Yakima Valley School
Inspection history, citations, penalties and survey trends for this long-term care facility in Selah, Washington.
- Location
- 609 Speyers Road, Selah, Washington 98942
- CMS Provider Number
- 50A261
- Inspections on file
- 44
- Latest survey
- November 3, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Yakima Valley School during CMS and state inspections, most recent first.
A resident with moderate intellectual disability, autistic disorder, and epilepsy was admitted without the required PASRR documentation, despite facility policy mandating its completion before admission. The Admissions Coordinator acknowledged the oversight, and the Administrator confirmed the failure to ensure the PASRR process was followed.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet required safety standards, resulting in insufficient oversight.
Three residents with intellectual disabilities were subjected to physical restraints during dental procedures without documented medical symptoms, provider orders, or evidence that less restrictive interventions were attempted, in violation of facility policy and federal requirements. Staff interviews confirmed that required assessments and documentation were not completed for these restraint episodes.
A deficiency was identified when several residents with severe cognitive and physical care needs did not receive timely assistance with eating and toileting due to insufficient nursing staff. Staff interviews and observations showed that residents requiring close supervision or one-to-one care were left unattended or had to wait for care, as available staff were stretched thin or reassigned to cover shortages elsewhere. The issue was exacerbated by a high number of staff out due to injuries, leading to delays and unmet care needs for residents.
Several residents with severe cognitive impairments and dependence on staff for eating were left waiting significantly longer than others to be served or assisted with their meals, due to staff shortages and prioritization decisions. This resulted in a lack of inclusion and decreased dignity for these residents.
A resident with intellectual disabilities and epilepsy was transferred to the hospital with sepsis, but neither the resident nor their representative received the required written notice of bed hold or hospital transfer. Staff interviews confirmed that the notifications were missed due to a breakdown in the facility's communication process.
A resident's PASARR assessment was found to be inaccurate, as it failed to include an active diagnosis of anxiety along with depression. The Social Service Director was unaware of the anxiety diagnosis, and the established process for verifying SMI diagnoses in PASARR assessments was not followed.
Three residents with complex medical and cognitive needs were admitted without complete baseline care plans, as required. The care plans lacked initial goals, physician orders, and dietary orders, and there was no documentation that written summaries were provided to the residents or their representatives. Staff interviews revealed a lack of awareness about these requirements.
A resident with intellectual disabilities and autism experienced ongoing left knee pain and limping, but staff failed to follow physician and orthopedic specialist orders for imaging with IV sedation, did not implement recommended interventions, and did not update the care plan to reflect the resident's condition. Attempts to arrange imaging were unsuccessful, blood tests were delayed, and staff did not coordinate care or follow up with providers as required.
A resident with severe cognitive impairment was not properly offered or educated about the COVID-19 vaccine, and there was no documentation of immunization assessment, education, or consent/declination. Staff confirmed that the required follow-up with the resident's representative did not occur, and the facility's process for vaccine education and consent was not followed.
A resident with severe intellectual disabilities, impaired vision, and a history of falls was left unsupervised in a hallway when their assigned staff left to take out the garbage without notifying others. The resident, who required constant line-of-sight supervision, was later found with a hematoma and bruising around the right eye, indicating an unwitnessed fall or contact with a firm surface. Staff interviews confirmed the care plan was not followed, resulting in the resident being left alone and injured.
A registered nurse in an LTC facility misappropriated controlled medications by replacing oxycodone with loratadine for five residents with profound intellectual disabilities and other conditions requiring pain management. The tampering was discovered by a pharmacist, leading to an investigation that identified the nurse responsible for the drug diversion. The facility's policy on controlled substance accountability was not followed, resulting in the substitution going undetected for a period.
A resident with cognitive impairments alleged being hit by staff, but the incident was not reported to the state agency or superintendent as required. Staff members who heard the claim did not fulfill their mandated reporting duties, leading to a deficiency citation.
The facility failed to ensure timely reporting of abuse allegations by staff, involving two residents with intellectual disabilities. Delays in reporting incidents to the NHA and SA hotline ranged from several hours to 17 days, compromising resident safety and well-being.
Two cognitively impaired residents were subjected to physical abuse by staff members, resulting in harm. A resident with severe cognitive impairment was hit and kicked by staff on separate occasions, leading to physical and psychosocial harm. Another resident was dragged across the floor by a staff member, causing distress. These incidents highlight a failure to protect residents from abuse and maintain a safe environment.
