Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bruce Mccandless Co State Veterans Nursing Home during CMS and state inspections, most recent first.
Failure to Protect Residents from Resident-to-Resident Abuse: Surveyors found repeated resident-on-resident assaults, threats, and fear involving multiple residents, including a cognitively impaired resident with PTSD who was shoved, grabbed, and hit several times and sustained bruising and abrasions. The facility did not consistently implement supervision, did not reassess ineffective separation and monitoring measures, and did not substantiate some deliberate assaults as abuse, limiting the investigation and response.
Medication Storage and Labeling Deficiencies: Staff failed to ensure medications on two hallway carts were properly labeled and expired items were removed. An open inhaler and multiple open eye drop bottles lacked open dates, several medication cards and creams were expired or missing expiration information, and an RN said she was unsure whether eye drops and inhalers needed open dates. The DON stated nurses should discard expired medications and that eye drops and inhalers should be labeled with an open date.
Lack of Meaningful Activities on Secure Memory Care Unit: Residents on the secure memory care unit were observed wandering without purpose, sitting idle, or moving in and out of common areas and resident rooms while no posted activity calendar or individual/group activities were observed. A resident repeatedly pushed on the courtyard door and went outside, another wandered into multiple resident rooms, and staff did not provide meaningful or person-centered activities during the observations.
A resident with COPD, pulmonary fibrosis, chronic respiratory failure, and obstructive sleep apnea used CPAP therapy, but the mask, tubing, headgear, and machine were not consistently cleaned or stored per orders or manufacturer guidance. Staff were unsure who was responsible for cleaning the CPAP components, the record lacked orders for cleaning the humidifier, machine, tubing, and storage, and the care plan did not address CPAP settings or equipment care.
A resident with an indwelling catheter was observed in bed with the drainage bag uncovered and laying on the floor next to the bed. Staff interviews and the facility’s catheter care policy confirmed the bag should have been covered in a privacy bag and kept below the bladder without touching the floor for dignity and infection control purposes.
A resident identified as a high fall risk required two-person assistance for bed mobility, as per her care plan. However, during incontinence care, only one CNA was present, leading to the resident falling off the bed and sustaining serious injuries, including fractures to the C1 and C2 vertebrae. The facility's failure to adhere to the care plan's requirements resulted in this incident.
The facility failed to include dosage information in physician's orders for Voltaren gel for four residents, leading to the use of a standard dose without proper authorization. Additionally, a resident did not receive timely follow-up care with a urologist as required. Staff interviews revealed a lack of awareness and uncertainty regarding these deficiencies.
The facility failed to assess and document the use of bed rails for three residents, neglecting to review risks versus benefits, obtain informed consent, and secure physician orders. Additionally, routine maintenance checks were not conducted, potentially compromising resident safety.
Two residents in a LTC facility were involved in a physical altercation, with one resident slapping the other on the hand. The facility failed to prevent this incident despite having policies in place to protect residents from abuse. The involved residents had severe cognitive impairments and behavioral issues, with one resident having a history of agitation and frustration. Staff witnessed the altercation and separated the residents, but the facility's actions were insufficient to prevent the incident.
A resident with multiple health conditions, including hypertension, was administered Amlodipine besylate despite having a diastolic blood pressure below the physician-ordered parameters on several occasions. The facility failed to notify the physician when the blood pressure was outside the prescribed range, as confirmed by staff interviews. This deficiency highlights a failure in adhering to professional standards of medication administration.
A facility failed to implement an effective antibiotic stewardship program, as evidenced by inadequate tracking and monitoring of antibiotic use for a resident with Alzheimer's, diabetes, and a history of UTIs. The resident was prescribed Cephalexin without a specified duration, and no documentation justified its use. When the resident developed a UTI with a multi-drug-resistant E. coli strain, Bactrim DS was prescribed without proper assessment. The DON, also the IP, was unsure about the use of McGreer's criteria and did not include the resident in antibiotic surveillance due to the preventive nature of the Cephalexin prescription.
