Alexander "Sandy" Nininger State Veterans Nursing

In the surveyor’s words

From the most serious findings on record at Alexander "Sandy" Nininger State Veterans Nursing, in the surveyor’s own words.

• Actual harm, isolatedF692Jan 9, 2025

  Based 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). The findings included: A review of the facility's policy titled, Dietitian, dated [DATE], showed the following: The Dietitian will work closely with the Interdisciplinary team, assess the nutritional needs of the residents, and collaborate effectively with other direct care staff and practitioners to assess and address nutritional issues with the facility population. […]

• No harm, potential for more than minimal, widespreadF812May 21, 2026

  Based 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. The findings included: 1. A tour of the Main Kitchen was conducted on 05/18/26 at 08:46 AM with the Dietary Manager (DM). The following items were observed: a. In the walk-in refrigerator, a full 6 inch deep, two third-sized hotel pan located on a shelf to the right of the entrance was observed with loosely wrapped raw white mushrooms. The pan was dated 05/08/26 and the mushrooms were observed to be browned and discolored indicative of spoilage. The DM stated mushrooms can be refrigerated for up to 30 days. b. […]

• No harm, potential for more than minimal, widespreadF812Apr 8, 2021

  Based on observations and interviews, the facility failed to maintain food safety requirements with storage, preparation, and distribution in accordance with professional standards for food service safety which included: failure to maintain sanitary conditions in the kitchen and failure to maintain sanitary conditions in 2 out of 3 pantries located in the Delta Unit. The findings included: During the initial tour of the kitchen conducted on 04/05/21 at 8:51 AM, accompanied by the Food Service Director (FSD), the following were noted: 1. In the walk-in freezer, the floor was observed with plastic garbage, brown residue, and a moderate amount of white debris. 2. […]

• No harm, potential for more than minimal, patternF803May 21, 2026

  Based 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. The findings included: 1. […]

• No harm, potential for more than minimal, patternF805May 21, 2026

  Based 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. The findings included: The facility provided the guidelines from the International Dysphagia Diet Standardization Initiative 2.0 (IDDSI) dated July 2019 which were the guidelines used for the consistency of the pureed diets. The standards described pureed consistency as extremely thick and able to retain its shape. It further stated that it cannot be poured. Recipes for Pureed Sauteed Squash and Pureed Garlic Mashed Cauliflower provided by the facility described the consistency as able to hold its shape on a plate, does not flow easily, and cannot be poured. 1. […]