The facility failed to implement policies for immediate abuse reporting and coordination with QAPI, leading to delayed protection for two residents. Staff did not report observed abuse incidents involving a resident with intellectual disabilities and another with cerebral palsy to the NHA and state hotline as required. Interviews revealed staff were unaware of reporting time frames, and the facility lacked specific policies for QAPI involvement.
A staff member at an LTC facility violated the privacy of four residents by taking unauthorized photographs with a personal cell phone and sharing them with an external individual. The residents, who had various cognitive impairments, were photographed without consent, breaching facility policies on resident privacy and electronic device usage.
The facility failed to ensure proper storage and labeling of medications, as observed during a medication pass. Five pre-poured medications were found in a single locked drawer, with some cups unlabeled and others mixed with chocolate pudding. An LPN admitted this was not standard practice, and the DON confirmed the correct process was not followed. The residents involved had various diagnoses, including epilepsy and intellectual disability.
The facility failed to ensure that refrigerators and cupboards in Cottages 401, 402, and 403 were free of expired foods and that refrigerator temperatures were logged appropriately. Expired food items and incomplete temperature logs were found, and staff admitted to overlooking these responsibilities.
The facility failed to maintain a resident's dignity during gastrostomy tube (GT) care. A resident with a GT and developmental delay was observed in the common area where an LPN lifted the resident's shirt and disconnected the tube feeding port in front of others. This action was against the facility's protocol, which requires such procedures to be done in private.
The facility failed to provide quarterly personal fund statements to two residents' representatives, despite the residents having severely impaired cognition and requiring assistance for ADLs. The facility's administrator admitted to being behind on mailing the statements, violating the facility's policy and WAC 388-97-0340(3)(a)(b)(c).
The facility failed to review and validate PASARR assessments for two residents, leading to inaccuracies in their diagnoses and placing them at risk for not receiving appropriate care. Staff interviews revealed a lack of proper procedures and training regarding PASARR reviews and updates.
The facility failed to ensure a resident was free of unnecessary psychotropic medications by not monitoring individualized targeted behaviors or having interventions in place. The resident, with multiple diagnoses including cerebral palsy and violent behavior, did not have a behavior plan, and staff acknowledged the care plan was outdated and lacked necessary interventions.
The facility failed to maintain proper infection control practices, including the use of appropriate PPE for a resident under COVID-19 isolation, hand hygiene during food handling, and adherence to enhanced barrier precautions for accessing medical devices.
The facility failed to ensure that licensed staff responsible for providing basic life support had current CPR certifications. Three staff members had expired certifications, and interviews revealed they were either unaware or misunderstood the renewal timeline. The Director of Nursing Services admitted that CPR classes were not rescheduled after the COVID-19 pandemic.
The facility failed to ensure that residents were served the appropriate diet texture, leading to choking hazards for two residents. One resident with dysphagia choked and required the Heimlich Maneuver after being served an incorrect diet texture. Another resident with cerebral palsy was given thickened chocolate milk, contrary to their diet order. Staff involved did not follow proper procedures for diet modifications.
Failure to Complete PASRR Prior to Admission
Penalty
Summary
The facility failed to ensure that the required Pre-admission Screening and Resident Review (PASRR) was completed prior to the admission of a resident with moderate intellectual disability, autistic disorder, and epilepsy. According to the facility's own policies, a PASRR Level 1 form must be completed before a resident is admitted. However, a review of the resident's medical record showed that no PASRR documents were received prior to their admission. The comprehensive assessment conducted after admission documented the resident's moderate cognitive impairment and a tendency to reject care from staff. During interviews, the Admissions Coordinator acknowledged that there was a process in place to ensure PASRR documentation was included in each resident's records before admission, but admitted that the PASRR for this resident was missing and had been overlooked. The Administrator was informed of the missing PASRR and confirmed the failure to follow the required process for this resident's admission.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to prevent potential incidents. No additional details regarding the specific hazards, the individuals involved, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Follow Protocols for Physical Restraint Use During Dental Procedures
Penalty
Summary
The facility failed to ensure that physical restraints were implemented in accordance with regulatory requirements and facility policy for three residents with intellectual disabilities who received dental care. Specifically, the use of physical restraints such as hand restraints, leg wraps, and body wraps during dental procedures was not supported by documented medical symptoms warranting their use, nor were provider orders obtained for the specific type of restraint applied. Additionally, there was no evidence that less restrictive interventions were attempted prior to the application of restraints, as required by both facility policy and federal guidelines. For each of the three residents reviewed, medical records and dental progress notes lacked documentation of the necessary assessments, provider orders, and justification for restraint use. The residents involved had significant cognitive impairments and, in some cases, additional diagnoses such as cerebral palsy, epilepsy, and anxiety. Despite these complex needs, the records did not reflect individualized assessment or documentation of behaviors that would necessitate restraint, nor did they show that alternative, less restrictive measures were considered or tried before restraints were used during dental procedures. Interviews with facility staff, including the DON and dental hygienist, confirmed that the required processes for restraint implementation were not being followed. Staff acknowledged that provider orders were not obtained, the restraint orders and monitoring form was not completed, and least restrictive measures were not consistently attempted. Annual consents were obtained from resident representatives, but this did not substitute for the required documentation and clinical justification for each instance of restraint use. The deficiency was further confirmed by the facility administrator, who stated that the correct process for implementing physical restraints during dental procedures was not being followed.