Failure to Protect Residents from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident abuse, including physical assaults, threats, and repeated aggressive incidents involving multiple residents in the secured memory care unit. The report states that nine of ten reviewed residents were involved in incidents of abuse or aggression, including residents #15, #3, #68, #27, #70, #46, #6, #50, and #59. Survey findings described repeated episodes of shoving, hitting, grabbing, threats of harm, and fear among residents, along with documentation of physical injuries such as abrasions and facial contusions and psychosocial harm including fear, anxiety, agitation, distress, and crying. One incident involved a cognitively impaired resident with a history of trauma and PTSD who was physically assaulted on four occasions by other residents. The resident was shoved, pushed, grabbed, and hit in the face and head, and the report states the resident sustained abrasions, facial contusions, fear, anxiety, agitation, and distress. The facility had placed the resident on one-on-one supervision, but the report states that this supervision was not implemented consistently and that the resident was involved in additional incidents within days. The report also states that line-of-sight observation was unmanageable by staff and that staffing and communication issues were potential unaddressed factors in the repeated incidents. The report also describes other resident-to-resident incidents that were not substantiated by the facility as abuse despite documentation that the acts were deliberate and harmful. In one event, a resident struck another resident in the face after a dispute over seating, and the victim later reported fear and avoidance of the assailant. In another event, a resident with dementia, PTSD, aphasia, wandering, rejection of care, and physical aggression entered other residents’ rooms, shoved residents, threatened to kill them, and attacked staff members who intervened. The report states that the facility failed to update care plans promptly after incidents, failed to identify effective interventions after repeated aggression, and did not document social services follow-up for psychosocial harm in some cases.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in two medication storage rooms. During observation of the Big Horn Bluff hallway medication cart, an open Serevent Diskus inhaler was found without an open date, and a bottle of Preparation H cream was found with an expiration date of December 2025. During observation of the Columbine hallway medication cart, an oxycodone 5 mg medication card was found with an expiration date of 12/2/25, two clonazepam 0.5 mg medication cards had no expiration date on the label, and open bottles of polyvinyl alcohol eye drops and Refresh tears eye drops were not labeled with open dates. Additional items on the Columbine hallway medication cart included an open Trelegy Ellipta inhaler without an open date, petrolatum 42% cream with an expiration date of August 2025, and liquid iodine with an expiration date of October 2025. RN #4 stated she was unsure whether eye drops and inhalers needed open dates. The DON stated nurses should be discarding expired medications and ensuring medications were stored properly, and said eye drops and inhalers should be labeled with an open date because each is good for a certain time frame after opening.
Lack of Meaningful Activities on Secure Memory Care Unit
Penalty
Summary
The facility failed to provide activities that met the interests and needs of residents on the secure memory care unit. During an initial walk-through, an activities calendar was observed on the non-secure side of the facility, but no specific activities were posted for the secure memory care unit. On the secure unit, no activities calendar was observed. During continuous observations on the unit, residents were repeatedly seen wandering without purpose, sitting in common areas without engagement, or pacing back and forth while staff did not provide meaningful or person-centered activities. Resident #27 was observed wandering, standing by windows, pacing, and later sitting in a recliner without meaningful activity. Resident #15 was observed watching other residents wander or sitting in a recliner in the common area. Resident #5 repeatedly pushed on the back door to the secure courtyard and was able to open it and go outside before being redirected by CNA #5. Resident #6 wandered through the common area, dining room, and into multiple resident rooms without staff intervention until later redirected. Resident #22 and Resident #59 also went outside to the secure courtyard, and staff were observed trying to bring residents back inside. Throughout the observations, no individual or group activities were observed or offered to the residents on the secure memory care unit.
CPAP Equipment Not Properly Cleaned, Stored, or Care Planned
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident who used CPAP therapy. The resident had diagnoses including pneumoconiosis due to asbestos and other mineral fibers, pulmonary fibrosis, interstitial pulmonary disease, acute and chronic respiratory failure, COPD, and obstructive sleep apnea. The resident was cognitively intact, had shortness of breath with exertion, at rest, and when lying flat, and used oxygen and a non-invasive mechanical ventilator. Observations showed the resident’s CPAP equipment was not consistently maintained or stored in a sanitary manner. The CPAP machine was seen on the resident’s nightstand with the nasal pillows attached to the tubing and lying across the top of the nightstand, while the headgear was hanging down toward the floor. On later observations, the headgear and tubing were draped across or wrapped behind the CPAP machine on the nightstand. The record showed only an order to clean the CPAP mask with soap and water or mask wipes upon rising, and there were no physician orders addressing cleaning of the humidifier, machine, tubing, or storage of the equipment. The comprehensive care plan did not include a CPAP care focus for machine settings or for cleaning and care of the CPAP equipment. Staff interviews showed CNA staff did not know who was responsible for cleaning the CPAP mask, tubing, or machine, and RN and IP staff were unsure about the cleaning frequency and responsibilities for the humidifier chamber, tubing, and machine. The DON stated the mask and tubing should be replaced every three months, the headgear and humidifier chamber every six months, and that the humidifier chamber should be emptied daily and dried, but also stated the manufacturer’s guidelines had not been reviewed at the time of interview.
