Senator Ben Atchley State Veterans' Home

In the surveyor’s words

From the most serious findings on record at Senator Ben Atchley State Veterans' Home, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF644Mar 11, 2026

  Based on medical record reviews, and interviews, the facility failed to ensure Pre-admission Screening and Resident Reviews (PASARR's) were submitted to the state-designated authority for a Level II evaluation after diagnoses of serious mental illness were identified for 3 residents (Residents #1, #12, and #126) of 4 residents reviewed for PASARR's.The findings include:Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Insomnia, Post-Traumatic Stress Disorder (PTSD), and Recurrent Depression.Review of a PASARR for Resident #1 submitted on 1/25/2026 (prior to admission), revealed the resident had diagnoses of Anxiety Disorder and Mild or Situational Depression, but did not include the diagnoses of Insomnia, and… […]

• No harm, potential for more than minimal, isolatedF761Mar 11, 2026

  Based on facility policy review, medical record review, observation, and interview, the facility failed to properly store medication in 3 of 4 medication carts reviewed for medication storage.The findings include:Review of the facility policy titled, MEDICATION STORAGE IN THE FACILITY Storage of Medications, dated 1/2019, revealed .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier .all medications dispensed from the pharmacy are stored in the container with the pharmacy label .Medication storage areas are kept clean .When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated per facility policy .All expired medications will be removed from the… […]

• No harm, potential for more than minimal, isolatedF600Jan 23, 2025

  Based on facility policy review, medical record review, observations and interviews, the facility failed to prevent resident to resident sexual abuse for 2 residents (Residents #1 and #2) of five residents reviewed for abuse when Resident #1 was observed with a hand inside Resident #2's brief on [DATE]. The facility was cited at F-600 at a Scope and Severity of D and was cited as past non-compliance. Noncompliance began on [DATE], was corrected and ended on [DATE]. The facility is not required to submit a Plan of Correction. The findings include: Review of the facility policy titled, Abuse and Neglect of Resident and Misappropriation of Resident's Property, dated [DATE], revealed .Sexual Abuse includes but is not limited to sexual harassment, sexual coercion or assault . […]

• No harm, potential for more than minimal, isolatedF641Feb 14, 2024

  Based on review of the Resident Assessment Instrument Manual 3.0 (RAI), medical record reviews, and interviews, the facility failed to accurately complete Minimum Data Set (MDS) assessments for 3 residents (Resident #132, #32, and #73) of 27 residents reviewed for MDS assessments. The findings include: Review of the Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.18.11 dated 10/2023, showed .Review the medical record including the discharge plan and discharge orders for documentation of discharge location .The following is guidance .in which a resident receives tube feeding .If the resident does not eat or drink by mouth and relies solely on nutrition and liquids through tube feedings .code GG0130A as 88… […]

• No harm, potential for more than minimal, isolatedF644Feb 14, 2024

  Based on medical record review and interview, the facility failed to refer 1 resident (Resident #94) after the resident was diagnosed with a serious mental disorder, to the state-designated authority for a Level II Pre-Admission Screening and Resident Review (PASRR) evaluation and determination of 7 residents reviewed for PASRR. The findings include: Resident #94 was admitted to the facility on [DATE] with diagnoses including Depression, Altered Mental Status, and Diffuse Traumatic Brain Injury. Review of the medical record showed Resident #93 received a diagnosis of Post Traumatic Stress Disorder (PTSD) on 7/30/2021. Review of a Notice of PASRR Level I Screen Outcome dated 11/21/2022, showed .DIAGNOSIS Major Depression .Depression . […]