Yukio Okutsu State Veterans Home

Inspectors wroteBased on record review and interview, the facility failed to ensure the Binding Arbitration Agreements (BAA) followed all the requirements as specified in the regulations. Specifically, the agreements residents were asked to enter into, did not explicitly grant the residents or their representatives the right to rescind the agreement within 30 calendar days of them signing it.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the resident's right to a dignified existence and is treated with respect and dignity for one resident (Resident (R)36) sampled. Registered Nurse (RN)6 referred to resident's who require assistance with meals as feeders in front of R36, who requires assistance with meals. As a result of this deficient practice, residents are at a potential risk of psychosocial harm.

Inspectors wroteBased on observation and interview, the facility failed to facilitate a resident's self-determination through support of the resident's choice of food preferences for one resident (Resident (R)58) sampled. R58's reported he informed the facility of his food preferences and still receives foods that he informed the facility he does not like, for example milk and fish. During lunch observation on 11/12/24, the resident was served salmon for lunch and the resident's meal ticket documented R58 dislikes fish. As a result of this deficient practice, residents are at risk for more than minimal physical and/or psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident or their representative was given written notice of transfer or discharge from the facility and that a copy of the notice was sent to a representative of the Office of the State Long-Term Care Ombudsman for two residents (Resident (R)7 and R43) sampled. This deficient practice has the potential to affect all the residents who are transferred or discharged from the facility.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive person-centered care plan (CP) for pain which included non-pharmacological interventions for one of five residents (Resident (R)16) sampled for unnecessary medication. Review of R16's CP for pain did not include non-pharmacological interventions as a standard of practice of multimodal approaches for pain relief according to the American Nurses Association (ANA). As a result of this deficient practice, resident is at risk for potential harm by potentially receiving unnecessary medications, which could include opioids, prior to implementing other effective modalities of pain relief (cold, heat, repositioning, exercise, stretching etc.).

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide appropriate medical care for one resident (R)58. The facility failed to manage R58's bowel regimen and manage the resident's diarrhea. This deficient practice has the potential to result in more than minimal psychosocial and physical harm.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide care consistent with professional standards of practice for the resident (Resident (R)25) who received hemodialysis (treatment to remove waste and excess fluids from the blood) treatments. Specifically, the facility did not ensure fluid restrictions were followed as ordered by the attending physician. This deficient practice could result in preventable adverse health conditions like fluid overload and congestive heart failure for residents with end stage renal disease.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%, as evidenced by two medication errors observed out of 30 opportunities, for an error rate of 6.67%. Safe and timely medication administration practices are essential for the health and well-being of the residents. As a result of this deficient practice, two residents (Resident (R)56 and 52) were placed at risk of negative outcomes due to medication errors. This deficient practice has the potential to affect all residents in the facility taking medications.

Inspectors wroteBased on observations and interviews, the facility failed to clean and maintain food serving equipment, dishes, and utensils in a sanitary condition. This deficient practice places the residents at risk for food borne illness and has the potential to affect all the residents who have meals served by the facility. Findings Include: 1) Concurrent observation and interview were conducted on 11/12/24 at 09:31 AM. Observation was made of a food warmer that contained an uncovered container of soup. The top of the food warmer had a worn down rubber seal and a buildup of dust and lint. The dust and lint were directly above the uncovered soup. Both the cook and the Dietitian (D)1 were shown the dirty warmer and the uncovered soup. D1 confirmed that the container of soup should have been covered and the food warmer should be cleaned. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident's medical record included documentation that indicated the resident did not receive the influenza immunizations for one of five residents (Resident (R)46) sampled for immunizations. R46 signed a consent form to receive the influenza immunization. However, R46 did not receive the influenza immunization and the resident's refusal and education regarding the benefits of the vaccination was not documented in his medical record. As a result of this deficient practice, R46 was placed at risk for more than minimal harm.