Failure to Provide Adequate Nursing Staff for Resident Supervision and Care
Penalty
Summary
The facility failed to provide adequate nursing staff each day to meet the individualized care and supervision needs of residents, as required by their acuity and level of supervision (LOS) designations. Multiple residents with severe cognitive impairments, intellectual disabilities, and communication disorders were observed not receiving timely assistance with essential activities such as eating and toileting. Staff interviews and direct observations revealed that residents who required staff to anticipate their needs, one-to-one supervision, or close monitoring were left unattended or had to wait extended periods for care due to insufficient staffing. Specific incidents included residents who were dependent on staff for eating being left without meals or waiting long periods before being assisted, as staff were occupied with other residents or on break. In one instance, a resident with PICA and a need for close supervision was able to access and consume non-food items from the refrigerator while staff were assisting others. Another resident, who required staff to be present during toileting, was left unsupervised, resulting in privacy concerns and incomplete hygiene. Staff reported that when short-staffed, they had to prioritize care, leaving some residents without the required supervision or assistance, and that even with normal staffing, there were not enough staff to meet all residents' needs simultaneously during mealtimes. The facility's staffing challenges were compounded by a significant number of nursing assistants and a registered nurse being out due to on-the-job injuries, particularly from cottages with residents exhibiting severe combative behaviors. This led to staff being reassigned from other areas, further reducing available personnel and impacting the ability to provide care as outlined in residents' care plans and LOS requirements. The Director of Nursing confirmed that staffing was based on the overall needs of each cottage rather than the specific care levels required by individual residents, and acknowledged unaddressed changes in supervision needs for some residents.
Failure to Serve Meals in a Dignified and Timely Manner
Penalty
Summary
The facility failed to provide care and services in a dignified manner by not serving meals to all residents in the dining area at the same time, specifically affecting three residents with severe cognitive impairments and dependence on staff for eating. Observations showed that these residents, who had diagnoses including intellectual disabilities, epilepsy, and mixed receptive-expressive language disorder, were left waiting for their meals or for staff assistance while other residents were already being served or assisted. In several instances, these residents waited significantly longer than others, with delays ranging from 14 to 58 minutes after other residents had begun eating or receiving assistance. Staff interviews and observations revealed that staffing shortages and prioritization of residents contributed to the delays. Nursing assistants reported being short-handed and having to decide which residents to assist first, resulting in some residents waiting extended periods before being served or assisted with their meals. The Director of Nursing Services acknowledged that staffing levels were based on supervision needs rather than the actual assistance required for feeding, and expected staff to call for additional help if needed. These actions and inactions led to a lack of inclusion and decreased dignity for the affected residents.
Failure to Provide Bed Hold and Hospital Transfer Notification
Penalty
Summary
The facility failed to provide a written notice of bed hold and a written notification of hospital transfer to a resident and their representative when the resident was transferred to the hospital. The resident, who had diagnoses including intellectual disabilities and epilepsy, experienced loose stools and an elevated temperature over three days. Following provider notification, the resident was sent to the hospital and subsequently admitted with sepsis. Review of the medical record confirmed that neither the resident nor their representative was offered a bed hold or given a notification of the hospital transfer. Interviews with facility staff revealed that the Social Services Specialist did not receive or missed the email notification regarding the resident's hospital admission, resulting in the omission of both the bed hold offer and the transfer notification. The Administrator acknowledged that the expected process was not followed, and the required notifications were not completed according to facility policy.
