Bruce Mccandless Co State Veterans Nursing Home

In the surveyor’s words

From the most serious findings on record at Bruce Mccandless Co State Veterans Nursing Home, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jan 29, 2026

  Based 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). […]

• Actual harm, isolatedF689Jun 6, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF761Jan 29, 2026

  Based 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. Findings include:I. Facility policy and procedureThe Medication Storage policy, revised 1/9/26, was received from the nursing home administrator (NHA) on 1/29/26. […]

• No harm, potential for more than minimal, patternF658Jun 6, 2024

  Based 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. Findings include: I. Failure to clarify physician's orders with dose information for Voltaren gel A. Professional reference According to the Voltaren gel drug information, retrieved on 6/4/24 from https://www.pdr.net/drug-summary/Voltaren-XR-diclofenac-sodium-2033. […]

• No harm, potential for more than minimal, patternF700Jun 6, 2024

  Based 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. Findings include: I. Professional reference The U.S. […]