant weight loss, and failed to have effective communication between the multidisciplinary staff for 1 of 4 sampled residents reviewed for nutrition (Resident #103).

Inspectors wroteBased on observations, interviews and record review, the facility failed to follow their own menu for fresh fruit, for 8 of 8 residents observed during dining (Resident #104, Resident #42, Resident #14, Resident #8, Resident #86, Resident #12, Resident #60, and Resident #35).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide palatable, appetizing and flavorful food for 8 of 8 residents (Resident# 58, Resident# 43, Resident# 59, Resident# 73, Resident# 88, Resident# 17, Resident# 32, Resident# 70).

Inspectors wroteBased on observations, record reviews, interviews, and policy review, the facility failed to provide the correct diet consistency for 9 residents on the Pureed consistency diet (Residents #41, #65, #25, #53, #11, #16, #45, #60 and #22). This had the potential to affect 14 residents that were prescribed the pureed consistency diet.

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, sanitary conditions, and to ensure the prevention of foodborne illnesses for 106 of 112 residents.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide residents' choices consistent with their interest assessments and care plan. Facility failed to honor resident choices regarding scheduled bedtime for 1 of 1 resident (Resident #114).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to address a grievance regarding hearing aids for 1 of 1 sampled resident (Resident #17).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide treatment and care, in accordance with professional standards for practice for 3 of 25 sampled residents (Resident #114, Resident #34, Resident #104).

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide a left hand splint as per Physician's order for 1 of 1 resident reviewed for Limited Range of Motion (Resident #19).

Inspectors wroteBased on observations, interviews, record reviews, and policy reviews, the facility failed to provide adequate supervision during a Hoyer lift transfer for 1 of 1 sampled resident (Resident #45). This had the potential to affect 50 residents who used Hoyer lifts. The facility failed to ensure that the oxygen tank was secured for 1 of 1 sampled resident (Resident #44).

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure controlled substance medication reconciliations were accurate for 2 of 9 sampled residents reviewed during the controlled substance record review on the facility's Delta and Alpha wings, for Residents #38 and #44.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure a treatment cart was locked while unattended during facility tour; failed to ensure medication cart and medications were secured during medication administration observation; and failed to dispose of expired over the counter medications (OTC) during medication storage review.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement CDC (Center for Disease Control and Prevention) guidelines and recommendations for Enhanced Barrier Precautions for 2 residents with wounds (Resident #61, and Resident #101).

Inspectors wroteBased on observations and interviews, the facility failed to ensure it was adequately equipped with functioning emergency call device in 2 of 12 bathrooms on the Alpha Unit.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow the Physician's orders for wound treatment (Resident #4), and failed to obtain a physician order for wound care (Resident #5), for 2 of 3 sampled residents reviewed for wound care (Residents #4 and #5).

Inspectors wroteBased on interview, observation, and record review, the facility failed to perform proper technique with catheter care for Resident #24 and failed to utilize a urinary catheter anchor for 3 of 14 residents identified with urinary catheters, Residents #24, #19, and #55.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5 percent, as evidenced by three medication errors in 25 opportunities which resulted in a medication error rate of 12 percent, for 2 of 5 sampled residents (Resident #83 and #34).