Inaccurate PASARR Assessment for Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the accuracy of a resident's Preadmission Screening and Resident Review (PASARR) assessment, which is required to identify individuals with serious mental illness (SMI) or intellectual/developmental disabilities (ID/DD). A review of the medical record for a resident admitted with diagnoses including a bone infection, depression, and anxiety showed that the comprehensive assessment documented both depression and anxiety. However, the PASARR assessment only marked depression under the SMI/ID section and did not include the resident's anxiety diagnosis. During interviews, the Social Service Director acknowledged being unaware of the anxiety diagnosis and confirmed the PASARR was inaccurate and needed correction. The Administrator also confirmed that the established process for verifying SMI diagnoses in PASARR assessments was not followed for this resident.
Failure to Develop Complete Baseline Care Plans and Provide Written Summaries
Penalty
Summary
The facility failed to develop baseline care plans (BCPs) for three residents upon admission, as required. For each resident, the BCPs were missing essential components, including initial goals, physician orders, and current dietary orders. Additionally, there was no documentation that a written summary of the care plan was provided to the residents or their representatives after completion. These omissions were identified through interviews and record reviews. The residents involved had significant medical and cognitive needs, including diagnoses such as autism, intellectual disability, epilepsy, cerebral palsy, osteomyelitis, and diabetes. Assessments showed that these residents required varying levels of assistance with activities of daily living (ADLs) and mobility. Staff interviews confirmed a lack of awareness regarding the required components for BCPs, and the Director of Nursing Services acknowledged not being aware of the need to include initial goals, physician, and dietary orders in the care plans.
Failure to Follow Physician Orders and Coordinate Specialized Services for Pain Management
Penalty
Summary
The facility failed to follow physician's orders and provide appropriate specialized services for a resident with intellectual disabilities and autism who was experiencing worsening left knee pain and limping. The resident had been evaluated by an orthopedic specialist, who ordered imaging with IV sedation due to the resident's diagnoses, as well as interventions such as rest, activity modification, ice and heat application, and topical pain relief. Despite these orders, the facility did not ensure the imaging was completed, did not implement the recommended interventions, and did not update the resident's care plan to reflect the ongoing pain and mobility issues. Multiple attempts to arrange the ordered imaging were unsuccessful, with documentation showing confusion and lack of follow-through regarding the need for IV sedation and the appropriate facility for imaging. The resident was taken to a local hospital that could not perform the imaging as ordered, and there was no evidence that alternative arrangements were made in a timely manner. Additionally, blood tests verbally ordered by the provider to rule out rheumatoid arthritis were not obtained until over a month later, and the care plan was not updated to address the resident's pain or mobility changes. Staff interviews revealed a lack of understanding of the need to continue coordinating care after a specialist referral, as well as failures to implement and document physician orders and care plan updates. The Director of Nursing Services confirmed that staff did not follow up appropriately with the primary provider or implement the specialist's recommendations, and that provider notes were not consistently reviewed or acted upon after appointments.
Failure to Offer and Document COVID-19 Vaccine Education and Consent
Penalty
Summary
The facility failed to ensure that a resident or their representative was offered and educated on the COVID-19 immunization, as required by facility policy. Specifically, for one resident with diagnoses including autism, anxiety, and intellectual disabilities, and who had severely impaired cognition, there was no documentation in the medical record of a COVID-19 immunization assessment, education, or a signed consent/declination form for the years 2024 and 2025. The facility's policy required that residents or their representatives be offered the COVID-19 vaccine, receive education on its risks and benefits, and provide consent. Interviews with facility staff revealed that the process for offering and educating about the COVID-19 vaccine was not followed for this resident. The Infection Preventionist acknowledged that there was no documentation of education or consent from the resident's representative. Although the procedure was to send letters to representatives and follow up if there was no response, staff confirmed that the resident's representative was not contacted after failing to respond to the initial letter. The administrator also confirmed that the correct process was not followed for this resident.
Resident Left Unsupervised, Sustains Injury Due to Failure to Follow Supervision Requirements
Penalty
Summary
A deficiency occurred when a resident with severe intellectual disabilities, anxiety disorder, obsessive-compulsive disorder, and bilateral cataracts was not provided the required level of supervision as outlined in their care plan. The resident, who had a history of falls and was assessed as needing Level of Supervision (LOS) 3 due to lack of safety awareness, impaired vision, and poor coordination, was left unsupervised in a back hallway. The assigned staff member left the resident alone to take out the garbage without notifying other staff, despite the care plan requiring the resident to always be within staff's line of sight. As a result of being left unsupervised, the resident experienced an unwitnessed fall or contact with a firm surface, leading to a hematoma and bruising around the right eye. Staff later found the resident walking in the hallway with visible injuries. Interviews confirmed that the staff member did not follow the care plan and failed to communicate the resident's whereabouts to other staff, resulting in the resident being left alone and sustaining harm.
