Bruce McCandless Co State Veterans Nursing Home

Inspectors wroteBased on record review, observations, and interviews, the facility failed to provide a safe environment and protect residents from resident-to-resident abuse, involving nine of ten residents reviewed (#15, #3, #68, #27, #70, #46, #6, #50 and #59) out of 33 sample residents. Record review and staff interviews revealed Resident #68, significantly cognitively impaired and with a history of trauma, was the victim of four incidents of resident-to-resident physical abuse (11/8/25, 11/25/25 (twice) and 12/3/26). The abusive incidents contributed to the resident being physically abused (shoved, pushed, grabbed, and hit in the face and head), and sustaining physical harm (abrasions, facial contusions) and psychosocial harm (fear, anxiety, agitation, distress (crying). [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured and labeled in accordance with accepted professional standards for two of two medication storage rooms. Specifically, the facility failed to:-Ensure medications were labeled with the date they were opened; and, -Ensure expired medications were properly disposed of.

Inspectors wroteBased on observations and interviews, the facility failed to provide activities that meet the interest and needs of the residents on the secure memory care unit. Specifically, the facility failed to provide meaningful and person centered activities for residents residing in a secure memory care unit (cross-reference F600 for abuse).

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#11) of two residents who required respiratory care received care consistent with professional standards of practice out of 33 sample residents. Specifically, the facility failed to:-Follow physician's orders to maintain, clean, sanitize and store Resident #11's continuous positive airway pressure (CPAP) mask and machine; and, -Ensure a care plan was in place to include settings, cleaning, disinfecting and storage of the CPAP for Resident #11.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control programdesigned to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to ensure Resident #24's catheter drainage bag was not stored on the floor to prevent potential contamination.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (#49) of eight residents reviewed for accident hazards out of 34 sample residents. Resident #49 was identified as a high fall risk through facility assessment. Resident #49 needed substantial to maximum assistance rolling from left to right/right to left in bed. Resident #49's care plan was reviewed on 4/4/24 and included an intervention for the assistance of two people with bed mobility (scooting, rolling, or moving from lying to sitting or sitting to lying) and transfers in and out bed. Resident #49 sustained a fall out of bed on 4/11/24 while receiving incontinence care from certified nurse aide (CNA) #1. CNA #1 was providing care for the resident without another staff member in the room for assistance. [...]

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure four (#10, #26, #21, #44) of eight out of 34 sample residents were provided services that meet professional standards of quality. Specifically, the facility failed to: -Clarify the physician's orders with dose information for Residents #10, #26, #21 and #44 for Voltaren gel (topical pain medication); and, -Ensure Resident # 21 received follow up care with the urologist.

Inspectors wroteBased on observations, record review and interviews, the facility failed to use a person centered approach when determining the use of bed rails and transfer poles for three (#12, #10 and #20) of eight residents reviewed for accident hazards out of 34 sample residents. Specifically, for Residents #12, #10 and #20, the facility failed to: -Review the risks versus the benefits of using a bed rail with the resident or the resident's representative prior to use; -Obtain informed consent for the installation and use of bed rails prior to use; -Obtain physician's orders for bed rails; and, -Conduct routine maintenance of the bed rails to evaluate the continued safety of the bed rails.

Inspectors wroteBased on record review and interviews, the facility failed to take steps to protect two (#35 and #36) of two residents reviewed for abuse out of 34 sample residents. Specifically, the facility failed to prevent a physical altercation between Resident #36 and Resident #35.

Inspectors wroteBased on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#10) of one resident out of 34 sample residents. Specifically, the facility failed to ensure Resident #10's blood pressure medication was consistently held when her diastolic blood pressure (the bottom number of a blood pressure reading) was below the physician ordered parameters.

Inspectors wroteBased on record review and staff interviews, the facility failed to develop and implement an antibiotic stewardship program which included antibiotic use protocols and a system to monitor antibiotic use for one (#21) of one resident out of 34 sample residents. Specifically, the facility failed to effectively track and monitor the use of long-term and short-term antibiotics prescribed for Resident #21.

