Washington State Walla Walla Veterans Home

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision was consistently implemented to prevent resident-to-resident altercations with Resident 1 for 1 of 4 residents (Resident 2) reviewed for avoidable accidents. This failure placed the residents at risk for additional physical altercations, serious injury, and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical and verbal abuse by Resident 2 for 1 of 3 residents (Resident 1) reviewed for abuse. This failure placed the residents at risk for continued abuse, injury, and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse prevention policy in the areas of prevention and protection for 1 of 3 residents (Resident 1) reviewed for abuse. This failure placed the residents at risk for continued unidentified abuse, fear, and dissatisfaction with their living situation.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision and update care plan interventions to prevent resident-to-resident altercations with Resident 2 for 1 of 3 residents (Resident 1) reviewed for accidents. This failure placed the residents at risk for potential verbal and physical abuse, serious pain and injury, and emotional distress.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify hazards and risks to ensure the resident's environment remained free of accident hazards for 1 of 3 residents (Resident 80) reviewed for hospitalization. The failure to consistently complete a thorough safety assessment of Resident 80's environment with the use of their powered wheelchair (w/c) caused Resident 80 to experience harm when they drove their powered w/c off a curb and sustained an injury that required hospital and surgical intervention.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a Preadmission Screening and Resident Review [(PASARR) a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment] accurately reflected residents' mental health conditions for 4 of 8 residents (Resident 5, 12, 13, and 7) reviewed for unnecessary medications. This failure placed the residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to discard expired foods and complete daily cleaning tasks for 6 of 8 kitchens ([NAME], Umatilla, Palouse, [NAME], [NAME], and [NAME]) and 1 of 1 dry storage area, and the facility failed to consistently monitor cooked food temperatures prior to serving regular and pureed food for 1 of 3 staff (Staff W) observed for safe and sanitary kitchen. This failed practice placed residents at risk for Food borne illness (caused by consuming foods that are contaminated with harmful pathogens [bacteria that reproduce rapidly once entered in the body and can damage tissues and cause illness]).

Inspectors wroteBased on interview and record review, the facility failed to ensure, 1) residents on as needed (PRN) psychotropic medications (drugs that affect brain activities associated with mental processes, emotions and behavior) were limited to 14-days or had a documented rationale for the extended use of the PRN psychotropic and, 2) that non-pharmacological interventions (alternative treatment of a resident's symptoms that are directed toward understanding, preventing and relieving a resident's distress or loss of abilities and do not involve the use of medications) were consistently attempted to reflect an adequate need of the medication for 2 of 5 residents (Residents 7 and 35) reviewed for unnecessary medications. This failure placed residents at an increased risk for experiencing medication-related adverse side effects, and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to recognize a change in condition for 1 of 3 residents (Resident 13) reviewed for hospitalization and follow physician orders as written for 3 of 4 residents (Resident 8, 6, and 80) reviewed accuracy of physician orders related to fluid restrictions and hospitalization. This failure placed all residents at risk for delay in treatment, medical complications, and negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who were trauma survivors received culturally competent, trauma informed care (TIC), complete with identified experiences and preferences regarding potential triggers (a stimulus that could prompt a recall of a previous traumatic event even if the stimulus itself is not traumatic or frightening) that may cause re-traumatization (occurs when a current situation triggers the emotional and physical responses of past trauma, making it feel as if the original traumatic event was happening again) for 1 of 4 residents (Resident 7) reviewed for TIC. This failure placed the resident at risk for unidentified triggers and re-traumatization.

Inspectors wroteBased on interview and record review, the facility failed to maintain a Quality Assurance Performance Improvement (QAPI) program that, 1) included the thorough collection of data/feedback and systematic investigations and/or analysis regarding adverse events (an unexpected, undesirable and usually unanticipated event that causes death or serious injury to a resident) within the facility and, 2) showed actions taken towards development of activities regarding, recent adverse events within the facility, problem prone areas, and contributing factors that could impact quality of care, quality of life, and/or resident safety for 1 of 1 QAPI program, reviewed for quality assessment and assurance. This failure placed residents at an increased risk for unidentified complications, prompted corrective action regarding adverse events and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee included the required members that met at least quarterly (once every quarter of the year or every three months) for 2 of 4 quarters (Q3 2025 and Q4 2025) reviewed for QAA. The failure to meet quarterly increased the facility's risk of unrecognized quality deficiencies, the facility's ability to effectively correct identified issues and ongoing unmet care needs regarding residents' quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide notification of injury to the Resident's Representative (RR) for 1 of 3 residents (Resident 1) reviewed for notification. This failure placed the resident at risk of not having their representative involved in health care decision making for timely care and services.