Misappropriation of Controlled Medications by Staff
Penalty
Summary
The facility failed to protect five residents from the misappropriation of controlled medications by a registered nurse, identified as Staff C. The nurse was involved in drug diversion, where oxycodone tablets prescribed for the residents were replaced with loratadine tablets. This substitution was discovered when the Clinical Pharmacist, Staff D, noticed tampered bingo cards with cut and taped foil backs. The tampering affected the medication administration for Residents 1, 2, 3, 4, and 5, who were all long-term residents with profound intellectual disabilities and other medical conditions requiring pain management. Resident 1, who had diagnoses including profound intellectual disabilities, cerebral palsy, and dysmenorrhea, was prescribed oxycodone for chronic pain. However, 14 doses of loratadine were administered instead of the prescribed oxycodone. Similarly, Resident 2, with profound intellectual disabilities and hip dislocation, received loratadine instead of oxycodone on two occasions. Resident 3, also with profound intellectual disabilities, received 25 doses of loratadine instead of oxycodone. Resident 4, with cerebral palsy and kidney stones, received eight doses of loratadine, and Resident 5, with cerebral palsy and osteoarthritis, received 22 doses of loratadine instead of the prescribed oxycodone. The facility's policy on controlled substance accountability was not adhered to, as evidenced by the tampered bingo cards and the failure to detect the substitution of medications in a timely manner. The Acting Director of Nursing, Staff E, initiated an investigation after being notified by the pharmacist, which led to the identification of Staff C as the individual responsible for the diversion. The tampering was not visible unless the bingo cards were held up to a light source, and the loratadine tablets were similar in appearance to the oxycodone tablets, facilitating the substitution. The incident was reported to law enforcement, and interviews were conducted with the involved staff members.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of potential abuse involving a resident, which was required by the Washington State Reporting Guidelines for Nursing Homes. The incident involved a resident with diagnoses including autistic disorder, moderate intellectual disabilities, and disruptive mood disorder, who claimed to have been hit in the eye by a facility staff member. This claim was communicated to the facility by the resident's public school teacher. Upon receiving the report, the facility administration removed the identified staff from direct care and initiated an investigation. However, the initial allegation was not reported to the state survey agency (SA) abuse hotline or the facility's superintendent as required. Staff members who were aware of the resident's claim, including a Licensed Practical Nurse and a Nursing Assistant, did not report the incident to the SA or notify the superintendent. The Developmental Disabilities Administration's Statewide Investigation Unit later conducted an investigation and could not substantiate the allegation. Despite this, the failure to report the initial claim was a repeat citation from a previous Statement of Deficiencies, indicating a lapse in following mandated reporting procedures.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to ensure that staff members reported allegations of abuse immediately to the Nursing Home Administrator (NHA) and the State Agency (SA) abuse hotline, as required by regulations. This deficiency involved seven staff members who did not report incidents of abuse in a timely manner, placing residents at risk for continued abuse. The delay in reporting resulted in a significant lapse of up to 17 days before the alleged perpetrators were removed from direct resident care. Resident 1, who has profound intellectual disabilities and autism, was involved in two separate allegations of abuse. In the first incident, Staff M witnessed another staff member physically abuse Resident 1 but did not report it immediately to the NHA or SA hotline. The facility administration was only informed 17 days later, leading to a delayed response. In the second incident, Staff D witnessed abuse but was confused and did not report it immediately, while Staff F also failed to report what they observed. The facility was notified of this incident later that night, but the SA hotline was not informed until the following day. Resident 3, who has cerebral palsy and intellectual disabilities, was also involved in an abuse allegation. Staff J and Staff H observed another staff member dragging Resident 3 across the floor but did not report the incident immediately. The NHA was notified 10.5 hours after the incident, and the SA hotline was informed 11 hours later. These delays in reporting abuse incidents highlight a significant deficiency in the facility's adherence to mandatory reporting requirements, compromising resident safety and well-being.
Removal Plan
- The facility provided all staff mandatory training on Abuse, Neglect, and Mandatory Reporting with a live instructor in a classroom setting.
- The staff training plan included on-call staff and new hires.
- Staff were provided with a small how to report card that included numbers for the SA abuse hotline and a designated Officer of the Day (NHA/Superintendent and Director of Nursing Services [DNS]), who were on-call and available.
