Yakima Valley School

Penalty

No penalty information released

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 ensure that a resident who had expressed a desire to work and had previously worked with facility staff was given the choice to perform voluntary services at the facility. Resident 44 was admitted with diagnoses including Autistic Disorder, ADHD, and Intermittent Explosive Disorder. The resident’s 03/04/2026 comprehensive assessment showed the resident was cognitively intact and able to make needs known, and the record also showed the resident became an adult and their own responsible decision maker in January 2026. The record and interviews showed Resident 44 had a history of mowing lawns and doing yard work with staff in 2025 and had continued interest in those activities. During observation and interview, the resident stated they liked mowing lawns, had done so the prior year, wanted to keep working, and did not understand why they were no longer allowed to continue. The care plan identified preferred activities including video games, watching TV, building/fixing things, yard work, and lawnmowers, and stated the resident was to actively participate in gardening and yard activities. Recreation records showed the resident participated in lawn mowing with staff in September 2025 and enjoyed the activity. Staff interviews showed that a volunteer work safety agreement was developed and signed on 03/27/2026 by Resident 44, Staff V, and Staff W for outdoor lawn care, landscaping, and related tasks. Staff V stated the resident had completed the requirements and that the plan was to work with MOD staff, but MOD later stopped the arrangement because of safety and liability concerns. Staff W and Staff Y stated they were concerned about the use of a gas-powered lawnmower and who would be liable if the resident were injured. Staff B stated the resident had the right to perform voluntary work and that it had already been implemented in the care plan, while Staff A stated the facility did not provide the resident the work services that had been chosen and planned, and said, "We failed (Resident 44) in that situation."

Penalty

No penalty information released

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 ensure residents were given the opportunity to formulate advance directives and failed to notify a resident of the right to formulate an advance directive when the resident was able to make decisions about their own rights. The deficiency involved Resident 44, who was admitted with diagnoses including Autistic Disorder, ADHD, intermittent explosive disorder, and a problem related to education and literacy. The resident’s 03/04/2026 comprehensive assessment showed the resident was cognitively intact and able to make needs known, and the record also showed the resident became their own responsible person/decision maker in January 2026 with no advance directives noted. Record review showed a social service questionnaire dated 03/05/2026 in which the resident’s representatives completed the advance directive questions and selected “No” to all advance directives. During interviews, staff stated Resident 44 was cognitively intact, able to make their own decisions, and their own responsible party since becoming an adult. Resident 44 stated staff had begun approaching them for decisions about choices and plan of care, that they no longer had a guardian, and that they were unaware of what an advance directive was. The resident also stated no staff had asked whether they wanted to complete a POLST form or other advance directives. Staff from Social Services stated their process was to send the advance directive questionnaire annually and include it in admission documents, but they sent and reviewed the questionnaire with resident representatives/guardians rather than with the resident. Staff stated they did not send, review, or educate Resident 44 on advance directives and had sent the questionnaire to the resident’s previous guardian. Staff K stated the POLST form was reviewed quarterly with resident representatives/guardians and had not been reviewed with Resident 44, despite acknowledging the resident was cognitively intact and had the right to formulate an advance directive. Staff B stated the correct process was not followed when Resident 44 became an adult and could make their own decisions.

Penalty

No penalty information released

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 protect a resident’s right to be free from physical abuse for 1 of 3 residents reviewed for abuse and neglect. The resident had severe intellectual disabilities, osteoarthritis, obsessive compulsive disorder, limited verbal communication, required assistance with most ADLs, used a wheelchair for outside activities, and had visual impairment in both eyes. The resident’s care plan described behaviors including screaming, yelling, biting, scratching, physical aggression, dropping to the floor, and attempts to bite or scratch others, and directed staff to use calm, soothing approaches and therapeutic behavior supports. On the day of the incident, a contracted community service worker visited the resident while the resident was seated at a table. The resident reached to hold the worker’s wrist/hand and walked with the worker without struggle or outburst. Staff F immediately and forcefully removed the resident’s hand from the worker’s wrist/hand and placed hands on the resident’s shoulder and waist to move the resident back toward the chair while the resident screamed and resisted. Staff L reported that Staff M assisted and that the resident was forced into the chair and sat down hard. Multiple interviews described the same event with similar details. Staff L stated the resident was not acting aggressively toward the worker and that the resident’s hand-holding was not unusual. Staff G and Staff M described the resident arching their back, resisting, yelling, and being turned or directed back to the chair, with the resident falling or being let down hard into the chair. Staff F stated they did not consider abruptly removing the resident’s hand from the worker’s wrist/hand and forcibly redirecting the resident while the resident was yelling and resisting to be abuse or mistreatment. Staff B was unaware of the incident until law enforcement called, and Staff C stated they had heard about the incident but did not chart anything.