Inspectors wroteBased on interviews and record review, the facility failed to provide competent nursing services for one resident (Resident (R)166) sampled. Specifically, nursing staff did not take immediate action and seek a higher level of care for R166's respiratory distress. As a result of this deficient practice, R166 was placed at risk of more than minimal physical harm.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure one of the residents (Resident (R) 161) in the sample was free from accident hazards from the use of a mechanical lift. A facility staff independently operated the mechanical lift without assistance form another staff member. As a result of this deficient practice, R161 sustained multiple fractures to his vertebra and ribs. This deficient practice has the potential to affect all residents that require the use of a mechanical lift for transfers.

Inspectors wroteBased on record review (RR) and interview, the facility did not provide a written notice to specify a bed-hold at the time of transfer. In addition, the facility failed to provide written information to the resident and/or resident representative at the time of transfer.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure dishes used to serve food were appropriately sanitized in accordance with professional standards for food service safety. This deficient practice placed all the residents in the facility at risk for possible foodborne illnesses.

Inspectors wroteBased on observation, interviews and record review (RR), two residents of the three sampled resident (R)38 and R43, failed to receive accurate assessments, reflective of their status at the time, to identify relevant care areas. As a result of this deficiency, their care plans (CP) did not identify focus areas needed to ensure they maintain or attain their highest medical, functional, and psychosocial potential. All residents are at risk of not receiving an accurate assessment.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to implement person-centered comprehensive care plan for one of two sampled residents (Resident (R) 39). An intervention to prevent falls for R39 was not implemented. As a result of this deficient practice, the R39 was placed at risk for potential harm from avoidable falls and has the potential to affect all resident at the facility on close monitoring.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet the standards of good clinical practice and ensure timeliness of revisions to the Care Plan (CP) of two Residents (R) of a sample size of 3, R9 and R43. Specifically, R9's dental issue, was not addressed in his CP and R43's hearing aid was not being used. As a result of these deficiencies there was the potential they would not meet their highest level of medical, physical and psychological well-being. This deficient has the potential to affect all residents.

Inspectors wroteBased on interviews, observation and record review, the facility failed to provide consistent repositioning for one of the one sampled residents (R) 45 in the sample. R45 had an existing Stage 4 (Full-thickness skin and tissue loss) Pressure Ulcer (PU) on the sacrum. As a result of this deficiency, R45 was at increased risk for new PU's and the potential of healing the current PU was decreased. This deficient practice could affect any resident identified at risk for the development of PU, and those with current PU's, resulting in preventing them from reaching their highest physical and psychosocial well-being. as ordered, and consistent with professional standards of practice.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the medication error rate was less than 5 percent for one of five sample residents Resident (R)46. This deficient practice has the potential to harm other residents and failure for R46 to reach their highest practicable level of health and well-being.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure appropriate temperatures for one of its two medication refrigerators that are monitored and maintained. This deficient practice has the potential to negatively affect the efficacy and integrity of medications that require storage at proper temperatures.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure shared medical devices were properly disinfected after use. Specifically, the facility did not use the appropriate disinfectant to wipe the shared blood glucose meter (device used to measure blood sugar levels). The facility also failed to ensure proper hand hygiene was used to prevent the transmission of commumnicable diseases and infections. The deficient practice have the potential to spread communicable diseases and infections to other residents that use the same device to have their blood sugar levels checked.

Inspectors wroteBased on observations, record review and interview with staff members, the facility failed to ensure residents received care to prevent development of new pressure inuries and provide care to promote healing and prevention of infections from developing for two (Residents 11 and 54) of four residents included in the sample. The facility failed to develop a person-centered care plan for the prevention of development and infection of pressure injuries; implement the resident's care plan to facilitate healing of the pressure injuries (application of foam boots and elevating feet); and provide resident with informed choices regarding the treatment of the pressure ulcers. As a result of the deficient practice, Resident (R)11 developed two facility-acquired pressure injuries which worsened, Stage 4 pressure injury to the left heel and Stage 3 pressure injury to the right buttock. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that adequate pain management was provided to one resident (R34) in the sample. As a result of this deficient practice, R34 experienced pain that interfered with his movement, affected his mood, and diminished his appetite, thereby preventing him from attaining his highest practicable level of well-being.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop resident-centered comprehensive care plans supporting resident's choices and interventions to achieve the resident's goals for 9 residents (R), R16, R27, R109, R11, R54, R13, R22, R34, and R56, out of a sample of 19 residents. This deficient practice failed to recognize individualized care and medical needs of each resident with measurable objectives and timeframes to help them attain or maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations and interview with residents and staff, the facility failed to ensure there were sufficient nursing staff to assure residents' highest practicable physical, mental and psychosocial well-being was attained or maintained.