Catheter Drainage Bag Stored on Floor
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of diseases and infection. The deficiency involved Resident #24, who was observed lying in bed with a catheter drainage bag that was not covered with a privacy bag and was laying on the floor next to the bed. The observation showed the drainage bag was not stored below the level of the bladder in a manner consistent with the facility’s catheter care policy. The facility’s Indwelling Catheter Care policy stated that catheter drainage bags should be covered at all times while in use and located below the level of the bladder. During interviews, a CNA stated the drainage bag should be in a privacy bag attached to the bed frame and should not be on the floor. An RN stated it should be stored in a privacy bag attached to the bed frame or in a pan to keep it from touching the floor. The IP and DON also stated the bag should be kept below the bladder and not touch the floor for dignity and infection control purposes.
Failure to Provide Adequate Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards, resulting in a significant injury to Resident #49. Resident #49, identified as a high fall risk, required substantial to maximum assistance for bed mobility and transfers, as documented in her care plan. Despite this, CNA #1 provided incontinence care without the assistance of another staff member, contrary to the care plan's requirement for two-person assistance. During the care, Resident #49 rolled too far and fell off the bed, sustaining serious injuries including fractures to the C1 and C2 vertebrae. Resident #49 had a complex medical history, including Alzheimer's disease, dementia, and a history of falls, which contributed to her high fall risk status. The care plan, which was reviewed shortly before the incident, clearly outlined the need for two-person assistance for bed mobility and transfers due to her non-weight bearing status and previous falls. However, on the night of the incident, CNA #2 left the room after assisting with the transfer, leaving CNA #1 to manage the resident alone, which was not in accordance with the care plan. The incident occurred because CNA #1 attempted to provide care without the necessary support, leading to the resident's fall. The facility's failure to adhere to the care plan's requirements for two-person assistance during bed mobility directly resulted in the resident's fall and subsequent injuries. The staff's misunderstanding of the care plan requirements and the lack of clear communication about the resident's needs contributed to this deficiency.
Deficiencies in Medication Orders and Follow-Up Care
Penalty
Summary
The facility failed to ensure that physician's orders for Voltaren gel, a topical pain medication, included the necessary dosage information for four residents. The orders for these residents specified the application of Voltaren gel to various body parts but did not include the required dosage, which is essential for safe administration. This oversight was identified during a review of the medication administration records and was confirmed through staff interviews. A registered nurse acknowledged that the dosage was missing and stated that she used a standard dose without a physician's order for it. Additionally, the facility did not arrange follow-up care for a resident who was supposed to return to a urologist for evaluation six months after a previous visit. The resident, who had Alzheimer's dementia, diabetes, and a history of urinary tract infections, was receiving treatment for bladder incontinence. Despite the urologist's note indicating the need for a follow-up appointment, the facility failed to coordinate this care, as revealed by a review of the resident's electronic medical record. Interviews with staff, including the Director of Nursing and the Nursing Home Administrator, highlighted a lack of awareness and uncertainty regarding the missing dosage information and the unarranged follow-up care. The Director of Nursing admitted that a measured dose was necessary for Voltaren gel and that incomplete medication orders should be clarified with the physician. The Nursing Home Administrator could not find documentation of the follow-up care and was unsure why it was not arranged.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to use a person-centered approach when determining the use of bed rails and transfer poles for three residents reviewed for accident hazards. Specifically, the facility did not review the risks versus the benefits of using a bed rail with the residents or their representatives prior to use, did not obtain informed consent for the installation and use of bed rails, did not obtain physician's orders for bed rails, and did not conduct routine maintenance of the bed rails to evaluate their continued safety. For Resident #12, who was severely cognitively impaired and required assistance with various activities of daily living, the facility's comprehensive care plan included the use of two assist bars/bed rails. However, there was no documentation in the resident's electronic medical record indicating that the facility reviewed the risks versus benefits, obtained informed consent, or obtained physician orders for the bed rails. Additionally, the facility's audits did not list bed rails or specify what components were inspected during the audit. Similarly, for Residents #10 and #20, the facility's comprehensive care plans included the use of assist bars/bed rails, but there was no evidence of risk versus benefit discussions, informed consent, or physician orders. Staff interviews revealed that the facility did not consider the assist bars as bed rails and therefore did not have conversations regarding consent and risk versus benefits. The facility also lacked documentation of inspections and maintenance checks for the bed rails, which could pose safety risks such as resident entrapment.