Inspectors wroteBased on observation, interview and record review the facility failed to provide supervision to prevent elopement (leaving the facility unsupervised and undetected) for 1 of 3 residents (Resident 1) reviewed for accidents. This failure placed the residents at risk for exposure to the elements, serious harm and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare palatable, appetizing, and appealing meals for 8 of 15 residents (Resident 78, 48, 46, 39, 6, 20, 71, and 38) who voiced concerns regarding food quality during a Resident Council (a group of residents from each of the neighborhoods who meet to discuss and address concerns) meeting and other interviews. This deficient practice placed residents at risk for dissatisfaction with the food, a diminished dining experience and the potential for less than adequate nutritional intake.

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct a complete and thorough assessment for self-administration of medications for 1 of 2 residents (Resident 39) reviewed for safe self-medication administration. This deficient practice placed residents at risk for medication errors and adverse medication interactions.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an environment that reflected the physical needs and preferences of 1 of 2 residents (Resident 6) reviewed for accommodation of needs. This deficient practice placed the resident at risk for a diminished quality of life and increased dependence on staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure accuracy for the Pre-admission Screening and Resident Review [(PASARR) a federally required form that is used to help ensure individuals were not inappropriately placed in nursing homes for long term care] and Level II comprehensive evaluations were obtained for 2 of 6 residents (Resident 10 and 70) reviewed for PASARR. This failure placed residents at risk for not receiving necessary mental health care and services.

Inspectors wroteBased on interview and record review, the facility failed to review and revise the care plan related to urinary tract infection (UTI) treatment and prevention for 1 of 3 residents (Resident 17) review for care plan accuracy and revision. This deficient practice placed residents at risk for unmet and unidentified care needs.

Inspectors wroteAMENDED Based on observation, interview, and record review the facility failed to comprehensively assess and determine potential causative factors for recurrent urinary tract infections (UTIs) and provide UTI treatment consistent with professional standards of practice for 1 of 3 residents (Resident 17) reviewed for continuous urinary catheter (a flexible tube that inserted into the bladder to drain urine) use. This deficient practice placed residents at risk of unnecessary UTIs, antibiotic (medication used to fight infections caused by bacteria) use and delays in UTI treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care in accordance with accepted standards of practice for 2 of 2 residents (Resident 17 and 6) reviewed for respiratory care related to CPAP (Continuous Positive Airway Pressure) and BiPAP [(Biphasic Positive Airway Pressure) medical devices used to maintain an open airway while sleeping] use. This deficient practice placed residents at risk for respiratory status complications and potentially contributed to a recently treated sinus infection for Resident 17. Review of the facility policy, titled CPAP /BiPAP Support showed device pieces such as mask and tubing were to be cleaned with soap and water daily, and the filter and water chamber cleaned weekly. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed proper food handling and storage practices for 2 of 3 residents' (Resident 20 and 72) personal refrigerators and 2 of 3 dining areas ([NAME] House and Cayuse House) reviewed for food safety. The failure to obtain and record refrigerator temperatures and store residents' personal condiments based on manufacturers' recommendations placed residents at risk for consuming expired food and food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed infection prevention and control measures for the use of Personal Protective Equipment (PPE) and hand hygiene with contact enteric precautions (safety measures used by healthcare workers to prevent the spread of infectious agents that pose an increased risk for transmission through direct or indirect contact) for 6 of 7 staff (Staff G, H, I, L, J, and K) reviewed for infection control. These failures placed residents, staff, and visitors at risk of exposure and cross contamination of an infectious disease.

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide the necessary adequate supervision for 1 of 3 residents (Resident 1) reviewed for elopement (leaving a facility without notice or supervision). This failure allowed Resident 1 to exit the facility unnoticed and placed the resident at risk for serious injury and/or exposure to the elements.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication cart was locked when left unattended by 2 of 4 staff (Staff B and C) reviewed for medication storage. This failure placed the residents, staff, and visitors at risk for unauthorized access to medications resulting in negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure services were provided to treat a resident for an uncontrolled elevated heart rate for 1 of 3 residents (Resident 1) reviewed for quality of care, despite staff awareness of new medication and treatment orders sent by the provider to the facility and Resident 1's continued elevated heart rate (HR). The failure of providing timely staff follow up with the provider's office to obtain the medication and treatment orders for Resident 1, placed them at risk for development and/or worsening medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the resident's representative for 1 of 3 residents (Resident 1), reviewed for notification of change. Failure to notify the representative of a change in the resident's skin condition placed the resident at risk of not having their representative involved in the health care decision making process for timely care and services.