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F0609
D

Failure to Notify State Agency of Resident Elopement

Toppenish, Washington Survey Completed on 06-30-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the state agency regarding an elopement incident involving a resident. The resident, who had diagnoses including high blood pressure, Parkinson's Disease, reduced mobility, and a history of homelessness, was admitted to the facility and required partial to substantial assistance with transfers, dressing, and toileting. According to the comprehensive assessment, the resident was alert and oriented. On the day of the incident, staff discovered the resident's breakfast tray untouched and their belongings missing, indicating the resident had left the facility without notice. Staff were unaware of the resident's location and the resident had not been assessed as an elopement risk. The incident was not documented in the facility's incident reporting log for the relevant months, and the state agency was not notified as required. The DON confirmed that staff did not know the resident's whereabouts and that the state agency was not contacted. Social Services attempted to reach the resident by phone, but the number was not working, and law enforcement was notified the following day. However, the incident was not logged, and Social Services staff were unaware of the requirement to notify the state agency.

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