VA Nursing Home Neglect: Bedsores, Falls, and Drug Errors

Families trust VA nursing homes to care for veterans who can no longer fully care for themselves. Most do that work well. But when a facility fails to turn a bedbound resident, loses track of a veteran who wanders, ignores worsening depression, or gives the wrong drugs, the results can be devastating: infected wounds, broken hips, psychiatric crises, and preventable deaths.

This guide covers four of the most common forms of VA nursing home negligence: bedsores, improper monitoring, lack of mental health services, and medication mismanagement. It explains what each looks like, what the VA Office of Inspector General (OIG) has found, and what legal options families have.

First Question: Who Runs the Nursing Home?

“VA nursing home” can mean three very different places, and the answer decides which law applies and against whom you file. Our post VA Nursing Home & Community Living Center Malpractice: Is It Covered by the FTCA? covers this in more depth.

Type of Facility	Who Owns and Runs it	Law that Usually Applies
VA Community Living Center (CLC)	The Department of Veterans Affairs. VA operates 134 CLCs (VA OIG).	Federal Tort Claims Act (FTCA), using the malpractice law of the state where the CLC sits
State Veterans Home	A state or tribal government. There are 172 State Veterans Homes; VA pays per diem and surveys them but does not run them (VA fact sheet).	State nursing home and malpractice law, plus that state’s rules on suing the state
Community nursing home under VA contract	A private company. VA purchases the care by contract (VA North Florida).	State nursing home negligence law against the facility

The difference matters. VA has no authority over the management or control of a State Veterans Home (Congressional Research Service), so neglect at a non-VA facility generally does not give rise to an FTCA claim against the United States, even though VA helped pay for the care.

Rawls Law Group handles CLC claims under the FTCA nationwide. For State Veterans Homes and private community nursing homes, we handle claims in Virginia, Maryland, and Washington, D.C., and we can help families elsewhere find a qualified local attorney. See our nursing home negligence page.

Bedsores and Pressure Injuries:

Pressure injuries, also called bedsores, pressure ulcers, or decubitus ulcers, form when unrelieved pressure or friction damages the skin and tissue over bony areas like the tailbone, hips, and heels. They occur most often in elderly and immobile people, and repositioning is one of the main ways to prevent them (Cochrane Review). Researchers describe them as mostly preventable complications in nursing homes, and international prevention guidelines have long used a two-hour repositioning standard (TEAM-UP trial, Advances in Skin & Wound Care).

Clinicians typically stage wounds by depth:

Stage 1: Red, intact skin that stays red when you press on it.
Stage 2: A shallow open sore or blister.
Stage 3: A deeper wound that reaches the fat layer.
Stage 4: Exposed muscle, tendon, or bone, with a high risk of bone infection and sepsis.
Unstageable or deep tissue injury: Dead tissue or discolored skin hides the extent of the damage.

What Prevention Requires:

A careful CLC assesses every resident’s pressure injury risk on admission and regularly afterward, turns and repositions residents who cannot move themselves, uses pressure-relieving mattresses and cushions, manages moisture and incontinence, monitors nutrition and weight, and inspects the skin daily. When a wound appears, staff should document it, measure it, notify a provider, and start a treatment plan.

What the OIG has Found at VA CLCs:

At the Northport VA Medical Center in New York, the OIG found that the CLC’s pressure ulcer rates were consistently higher than regional and national VA averages, and it recommended stronger pressure ulcer management (OIG 11-01437-41).
At the Coatesville VA Medical Center in Pennsylvania, the OIG recommended that leaders evaluate the CLC’s wound prevention processes (OIG 19-06391-119).

Is a Bedsore Automatically Negligence?

No. Some residents are so ill that a wound develops despite good care. But a Stage 3 or Stage 4 wound, a wound that staff did not document until it had advanced, or a wound that kept worsening while the care plan stayed the same is a strong reason to have an expert review the records. Learn more on our hospital bedsores page and in Nursing Home Negligence Law: Pressure Ulcers.

Improper Monitoring: Falls, Wandering, and Missed Decline

Staff must watch nursing home residents closely. Monitoring failures are often less visible than wounds, but they cause some of the most serious harm.

Falls:

A fall can be catastrophic for an older veteran with dementia or bone loss. Prevention means assessing fall risk, putting precautions in the care plan, and actually carrying them out: bed alarms, low beds, non-slip footwear, scheduled toileting, help with transfers, and call bells within reach.

At the James A. Haley Veterans’ Hospital CLC in Tampa, the OIG substantiated that staff had not implemented fall precautions before one resident’s fall, and that another resident fell and died nine days later. During the review period, the CLC exceeded VHA-wide rates for falls with major injury, and inspectors found that staff implemented fall precautions inconsistently across 46 resident rooms (OIG 17-01491-112; summary). At Coatesville, the OIG recommended better documentation of fall prevention and post-fall assessments, and better call bell practices (OIG 19-06391-119).

