Alwyn C Cashe State Veterans Nursing Home

Inspectors wroteBased on interview, and record review, the facility failed to notify the family representative in writing of a room change for 1 of 3 residents reviewed for Resident's Rights, of a total sample of 4 residents, (#1).

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop an individualized comprehensive care plan to include a pacemaker and compression stockings for 1 of 3 residents reviewed for quality of care, of a total sample of 4 residents, (#1).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide expected provision of care and follow physician's orders for compression stockings for 1 of 3 resident reviewed for quality of care, of a total sample of 4 residents, (#1).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Cardiology services were provided per physician's orders for 1 of 3 residents reviewed for administration, of a total sample of 4 residents, (#1).

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents' right to be free from neglect by not ensuring the staff maintained a secure environment and implemented measures to mitigate the risks to prevent elopement for 1 of 7 residents reviewed for elopement, of a total sample of 11 residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was outside the facility unsupervised, there was reasonable likelihood he could have fallen, become lost, been accosted/harmed by a stranger or been hit by a car. On 8/07/25 at approximately 4:32 AM, the facility failed to prevent a resident with severe cognitive impairment from exiting the facility unsupervised. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to maintain a secure environment to ensure vulnerable residents did not exit the facility without supervision for 1 of 7 residents reviewed for elopement, of a total sample of 11 residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was outside the facility unsupervised, there was reasonable likelihood he could have fallen, become lost, been accosted/harmed by a stranger or been hit by a car. On 8/07/25 at approximately 4:32 AM, the facility failed to prevent a resident with severe cognitive impairment from exiting the facility unsupervised. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity by failing to recognize each resident's individual preference whether to wear a clothing protector at meals for 31 residents observed on the memory care unit out of a total sample of 25 residents.

Inspectors wroteBased on observation, interview and policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections when linen was folded without demonstrating proper folding techniques and hygiene protocols.

Inspectors wroteBased on interview, and record review, the facility failed to develop a comprehensive person-centered care plan to meet the resident's medical, nursing, mental and psychosocial needs for 2 of 2 residents reviewed for comprehensive care plans out of a total sample of 25 residents, (#10 and #49).

Inspectors wroteBased on observation, interview, and record review the facility failed to provide appropriate care and services to maintain and clean a Continuous Positive Airway Pressure (CPAP) machine for 1 of 1 residents reviewed for respiratory services, of a total sample of 25 residents, (#49).

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent medication errors greater than 5 percent (%) for 3 of 4 residents sampled for medication administration, (#29, & #18), of a total sample of 25 residents. There were 4 errors in 30 opportunities by 2 of 3 nurses observed, for a medication error rate of 13.3 %.

Inspectors wroteBased on interview, and record review, the facility failed to implement its policy and procedures for the prohibition of abuse and neglect related to providing staff education, conducting a thorough incident investigation, and protecting residents in response to an allegation of neglect for 1 of 2 residents reviewed for neglect, of a total sample of 4 residents, (#1); and failed to minimize the risk for neglect for residents who had abnormal diagnostic test results.

Inspectors wroteBased on interview, and record review, the facility failed to conduct a thorough medication regimen review and ensure adequate monitoring of a high-risk drug to minimize adverse consequences for 1 of 3 residents reviewed for laboratory test results, of a total sample of 4 residents, (#3).

Inspectors wroteBased on interview, and record review, the facility failed to utilize its Quality Assurance and Performance Improvement (QAPI) program to monitor a Performance Improvement Project (PIP) and determine the effectiveness of selected interventions related to preventing recurrence of deficient practices for 1 of 4 residents reviewed for diagnostic test results, of a total sample of 4 residents, (#1); and failed to implement the QAPI policy and procedures to maintain adequate oversight of a PIP to ensure all residents with abnormal diagnostic test results received timely and appropriate care and services.

Inspectors wroteBased on interview, and record review, the facility failed to promptly report a critical result to the ordering physician for 1 of 3 residents reviewed for laboratory test results, of a total sample of 4 residents, (#1).

Inspectors wroteBased on interview, and record review, the facility failed to promptly report an abnormal chest x-ray result to the ordering physician for 1 of 4 residents reviewed for diagnostic test results, of a total sample of 4 residents, (#1).

Inspectors wroteBased on interview and record review, the facility failed to ensure freedom from a physical restraint that inhibited movement and activity for 1 of 2 residents reviewed for restraints, of a total sample of 10 residents, (#1). The facility's failure to promote resident #1's rights to be treated with respect and dignity and to be free from abuse resulted in psychosocial harm. Using the reasonable person concept there was potential for outcomes such as continued agitation and anxiety, loss of dignity, dehumanization, and feelings of fear and imprisonment. Resident #1, a cognitively impaired resident, was inappropriately restrained in his wheelchair and he struggled to move freely and stand. Improper use and monitoring of an improvised restraint placed resident #1 at risk for skin breakdown, injury during attempts to free himself, and accidents including falls and strangulation.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Memory Care Unit had sufficient staff with appropriate competencies and skill sets to meet the needs and ensure the safety of 1 of 4 residents reviewed for behavioral symptoms, of a total sample of 10 residents, (#1). The facility's failure to ensure there were adequate staff to supervise and monitor residents on the specialized Memory Care Unit; and failure to ensure staff demonstrated competencies related to recognizing behavior patterns and implementing appropriate approaches, resulted in psychosocial harm. Using the reasonable person concept there was potential for outcomes such as continued agitation and anxiety, loss of dignity, dehumanization, and feelings of fear and imprisonment for resident #1, and placed all residents on the unit at risk. [...]

Inspectors wroteBased on interview and record review, the facility failed to utilize its Quality Assurance and Performance Improvement (QAPI) program to identify the root cause of an incident related to unauthorized restraint of a cognitively impaired resident, for 1 of 4 residents reviewed for behavioral symptoms, of a total sample of 10 residents, (#1); and failed to develop and implement a performance improvement plan (PIP) to ensure the safety and provision of appropriate care and services for all residents on the specialized Memory Care Unit.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prohibition policy and procedures by ensuring frontline staff recognized and reported the use of an unauthorized physical restraint for 1 of 2 residents reviewed for restraints, of a total sample of 10 residents, (#1), and failed to ensure thorough and accurate reporting of investigative findings.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent medication errors greater than 5% for 2 of 6 residents sampled for medication administration, (#154, #302). There were 2 errors in 31 opportunities by 2 of 2 nurses observed for a medication error rate of 6.45%.

Inspectors wroteBased on observation, interview and record review, the facility failed to post the nurse staffing hours daily and failed to identify the facility in the form posted.