Penalty

No penalty information released

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 implement its abuse policy regarding identifying, reporting, and investigating a potential allegation of abuse involving one resident. The resident had been in the facility since 10/01/1996 and had severe intellectual disabilities, visual impairment, and multiple mental health behavioral issues. The resident was unable to communicate verbally but could state some words, required assistance with most ADLs, and had a behavior care plan addressing screaming, yelling, biting, scratching, physical aggression, and dropping to the floor. On 04/22/2026, a community service contract provider reported an incident involving the resident and facility staff. Staff L stated that Staff F abruptly and forcibly removed the resident from holding Staff L's hand, placed hands on the resident to redirect them toward a chair, and pulled the resident's collar while the resident was arching their back, yelling, and resisting. Staff L reported that the resident was forced into the chair and sat down hard. During interviews, Staff G and Staff M described seeing Staff F and Staff M assist the resident back to the chair while the resident resisted, arched their back, and yelled, and Staff F stated they peeled the resident's fingers from Staff L's wrist and forced the resident back to the chair because they thought the resident might hurt Staff L. The facility did not recognize the event as potential abuse or mistreatment, did not timely report the allegation internally as abuse, and did not conduct a timely and thorough investigation. Staff L stated they had not received orientation on reporting abuse and did not know the superintendent. Staff G did not report what they observed and was unaware of potential mistreatment. Staff M was not removed from resident contact until the investigation was finalized and continued working with residents through 04/30/2026. Staff A stated the facility did not orient contracted agencies on mandated reporting, was unaware Staff M was involved, and failed to remove Staff M from resident contact pending investigation. The report cited WAC 388-97-0640(2).

Penalty

No penalty information released

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 consistently document the condition of a pressure injury for one resident and failed to open a care plan with specific interventions for the wound. The resident had cerebral palsy, quadriplegia, diabetes mellitus, anxiety disorder, moderate impaired cognition, a suprapubic catheter, a colostomy, and was dependent on staff for bed mobility and transfers. The resident was identified as being at risk for pressure injuries, and later stated they had a small open area on their bottom while lying in bed on an alternating air mattress. Record review showed the resident’s skin breakdown began as bleeding and macerated tissue between the right buttock and thigh, then continued as an open area on the right lower buttock and right lateral upper thigh. Nursing notes repeatedly described the wound as open, raw, or improving, but did not include measurements, depth, or stage for multiple entries. The first documented measurement was 17 days after the wound was first noted, and the wound was not staged until the wound provider’s initial evaluation identified it as a stage 3 pressure injury. A later nursing note documented a small amount of light green drainage, and the provider documented a non-healing pressure sore with a foul-smelling dressing and a pale wound bed. The resident’s care plan dated 02/18/2026 included general risk for impaired skin integrity, but it did not include the resident’s pressure injuries or interventions for them. A temporary problem was opened for bleeding skin on the right backside, but staff interviews showed the wound should have had an acute care plan and wound assessment opened when it was first identified. Staff also stated they were not aware the resident had a stage 3 pressure injury, and the DON stated that when the wound first opened there should have been an incident report, a wound assessment opened, and a care plan opened with interventions.

Penalty

No penalty information released

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 maintain an infection prevention and control program for its Legionella Water Management Program (WMP). The March 2026 WMP identified control measures for the facility’s seven cottage sets and main building, including chlorine testing, water heater temperatures, and restrictions on decorative fountains, but it did not specify how the control measures for the four occupied cottages and main building were to be monitored, the frequency of monitoring, acceptable ranges, or what actions would be taken when control measures were outside acceptable ranges. The facility policy titled Legionella Water Management Program, revised March 2026, stated the WMP would include specific control measures, acceptable ranges, a system to monitor control limits and effectiveness, and a plan for when control measures were not being met or were not effective. During interview, the Maintenance Supervisor stated the facility was monitoring chlorine and pH for all cottages and the main building, but did not have acceptable ranges or parameters and was only writing down the levels. The supervisor also stated they were unsure what actions would be needed if the control measures were outside acceptable ranges. During observation, the chlorine level tested from a sink in the main building lower basement office was 0.11 milligrams per milliliter, and the supervisor was unsure whether that level was within acceptable range. The Infection Preventionist and Superintendent also stated the WMP lacked specifics on monitoring frequency, acceptable ranges, and actions to take when control measures were not within acceptable parameters. The facility also failed to ensure staff used an EPA-registered disinfectant for cleaning and disinfecting environmental surfaces and resident rooms. The cleaning and disinfecting policy stated environmental surfaces in resident cottages, including walls and floors, would be properly cleaned and disinfected with an EPA-registered disinfectant, and manufacturer instructions would be followed. During observation, custodial staff reported using Waxie 330 odor controller/degreaser on resident room surfaces, Waxie 210 neutral floor cleaner on floors throughout the facility, and Waxie 730 hydrogen peroxide disinfectant for some kitchen, dining, family, and high-touch surfaces. Record review showed Waxie 330 was not a registered disinfectant and Waxie 210 was a daily floor cleaner, not a registered disinfectant. Staff also stated Waxie 210 was used on all floors, including in a resident TBP room, and the Infection Preventionist stated the facility process was to use Waxie 730 to disinfect resident rooms, floors, and high-touch surfaces, while Waxie 210 was not the correct process for resident room disinfection.

