Alwyn C Cashe State Veterans Nursing Home

In the surveyor’s words

From the most serious findings on record at Alwyn C Cashe State Veterans Nursing Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Sep 5, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF689Sep 5, 2025

  Based 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. […]

• Actual harm, isolatedF604Sep 14, 2024

  Based 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. […]

• Actual harm, isolatedF741Sep 14, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF550Feb 27, 2025

  Based 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. Findings: On 2/24/25 at 11:59 AM, in the Freedom memory care unit dining room, facility staff were observed putting clothing protectors on all 19 resident without first asking if they wanted to wear one. […]