Inspectors wroteBased on observations, record review and interview, the facility failed to implement appropriate and timely interventions to ensure two (#71 and #46) out of five residents reviewed for pressure ulcers received the necessary care and treatment to prevent the development of a pressure injury (ulcer), out of 37 sample residents. Specially the facility failed to ensure: -Necessary interventions to assist Resident #71, despite the facility being aware of the resident's compromised health and skin condition, contributed to the resident developing a stage three (3) pressure ulcer to the coccyx. -Resident #71 with pressure relief, timely incontinent care and friction reduction, to prevent the development of a moisture induced stage three (3) pressure injury. [...]

Inspectors wroteBased on record review, observation, and interviews the facility failed to reduce the risk of all known or foreseeable accident hazards that cannot be eliminated and ensure that each resident received adequate supervision and assistance devices to prevent accidents, for two (#29 and #53) of three residents reviewed for falls out of 37 sample residents. Specifically, the facility failed to ensure Residents #29 and #53 were free from continued falls. The facility failed to: -Ensure each resident (#29 and #53) were fully assessed following each fall episode for all possible accidents/hazards factors which might result in a fall. -Ensure each resident (#29 and #53) were provided consistent oversight, supervision and monitoring while engaged in known impulsive and unsafe behaviors. -Ensure each resident (#29 and #53) received prescribed fall interventions consistently and effectively. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure four (#10, #61, #50, and #34) of seven residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, hygiene, dressing and grooming, out of 37 total sample residents. Specifically, the facility failed to provide: -Timely dining assistance to Residents #61, #50 and #10; and -Scheduled showers for Resident #34.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure menus met the needs of residents and were followed during meal service. Specifically, the facility failed to ensure menus were followed, and menu items were not omitted without nutritive substitutions being made or offered to dependent residents who were not capable of voicing preferences or making their own menu choices.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to develop and implement a comprehensive person-centered care plan for two (#75 and #46) out of 23 sample residents. Specifically, the facility failed to ensure the comprehensive, person-centered care plan included: -Resident #75's recent inappropriate verbal outbursts; -Resident #46's need for regular fingernail care. Cross-reference Resident #75 to F600, failure to ensure resident free from abuse. Cross-reference Resident #46 to F686, failure to prevent pressure injury.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to review and revise comprehensive care plans for three (#50, #72, and #88) of 23 residents out of 37 total sample residents. Specifically, the facility failed to: -Ensure Resident #88's care plan was reviewed and revised to include pain related to headaches and non-pharmacological interventions (interventions that do not involve the use of medications) for pain; -Ensure Resident #50's care plan was reviewed and revised to include times for removal of wheelchair tray table; and -Ensure Resident #72's care plan was reviewed and revised to include times for removal of wheelchair lap buddy (a cushioned device that fits in a wheelchair to help remind a person not to get up unassisted).

Inspectors wroteBased on observations, record review and interviews the facility failed to provide appropriate treatment and services to increase range of motion (ROM) or prevent further decrease in ROM for one (#61) of five out of 37 total sampled residents. Specifically the facility failed to -Ensure Resident #61 received a consistent range of motion therapy program to ensure the resident did not experience a reduction in his muscle strength or range of motion (ROM) function. -Provide proper assessment for the resident to obtain the highest practicable, mental, social and physical well being. Findings Include I. Policy and procedure The facility's ROM policy was received on 2/26/2020 at 1:00 p.m.from the nursing home administrator (NHA), the policy read in pertinent parts, -The policy included instructions to assess the resident for disability, pain or weakness. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure drug regimens were free from unnecessary medications for one (#70) of five residents reviewed for medication use of 37 sample residents. Specifically, the facility failed to ensure medication was not administered when the resident's vitals were outside appropriate parameters.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that residents were free of unnecessary psychotropic medications for one (#73) of five residents out of 37 total sample residents. Specifically, the facility failed to: -Track hours of sleep to evaluate the effectiveness of an antidepressant being utilized as a hypnotic for the diagnosis of insomnia; -Appropriately identify and track individualized targeted behaviors for psychotropic medications; -Attempt gradual dose reductions (GDR) for psychotropic medications.