Clifford Chester Sims State Veterans Nursing Home

In the surveyor’s words

From the most serious findings on record at Clifford Chester Sims State Veterans Nursing Home, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF684Jun 25, 2026

  Based on observations, interviews, and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 1 resident sampled for non-pressure related skin conditions (Resident #64) and 1 of 2 residents sampled who received insulin (Resident #12). The findings include: 1. Observations were conducted of Resident #64 on 06/23/2026 at 1:24 PM, 06/23/2026 at 2:42 PM, 06/24/2026 at 8:47 AM, and 06/24/2026 at 11:20 AM. Resident #64 was observed with an undated dressing present on his right forearm. It was also noted that Resident #64 was not wearing protective sleeves on his arms during any of the observations. Resident #64 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, isolatedF887Jun 25, 2026

  Based on record review and staff interview, the facility failed to implement the facility's policy for administering COVID-19 vaccinations to 1 of 5 sampled residents (Resident #51). The findings include: Review of Resident #51's medical record revealed they were admitted to the facility on [DATE]. The record revealed Resident #51's responsible party gave consent for them to receive the COVID-19 vaccine on 12/19/2025 and that they had not had a COVID-19 vaccine since 2021. An interview was conducted with the facility's Risk Manager on 06/25/2026 at 8:54 AM. She confirmed the facility's Infection Preventionist was not available for interview. She confirmed Resident #51 had not received the COVID-19 vaccine although the responsible party had consented for the vaccine on admission. […]

• No harm, potential for more than minimal, isolatedF585Feb 1, 2024

  Based on observations, interviews, and record review the facility failed to ensure that all grievances were resolved for 2 of 2 residents sampled for personal property. (Resident #11 and #26) The findings include: Resident #11 On 01/29/24 at approximately 1:00 PM, an interview was conducted with Resident #11 concerning personal property. Resident #11 indicated that he had a cell phone go missing a few months ago. He also stated when clothing goes to the laundry, it often goes missing and does not come back. When asked if he had notified the facility, Resident #11 stated that he had. A review was conducted of the facility's grievance logs which revealed no grievance form concerning Resident #11's missing cell phone. […]

• No harm, potential for more than minimal, isolatedF921Feb 1, 2024

  Based on observations and interviews, the facility failed to maintain a safe environment for staff in the laundry room. The findings include: On 2/1/24 at approximately 12:40 PM, a tour was conducted of the laundry's dirty linen room, which revealed standing water on the floor in front and behind the three industrial washing machines that the facility uses to launder the resident's linens and personal clothing. (Photographic evidence obtained) On 2/1/24 at approximately 12:57 PM, an interview was conducted with the Supervisor of Laundry and Housekeeping concerning the leaking washing machines. The Laundry Supervisor indicated that the washing machines have been leaking for about 2 months now and that she has been reporting the issue to maintanence. […]

• No harm, potential for more than minimal, isolatedF644Sep 15, 2022

  Based on record review, staff interview, and policy review, the facility failed to refer a resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident #40) The findings include: Review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE] and had a level I PASARR completed on 7/1/2021. Further review revealed the resident was prescribed [MEDICATION(S)] (an antipsychotic medication) on 8/26/2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The record failed to contain evidence of a level II PASARR resident review. An interview was conducted with the facility Licensed Clinical Social Worker on 9/13/2022 at 3:31 PM. She reviewed Resident #40's record and confirmed a level II PASARR had not been completed. […]