Failure to Protect Cognitively Impaired Residents from Abuse
Penalty
Summary
The facility failed to protect two cognitively impaired residents from physical abuse, resulting in harm. Resident 1, who had severe cognitive impairment and was dependent on staff, was subjected to physical abuse on two separate occasions. On the first occasion, a staff member was observed hitting Resident 1 in the head in an attempt to stop the resident's self-injurious behavior. Despite the facility being informed of the allegation, there was initially insufficient evidence to conclude the abuse occurred, and the investigation was handed over to law enforcement. On the second occasion, another staff member was reported to have kicked Resident 1 in the face, which was corroborated by multiple witness statements and a change in the resident's sleep behavior. Resident 1's care plan indicated they required one-to-one supervision when awake and frequent checks when asleep due to their self-injurious behaviors. Despite these measures, the resident was left vulnerable to abuse by staff members. The incidents led to physical and psychosocial harm, as evidenced by changes in Resident 1's sleep and eating patterns, and increased withdrawal. The facility's failure to ensure the safety and protection of Resident 1 from abuse by staff members highlights a significant deficiency in maintaining a safe environment for residents. Resident 3, another cognitively impaired resident, was also subjected to physical abuse. Staff members witnessed Resident 3 being dragged across the floor by a staff member after the resident refused to comply with instructions. Despite the resident's care plan requiring enhanced supervision, the staff member's actions were aggressive and inappropriate, leading to distress for Resident 3. Witnesses reported the resident screaming during the incident, and although a full body check revealed no injuries, the event demonstrated a failure to protect Resident 3 from harm and maintain their dignity.
Failure to Report Abuse and Coordinate with QAPI
Penalty
Summary
The facility failed to have written policies and procedures that included the required time frames for the immediate reporting of abuse according to CFR S483.12(c)(1). Additionally, there was no written policy to define how staff would communicate and coordinate situations of abuse with the Quality Assurance Performance Improvement (QAPI) program as required by CFR S483.12(b)(4). This deficiency resulted in a delay in the protection of two residents who were reviewed for allegations of abuse, placing them at risk for unrecognized abuse and unmet care needs. Resident 1, who had profound intellectual disabilities and autism, was involved in two separate incidents where staff members failed to report abuse. Staff M, a Nursing Assistant, observed another staff member hitting Resident 1 in the head but did not report the incident before leaving their shift. Similarly, Staff D witnessed another staff member kicking Resident 1 in the face but only reported it to their shift charge after leaving work. Both incidents were not reported to the Nursing Home Administrator (NHA) and state abuse hotline as per facility policy. Resident 3, diagnosed with cerebral palsy and unspecified intellectual disabilities, was also a victim of abuse when two staff members observed another staff member dragging the resident across the floor. The observing staff members did not report the incident to the NHA and state abuse hotline according to policy. Interviews with staff revealed a lack of awareness regarding the time frames for reporting abuse and the absence of a specific policy related to QAPI and abuse allegations. The facility's training and policies did not adequately address these requirements, contributing to the deficiency.
Violation of Resident Privacy Due to Unauthorized Photography
Penalty
Summary
The facility failed to protect the personal privacy of four residents, as a staff member, identified as Staff C, a Nursing Assistant, recorded images of these residents on their personal cell phone without obtaining consent from the residents or their designated representatives. These images were then sent via text messages to an individual outside the facility. This breach of privacy was discovered through an anonymous report, which led to an investigation by the facility. The investigation revealed that Staff C had taken 14 photographs of the residents between August and December 2023, during the night shift in the living and dining areas. The residents were clothed and either sitting or lying down in these areas. The facility's policy explicitly prohibits the use of personal electronic devices to photograph or record residents, and sharing such information via text message or social media is also forbidden. Despite these policies, Staff C reportedly acknowledged knowing that sending these photos was against confidentiality rules. The residents involved had various diagnoses, including intellectual disabilities, autistic disorder, and impulse control disorders, with some requiring extensive assistance or supervision for their activities of daily living. The facility's investigator concluded that it was more likely than not that Staff C violated the residents' right to privacy by taking and sharing these photographs. Interviews with facility administrators confirmed awareness of the violation of resident rights.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure medications were properly stored and labeled, as observed during a medication pass. Specifically, five pre-poured medications were found in a single locked drawer of the medication cart, with three cups containing unlabeled crushed medications and a thick, clear liquid, and two cups containing multiple-colored crushed medications mixed with chocolate pudding. Staff AA, an LPN being trained by Staff M, admitted that the medications belonged to five residents and acknowledged that pre-pouring medications was not their normal practice. This was confirmed by Staff M, who stated that pre-pouring medications was not the standard procedure. The Director of Nursing Services, Staff B, confirmed that Staff AA did not follow the correct process and emphasized that medications should be prepared and distributed one resident at a time. The residents involved had various diagnoses, including epilepsy, intellectual disability, cerebral palsy, and depression. The improper handling and labeling of medications placed these residents at risk of receiving incorrect medication and potential adverse side effects.