Inspectors wroteBased on review of the facility's assessment, the facility failed to include the facility's assessment of the facility's resources to meet the needs of their resident population.

Inspectors wroteBased on observations, interviews, and record review, in response to a COVID-19 outbreak identified on 12/15/22, the facility failed to ensure appropriate protective and preventive measures for COVID-19 were executed, as evidenced by the facility failing to follow and implement their infection prevention and control policies and procedures, including standard and transmission-based precautions to control and prevent the spread of COVID-19. In addition, the facility failed to ensure staff conducting point-of-care (POC) COVID-19 self-testing conducted the testing per CDC and manufacturer guidelines and failed to ensure staff handling the collected specimens followed standard precautions. This deficient practice has the potential to contribute to the transmission and spread of COVID-19 in the facility, compromising resident, staff, and visitor safety.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean, sanitary, and homelike environment as evidenced by repeated instances of resident (R) urinal(s), both partially filled and empty, being placed/left on the top of the resident's bedside table(s). As a result of this deficient practice, resident safety was compromised as the residents' food and hydration items were also placed on the bedside table(s). This deficient practice has the potential to affect all residents at the facility who are using urinals.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat residents with respect and dignity to promote maintenance or enhancement of his or her quality of life.

Inspectors wroteBased on interview with residents, the facility did not assure staff provide ongoing communication to residents about their rights.

Inspectors wroteBased on resident interview, the facility failed to ensure residents are provided with informational notice of how to contact the Ombudsman or the State Agency.

Inspectors wroteBased on resident interview, the facility did not assure residents were aware of their right to examine the results of the most recent survey of the facility conducted by State or Federal surveyors.

Inspectors wroteBased on observations, interview, and record review, the facility failed to timely update the care plans for two residents (R), R21 and R49, out of a sample of 19 residents. This deficient practice does not assure interventions were revised to meet the care needs of the residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide appropriate medical care for four residents (R), R27, R109, R39, and R16 residents. The facility failed to manage bowel regimen to treat constipation for R27 and R109; obtain weights for R39 who has a complex medical history and is on medication to help rid his body of excess fluid; and medically treat and manage R16's rash. These deficient practices affected residents' ability to attain or maintain their highest practicable physical well-being.

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not assure 2 of 5 residents (Resident 109 and 34) received necessary behavioral health services to attain or maintain their highest practicable mental and psychosocial well-being. As a result of this deficient practice, these residents did not have their needs met, and were placed at risk for a decline in their quality of life. This deficient practice has the potential to affect all the residents at the facility in need of behavioral health services.

Inspectors wroteBased on observation and record review, the facility failed to ensure one resident (R) diagnosed with dementia, received the appropriate treatment and services to attain or maintain her highest practicable physical, mental, and psychosocial well-being. As a result of this deficient practice, R56 did not have her needs met, and was placed at risk for a decline in her quality of life. This deficient practice has the potential to affect all the residents at the facility with a diagnosis of dementia.

Inspectors wroteBased on observation and interview, the facility failed to ensure that one resident (R) was free from a significant medication error as evidenced by R47 being administered an insulin pen that was labeled as expired for six days. In addition, the insulin would have been administered for a seventh day had the state agency (SA) not intervened. Safe medication administration practices are essential for the health and well-being of the residents. As a result of this deficient practice, R47 was placed at risk of inadequate glucose control as a result of being administered expired insulin. This deficient practice has the potential to affect all residents in the facility receiving insulin.

Inspectors wroteBased on observation and interview, the facility failed to ensure all medications used in the facility were stored in accordance with professional standards. Proper storage practices of all medications and biologicals are necessary to ensure their integrity, safety, and efficacy.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that the health record for one resident (R)7, out of a sample of 19 residents, accurately conveyed R7's current wishes for medical treatment. This deficient practice has the potential to confuse caregivers to ensure the resident's wishes are executed.