Wandering and Elopement:

Veterans with dementia may try to leave the unit or wander into unsafe areas. A resident with a known history of wandering needs a documented plan, such as closer supervision, door alarms, or a secure unit. When staff find a veteran outside, injured, or missing, it points to a supervision failure that the facility should investigate.

Missed Signs of Decline:

Monitoring also means noticing when a resident is getting sicker and telling a provider. In its July 2025 report on the Batavia CLC, part of the VA Western New York Healthcare System, the OIG found that cumulative deficiencies in physician and nursing care may have contributed to a resident’s preventable decline and death (OIG 24-02930-175). Among the findings:

Staff did not report a high fingerstick blood sugar on day 20 of the stay to a physician for treatment.
By day 23, the resident’s blood sugar was more than four times the system’s upper limit of normal.
Leaders did not file a patient safety report about the missed result.
Medical provider staffing shortages increased patient safety risk.

Other missed-decline cases involve dehydration, weight loss, untreated infections, and changes in alertness that staff record in the chart but never act on. See nursing failures and failure to follow up on abnormal test results.

Lack of Mental Health Services:

Many veterans in long-term care live with PTSD, depression, anxiety, substance use disorders, or the behavioral symptoms of dementia. Moving into a nursing home, losing independence, or facing a serious diagnosis can make those conditions worse. Mental health care is part of the care a CLC owes its residents, not an extra. VA’s mental health policy, VHA Directive 1160.01, Uniform Mental Health Services in VHA Medical Points of Service, sets the baseline mental health services that VA facilities must offer (cited in OIG 25-03934-258).

Neglect in this area can look like:

No mental health evaluation after a resident shows new depression, withdrawal, or talk of hopelessness.
Ignoring suicide warning signs, with no screening, safety plan, or referral.
Leaving PTSD untreated until it resurfaces as nightmares, agitation, or fear of care routines like bathing.
Relying only on sedating drugs for the behavioral symptoms of dementia, instead of first looking for the cause, such as pain, infection, or fear, and trying non-drug approaches.
Long waits for psychiatry or psychology, or care plans that never address the problem.

VA’s own CLC oversight reflects these expectations. After the Batavia resident’s death, the OIG recommended that the CLC complete behavioral notes and conduct behavioral rounds consistent with system policy, and that all CLC nursing staff complete VA’s STAR-VA behavioral care training as expected (OIG 24-02930-175). STAR-VA is VA’s program for managing the behavioral symptoms of dementia without relying on medication alone.

When untreated mental health needs lead to a suicide attempt, a violent incident, an injury, or a steep decline, the family should ask whether the facility met the standard of care. For related reading, see VA Mental Health Treatment Limits: When Administrative Policies Harm Veterans.

Mismanagement of Medication:

Nursing home residents often take a dozen or more medications, and many of these drugs carry high risks for older adults. Medication errors in a CLC can include:

Wrong drug, wrong dose, or wrong time, including giving a dose to the wrong resident.
Missed doses of critical drugs like insulin, blood thinners, seizure medications, or heart medications.
Ignoring hold instructions, such as giving a blood pressure drug without checking the resident’s blood pressure first.
Failing to monitor blood sugar, kidney function, drug levels, or side effects.
Poor medication reconciliation when a resident moves between the hospital and the CLC, so staff drop, duplicate, or restart drugs by mistake. VHA Directive 1345 governs medication reconciliation, and the OIG has cited it in recent discharge reviews (OIG 25-04450-218).
Overuse of opioids or sedatives, which raises the risk of falls, confusion, and breathing problems. See The VA’s Prescription for Disaster.

Antipsychotics and Dementia:

Providers sometimes use antipsychotic drugs to calm agitation in residents with dementia. That use carries serious risk. In 2005, the FDA required a boxed warning on atypical antipsychotics after trials showed that elderly patients with dementia who took them died at 1.6 to 1.7 times the rate of those on placebo (HealthDay). In 2008, the FDA extended a similar warning to older, conventional antipsychotics (Psychiatric News).

The FDA has not banned these drugs, but providers should justify, document, and monitor their use, and reduce it when possible. In the Batavia CLC case, the resident received 21 doses of injectable antipsychotics during a 23-day stay, and the OIG found deficiencies in how nurses documented medication administration (OIG 24-02930-175).

Documentation Failures:

At the Coatesville CLC, a provider ordered nurses to hold a dementia medication if the resident’s systolic blood pressure fell below 100. Nurses failed to document blood pressure for 12 of 40 doses (30%), so the provider could not tell whether the drug was causing dangerously low blood pressure (OIG 19-06391-119).

Learn more on our medication errors page.

How a Claim Against a VA Community Living Center Works:

Neglect at a VA-run CLC generally gives rise to a medical malpractice claim against the United States under the Federal Tort Claims Act. You do not sue the individual nurses and doctors personally. The FTCA applies the law of the state where the CLC is located (U.S. Solicitor General brief), so that state’s rules on the standard of care and damage caps matter. For Virginia, for example, see What Virginia’s 2025 Medical Malpractice Damage Cap Means for Patients.

