Veteran Village

In the surveyor’s words

From the most serious findings on record at Veteran Village, in the surveyor’s own words.

• Actual harm, isolatedF686Oct 11, 2024

  Based on observations, interviews, and record reviews, the facility failed to prevent the significant worsening of a pressure area and the development of a Stage III (3) pressure area for one (1) Resident (R21) out of 19 sampled residents, who developed in house pressure areas. R21's mattress malfunctioned which led to the increase in size in one (1) pressure ulcer and the development of another. Finding include: Review of the facility policy titled, Wound Intervention and Prevention, dated ,d+[DATE], documented, The following is meant to be a guideline and is intended to assist in the decision-making process when determining appropriate treatment and prevention according to the underlying etiology of the alteration in skin integrity, the condition of the wound, and the overall condition… […]

• Actual harm, isolatedF773Oct 11, 2024

  Based on interviews and record review, the facility failed to notify the Medical Provider of urinalysis results ordered on 06/25/24 and 07/2/24, resulting in subsequent hospitalization of a Resident (R)12 with a Urinary Tract Infection. This deficient practice affected one (1) of one (1) residents reviewed for indwelling urinary catheters from a total of 19 residents sampled. Findings include: Review of R12's medical record revealed an initial admitted [DATE]. R12's primary medical diagnosis was Incomplete Paraplegia. His/her secondary medical diagnoses included Neuromuscular Dysfunction of Bladder. […]

• No harm, potential for more than minimal, isolatedF610Oct 11, 2024

  Based on interviews, record review, and review of facility policy, facility staff failed to implement the corrective actions as indicated in the facility's investigative report for an allegation of abuse. This deficient practice affected one (1) of two (2) residents reviewed for abuse from a total of 19 sampled residents. (Resident (R)48). Findings include: Cross Reference to F607 - Develop/Implement Abuse/Neglect Policies Review of the undated facility policy titled Abuse Investigation documented, An immediate investigation is warranted when abuse is suspected or reported, and a thorough investigative result will be documented. Step 11 of the policy directed staff to analyze the occurrence and implement changes to prevent further occurrences. […]

• No harm, potential for more than minimal, isolatedF656Oct 11, 2024

  Based on observation, interview, record review, and facility policy review, the facility failed to implement a comprehensive person-centered care plan for two (2) of 19 sampled residents by failing to: 1) Assess the placement of a gastrostomy (g-tube) tube prior to the administration of medications for one (1) of 19 sampled residents (Resident (R)36) and 2) Develop and implement interventions for episodes of hypoglycemia for residents with Diabetes for one (1) of five (5) residents reviewed for unnecessary medications from a total of 19 sampled residents. (R2) Findings include: 1. […]

• No harm, potential for more than minimal, isolatedF693Oct 11, 2024

  Based on observation, interview, record review and facility policy review, the facility failed to provide the appropriate treatment and services to prevent potential complications of enteral feeding for one (1) of one (1) sampled resident. Resident (R)36 received medications through a gastrostomy tube (g-tube), however, the g-tube was not aspirated for residual contents, or verified by auscultation for the proper placement prior to administration of the medications. Findings include: Review of the facility policy, dated 6/2024, and titled, Gastrostomy Tube Medication Administration, stated, Purpose: To provide medications via gastrostomy tube. Procedure: . 2. Prepare ordered medications . b. Crush pills and mix with 10-30cc [centimeters] water in one (1) medication cup . 4. […]