Expired Food and Incomplete Temperature Logs in Cottages
Penalty
Summary
The facility failed to ensure that the refrigerators and cupboards in Cottages 401, 402, and 403 were free of expired foods and that refrigerator temperatures were logged appropriately. During an initial tour observation, expired food items were found in the refrigerator/freezer of Cottage 403, including frozen waffle molds, pear molds, roast beef molds, and corn molds, all of which were expired. Additionally, there was an uncovered and undated bowl of peaches and a cup of undated white thick liquid. The cupboard above the sink contained five cans of chicken noodle soup that were expired. Similar issues were observed in Cottages 401 and 402, where undated and expired food items were found in the unit freezers and refrigerators. Furthermore, the temperature logs for the refrigerator/freezer in Cottage 402 were incomplete, with several dates missing and no deep cleaning documented for the month of observation. Interviews with staff revealed that the responsibility for checking and disposing of expired foods fell on the Nursing Assistants (NAs). Staff Y, a Registered Nurse, confirmed that NAs were supposed to check food dates daily and discard expired items. Staff V and Staff W, both NAs, admitted to overlooking the expired foods. Staff Z, the Dietary Manager, reiterated that it was the NAs' duty to check, clean, and dispose of expired foods from the refrigerator/freezer. This lack of adherence to food safety protocols placed residents at risk of consuming expired food, potentially decreasing their quality of life and causing harm.
Failure to Maintain Resident Dignity During GT Care
Penalty
Summary
The facility failed to provide care in a manner that maintained a resident's dignity for one of the two sampled residents reviewed for gastrostomy tube (GT) care. Resident 12, who was admitted to the facility with a diagnosis that included a GT and developmental delay, was observed sitting in a wheelchair in the common area. A Licensed Practical Nurse (LPN) was seen lifting Resident 12's shirt, exposing the resident's stomach, and disconnecting the tube feeding port from the gastrostomy port in front of other residents and staff. This action was contrary to the facility's protocol, as confirmed by another LPN, who stated that such procedures should be performed in a private area to maintain the resident's dignity and privacy.
Failure to Provide Quarterly Personal Fund Statements
Penalty
Summary
The facility failed to ensure quarterly personal fund statements were provided to residents and/or their resident representatives for two of nine sampled residents. Resident 43, who has intellectual disabilities and epilepsy, had severely impaired cognition and required assistance for activities of daily living (ADLs). The resident's representative reported receiving only three statements since the resident's admission, with the last statement dated 10/12/2023. Resident 47, who has learning disabilities and also had severely impaired cognition requiring extensive assistance for ADLs, had no statements sent to their representative as of 04/26/2024. During interviews, the resident representatives confirmed the lack of regular statements, and the facility's quarterly statement logbook corroborated these claims. The facility administrator admitted to being behind on mailing the quarterly statements, which is a violation of the facility's policy and Washington Administrative Code (WAC) 388-97-0340(3)(a)(b)(c). This failure placed residents at risk of not having an accurate accounting of their personal funds held in trust by the facility.
Failure to Review and Validate PASARR Assessments
Penalty
Summary
The facility failed to review and validate the Preadmission Screening and Resident Reviews (PASARR) for two residents, leading to inaccuracies in their assessments. Resident 47 was admitted with diagnoses including anxiety disorder and ADHD, but the PASARR incorrectly marked all diagnoses as 'no' under the SMI/ID section. Similarly, Resident 50, who was admitted with diagnoses including insomnia and PTSD, had their PASARR incorrectly marked as 'no' for all diagnoses, including PTSD. Both residents had severely impaired cognition and required extensive assistance with activities of daily living. Interviews with staff revealed a lack of proper procedures and training regarding the review and updating of PASARRs. Staff CC, the Resident Care Coordinator, stated that they only noted the date of PASARR completion in the resident's care plan, while Staff BB, the Institutional Counselor, admitted to not reviewing PASARRs for accuracy or updating them when diagnoses changed. The facility administrator expected the RCC to review PASARRs for accuracy and coordinate corrections with the PASARR coordinator or social services, but this was not being done. This failure placed the residents at risk for not receiving appropriate care and services for their needs.