File an SF-95 administrative claim with VA within two years of when the claim accrues (28 U.S.C. § 2401(b)). The form must include a specific dollar amount, called the sum certain. If the resident died, the estate or eligible family members can bring a wrongful death claim through the same process. See Wrongful Death Claims Against the VA: A Family’s Guide to the FTCA.

Section 1151 Benefits

If VA care harmed a veteran, the veteran may also qualify for disability compensation under 38 U.S.C. § 1151, and survivors may qualify for dependency and indemnity compensation. If a veteran obtains both an 1151 award and an FTCA recovery for the same injury, VA offsets the benefits by the FTCA amount (38 U.S.C. § 1151). An 1151 claim has no filing deadline, but the FTCA’s two-year clock keeps running while the 1151 claim is pending, so coordinate the two early. See How Section 1151 Benefits Affect Your VA Malpractice Settlement.

Claims Involving State Veterans Homes and Community Nursing Homes:

These claims generally follow state law, not the FTCA. Deadlines, notice rules, damage limits, and whether you can sue a state agency all vary by state. Some admission agreements also include arbitration clauses. Our nursing home negligence FAQs address several of these issues for Virginia families.

Warning Signs and What Families Should Do:

Warning Signs of Neglect:

New or worsening wounds, a foul smell, or unchanged dressings
Unexplained bruises, fractures, or repeated falls
Sudden weight loss, dry mouth, or signs of dehydration
Soiled bedding or clothing, or a resident who stays in the same position for hours
New confusion, heavy sedation, or a sudden change in behavior
Call bells out of reach or unanswered
Staff who cannot explain a resident’s medications, or a care plan that never changes

Steps to Take:

Put the resident’s safety first. If the resident is in danger or seriously ill, ask for an immediate medical evaluation or call 911.
Document what you see. Keep a dated log of visits, conversations, and conditions. Take photos where appropriate and where the facility permits it.
Ask for a care plan meeting. Request the resident’s care plan, wound assessments, fall assessments, and medication list, and ask what the staff plan to change.
Request the full medical record, including nursing notes, wound measurements, and medication administration records, through the facility’s Release of Information office. VA Form 10-5345 is the standard request form.
Report your concerns. For a CLC, contact the facility’s patient advocate in writing, and consider calling the VA OIG Hotline at 1-800-488-8244. For a State Veterans Home or private nursing home, you can also contact your state’s long-term care survey agency or ombudsman.
Check the facility’s record. VA publishes CLC Compare star ratings through its Access to Care website. Keep in mind that the OIG has found these ratings have limitations when comparing CLCs with private nursing homes (OIG 18-05113-81), and researchers have found that a one-star rating is a meaningful warning sign, while mid-range ratings say less (Penn LDI).
Speak with an attorney before the deadline approaches. Internal complaints and investigations do not stop the two-year FTCA clock.

Frequently Asked Questions About VA Nursing Home Care:

Can I sue a VA nursing home for neglect?

If the nursing home is a VA-run Community Living Center, you generally bring the claim against the United States under the FTCA, starting with an SF-95 that you file within two years. If it is a State Veterans Home or a private nursing home under VA contract, state law usually applies instead.

Is a State Veterans Home part of the VA?

No. State or tribal governments own and operate State Veterans Homes. VA helps fund and inspect them but does not run them, so neglect there generally does not give rise to an FTCA claim against the United States.

My father developed a Stage 4 bedsore in a CLC. Is that malpractice?

Not automatically, but a Stage 4 wound is a serious warning sign. A medical expert would review whether the CLC assessed his risk, repositioned him, used proper surfaces, monitored his nutrition, and treated the wound promptly. Contact our office today and schedule a free consultation.

Can we sue over antipsychotic medication given to a resident with dementia?

Possibly. Antipsychotics carry an FDA boxed warning for elderly patients with dementia. A claim may exist if staff gave the drug without a clear clinical reason, without monitoring, or in a way that caused harm such as a fall, stroke, aspiration, or death.

Will filing a claim affect my family member’s VA care?

Filing an FTCA claim does not take away a veteran’s right to VA health care. VA may, however, offset any 1151 disability benefits for the same injury by the amount of an FTCA recovery.

What does it cost to hire Rawls Law Group?

We work on a contingency fee basis, so you pay no attorney fee unless we recover money for you. Federal law also limits attorney fees in FTCA cases.

Talk to a VA nursing home negligence lawyer

Brewster S. Rawls, an Army veteran, has owned and operated Rawls Law Group since 1996. At Rawls Law Group, we handle VA and military medical malpractice claims, including CLC neglect, nationwide. If a VA nursing home harmed a veteran you love, contact us or call 804-344-0038 for a free, confidential case review.

This article provides general information, not legal or medical advice. Every case depends on its own facts.

VA Nursing Home Neglect: Bedsores, Falls, and Drug Errors

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