Failure to Prevent Resident Altercation
Penalty
Summary
The facility failed to protect two residents from abuse, specifically failing to prevent a physical altercation between them. The incident occurred in the activities room and was witnessed by staff. Resident #36 slapped Resident #35 on the back of her hand during a verbal altercation. The facility's policy on abuse, revised in October 2023, emphasizes the right of residents to be free from mistreatment and outlines procedures for identifying and preventing abuse, including the development of care plans for residents at risk of abuse. Resident #35, who is over 65 years old, has severe cognitive impairments, right-side paralysis, stroke, and hearing loss. She requires assistance with daily activities and has no documented behavioral symptoms. On the day of the incident, a nurse's progress note indicated redness on the back of her hand, although a subsequent nurse assessment found no visible injury or bruising. Resident #35 reported not feeling fearful of Resident #36 and was educated by social services to seek staff assistance to prevent further altercations. Resident #36, also over 65, has severe cognitive impairments, unspecified dementia, and major depression. He has a history of verbal behavioral symptoms and agitation, with 19 episodes documented between March and June 2024. His behavior care plan includes interventions to manage his aggression and frustration. On the day of the altercation, Resident #36 was frustrated due to personal circumstances involving his spouse, who resides in the same facility but in a separate room. Staff were aware of his behavioral history and attempted to manage his stressors and involve him in structured activities.
Failure to Adhere to Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident, specifically regarding the administration of blood pressure medication. The resident, who was over 65 years old and had multiple health conditions including hypertension, was prescribed Amlodipine besylate with specific parameters to hold the medication if the diastolic blood pressure was below 60 mmHg. However, the medication was administered multiple times when the resident's diastolic blood pressure was below the prescribed threshold, as documented in the medication administration records. The resident's medication administration records from February to May 2024 showed several instances where the medication was given despite the diastolic blood pressure being below 60 mmHg. These instances occurred on specific dates, with blood pressure readings such as 170/53 mmHg and 141/57 mmHg, among others. There was no documentation indicating that the resident's physician was notified when the blood pressure was outside the ordered parameters, which was a requirement. Interviews with staff, including a registered nurse and the director of nursing, confirmed that the medication was administered incorrectly. The staff acknowledged that the medication should have been held when the diastolic blood pressure was below 60 mmHg and that the physician should have been notified. The director of nursing noted the potential risks of administering the medication outside the prescribed parameters, such as increased falls or cardiac issues, but there was no follow-up documented to prevent future errors.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement an effective antibiotic stewardship program, as evidenced by the lack of tracking and monitoring of antibiotic use for a resident. The resident, who was over 65 years old and diagnosed with Alzheimer's dementia, diabetes, and a history of urinary tract infections (UTI), was prescribed Cephalexin for a UTI. However, the physician's order did not specify the duration of the antibiotic, and there was no documentation indicating that the facility's infection preventionist (IP) completed an antibiotic use assessment or documented the McGreer's criteria to justify the prescription. Further review of the resident's records revealed that the IP did not document or monitor the long-term use of Cephalexin on the surveillance documents. Additionally, when the resident experienced symptoms of a UTI, a urinalysis and culture identified a multi-drug-resistant strain of E. coli. The physician then prescribed Bactrim DS for the UTI, but again, there was no documentation of an antibiotic use assessment or McGreer's criteria to justify this prescription. Interviews with the Director of Nursing (DON), who was also the certified IP, revealed that the previous IP had resigned, and the DON was in the process of learning the IP tasks. The DON admitted to being unsure about which residents met McGreer's criteria or if assessments for antibiotic treatment had been completed. The DON also stated that the previous IP did not include the resident in the antibiotic surveillance documentation because the Cephalexin was prescribed for UTI prevention, not an active infection.
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Illustrative
What surveyors actually found near you
We read the 7 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Florence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hildebrand Care Center | 8.3 mi | ★★★★★ | 5 | 0 |
| Progressive Care Center | 8.3 mi | ★★★★★ | 0 | 0 |
| Skyline Ridge Nursing & Rehabilitation Center | 8.6 mi | ★★★★★ | 1 | 0 |
| Valley View Care Center | 8.9 mi | ★★★★★ | 1 | 0 |
| Canon Lodge Care Center | 8.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.