Failure to Monitor and Implement Interventions for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were free of unnecessary psychotropic medications, specifically for one resident who was not monitored for individualized targeted behaviors while receiving such medications. Resident 39, who has diagnoses including cerebral palsy, seizures, developmental disorders of speech and language, and violent behavior, was admitted to the facility and had a severely impaired cognition. Despite these conditions, the facility did not have a behavior plan or interventions in place for staff to follow if the resident exhibited behaviors. This lack of a behavior plan was confirmed during interviews with staff members, including a Psychology Associate and the Resident Care Coordinator, who acknowledged that the resident should have had a behavior plan and that the care plan was initially formulated for short-term care but had not been updated for long-term care needs. Additionally, the Director of Nursing Services stated that they would expect non-pharmacological interventions to be included in the resident's care plan. The review of the resident's behavior monitor sheets from February through the date of the report showed no documented behaviors or interventions for staff to follow. This oversight placed the resident at an increased risk for experiencing medication-related adverse side effects and unnecessary medications, as there were no documented strategies to manage the resident's behaviors without relying on psychotropic medications.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control practices for Resident 39, who was under COVID-19 isolation. Staff were observed wearing surgical masks instead of the required N95 respirators, gowns, goggles, and gloves, despite an inconclusive rapid COVID-19 test and pending lab results. The resident's room had an isolation cart and an aerosol sign indicating the need for higher-level PPE, but staff did not adhere to these precautions. Additionally, Resident 39 was seen walking into the common area without a mask, and staff did not redirect the resident back to their room to maintain isolation precautions. In the dining room, staff failed to perform hand hygiene and use gloves while handling food. Staff R, a Speech Language Pathologist, and Staff S, a Nursing Assistant, were observed serving food to residents without performing hand hygiene or wearing gloves. This was in direct violation of the facility's hand hygiene policy, which mandates hand hygiene before and after caring for a resident, performing invasive procedures, and handling food. Furthermore, Staff P, an LPN, was observed exiting an aerosol precautions room wearing only gloves and then entering another resident's room without removing the gloves or performing hand hygiene. Staff P also accessed Resident 12's gastrostomy tube port in the dining room while wearing only gloves, without the required gown and face protection. This was contrary to the enhanced barrier precautions that mandate the use of gown, gloves, and eye protection when accessing an indwelling medical device such as a gastrostomy tube.
Expired CPR Certifications Among Staff
Penalty
Summary
The facility failed to ensure that licensed staff responsible for providing basic life support in an emergency had current training and certification in Cardiopulmonary Resuscitation (CPR). Specifically, three out of four staff members reviewed (Staff E, F, and G) had expired CPR certifications. This deficiency was identified through a review of facility staff personnel files, which showed that Staff E's CPR certification expired on a specific date, Staff F's CPR certification expired on another specific date, and Staff G's CPR certification expired on yet another specific date. Interviews with the staff revealed that they were either unaware of their expired certifications or misunderstood the renewal timeline. During an interview, Staff G stated they were not aware their CPR certification had expired. Staff E mentioned they did not think they needed CPR training again until a later date. The Director of Nursing Services, Staff B, admitted that they were unable to schedule CPR classes during the COVID-19 pandemic and had not rescheduled them since the pandemic ended. Staff B also stated that they would have expected all nursing staff to be current on their CPR certifications. This failure to maintain up-to-date CPR certifications put residents at risk for delayed or incorrect life-saving treatment.
Failure to Provide Appropriate Diet Texture
Penalty
Summary
The facility failed to ensure that residents were served the appropriate diet texture, leading to choking hazards for two residents. Resident 1, diagnosed with Angelman syndrome and dysphagia, was given an incorrect diet texture for lunch, resulting in choking and requiring the Heimlich Maneuver. Staff I and Staff E, both Nursing Assistants, were involved in the incident. Staff E admitted to modifying the diet texture themselves instead of calling the kitchen for a new tray, as they were not trained to do so. This failure to follow proper procedures led to Resident 1 choking and needing emergency intervention. Resident 3, diagnosed with cerebral palsy and requiring thin liquids, was observed being given chocolate milk thickened to a honey consistency by Staff H, a Nursing Assistant. Staff H stated they were told they could serve the milk in this manner, despite it not being the correct diet texture. Interviews with the Food Service Manager and the Director of Nursing Services confirmed that it was not within the Nursing Assistants' scope of practice to alter diet textures or add thickening agents. The correct process of calling the kitchen for a new tray was not followed in both cases.
Latest citations in Washington
A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
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