Penalty

No penalty information released

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 ensure nurse staffing information was posted daily at the beginning of each shift in prominent locations readily accessible to residents and visitors for 4 of 4 units reviewed (203/4, 401/2, 403/4, and 405/6). The staffing data was observed posted on the second floor of the Main Building across from the DNS office on 04/27/2026, 04/28/2026, 04/29/2026, 04/30/2026, and 05/01/2026, but no staff posting was observed on the six living units where residents and visitors would have access during those dates. During interview and observation, the DNS stated the staff posting was updated at the beginning of each shift and posted outside the office. A sign outside the DNS office stated that Yakima Valley School maintains a current, daily posting in a uniform manner in a clearly visible place on 2 North outside the DNS office, and the DNS stated these signs were posted on the units to inform visitors where to find the staff information. On 04/29/2026, no sign was posted on unit 203/4 directing visitors and families to the staffing information, and an RN stated they had not seen any such signs on the units for a long time. The Superintendent/NH Administrator later stated the staff data postings were only on the second floor of the Main Building, which was locked on nights and weekends, and they were not aware the signs directing visitors and families where to find the staff posting were no longer on the living units.

Penalty

No penalty information released

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 ensure consistent one-to-one supervision for two residents who were both assigned level 4 supervision. Resident 2 had diagnoses including autistic disorder, conduct disorder, aphasia, and seizure disorder, and a comprehensive assessment showed severe cognitive impairment with behaviors toward self and others that placed the resident at significant risk for physical injury. The care plan required level 4 staffing, which was defined in the facility policy as one-to-one supervision with positioning to prevent danger or harm to self or others. Resident 2 was found with a two-centimeter laceration on the top of the head, and the facility could not determine how or where the injury occurred. The resident had one-to-one staff assigned 24 hours a day, seven days a week, yet the investigation found that none of the staff assigned to the resident or in the immediate vicinity saw or heard anything that could have caused the injury. Staff interviews and records showed no falls, no destructive or aggressive behaviors, and the injury remained classified as of unknown origin. The administrator stated the laceration should not have occurred for a resident with one-to-one staff assigned. Resident 1 had diagnoses including profound intellectual disability and anxiety disorder, required extensive staff assistance with mobility and toileting, and the care plan stated the resident could sit on the toilet, should be toileted every two hours, and should not be left unattended. During observation, the resident was on the toilet with the door closed and no staff standing by for five minutes, while staff were elsewhere in the cottage. Staff later stated they should stay with or stand outside the door because the resident could try to get up on their own and could fall or come out of the bathroom undressed. A staff member acknowledged not implementing the required supervision during that toileting episode, and a collateral contact reported seeing the resident left on the toilet with no staff nearby for at least 30 minutes on another occasion.

Penalty

No penalty information released

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 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.

Penalty

No penalty information released

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

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.

Penalty

No penalty information released

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 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.

Penalty

No penalty information released

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 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.

Penalty

No penalty information released

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 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.

Penalty

No penalty information released

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 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.

Penalty

No penalty information released

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 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.

Penalty

No penalty information released

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 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.

Penalty

No penalty information released

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 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.

Penalty

No penalty information released

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 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.

Penalty

No penalty information released

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

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.

Penalty

No penalty information released

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 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.

Penalty

No penalty information released

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 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.

Penalty

No penalty information released

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 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.

Penalty

No penalty information released

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 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.

Penalty

No penalty information released

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 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.

Penalty

No penalty information released

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 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.

Penalty

No penalty information released

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 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.

Penalty

No penalty information released

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 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.

Penalty

No penalty information released

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 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.

Penalty

No penalty information released

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 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.

Penalty

No penalty information released

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 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.

Penalty

No penalty information released

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 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.

Penalty

No penalty information released

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 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.

Penalty

No penalty information released

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 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.

Penalty

No penalty information released

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 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.