Yukio Okutsu State Veterans Home

In the surveyor’s words

From the most serious findings on record at Yukio Okutsu State Veterans Home, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 30, 2023

  Based 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. Findings include: Review conducted for the Facility Reported Incident (FRI) document retrieved from Aspen Complaints/Incidents Tracking System (ACTS) 10397. Initial report was submitted to the Office of Healthcare Assurance on 06/29/23 and the completed report on 07/07/23. […]

• Actual harm, isolatedF686Oct 14, 2022

  Based 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's pressure injury also became infected requiring antibiotic treatment. […]

• Actual harm, isolatedF697Oct 14, 2022

  Based 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. Findings include: Resident (R)34 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/11/22 at 01:29 PM, an interview was done with R34 at his bedside. R34 reported constant pain everywhere, but worse in his neck and hands. When asked, R34 stated that the pain medications he was on did little to relieve his pain. […]

• No harm, potential for more than minimal, widespreadF656Oct 14, 2022

  Based 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. Finding includes: 1) Cross Reference to F684. On 10/11/22 at 10:43 AM, R16 was observed while an interview was conducted with family member (FM)6. […]

• No harm, potential for more than minimal, widespreadF725Oct 14, 2022

  Based 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. Findings include: 1) On 10/12/22 at 09:00 AM an interview was conducted with the resident council representatives. The representatives were asked if they receive the help and care needed without waiting a long time. A representative reported the facility doesn't have enough workers, they leave faster than they are coming. The representative commented, the certified nurse aides are the backbone of the company. […]