Every finding on record at Yakima Valley School

Based on interview and record review, the facility failed to implement their abuse policy regarding identifying, reporting, and investigating potential allegations of abuse for 1of 1 sampled residents (Resident 38), reviewed for abuse. This failure to recognize abuse, to timely report allegations of potential abuse, and to conduct timely and thorough investigations based all residents in the facility at risk for abuse. Findings included. Review of the 07/2024 policy 15.3, Protection from Abuse: Mandatory Reporting, showed when identifying abuse or a reasonable cause of good faith intent of the circumstances presented to report to Residential Care Services for adults to the Complaint Resolution Unit (CRU) as mandated for incidents of abuse and supervisor/ administration of the facility that provides services to these residents/clients involved. The scope of the policy 15.3 showed that the policy was to be given to all contractors, volunteers, employees, interns, residential service providers on the requirements of mandatory reporting requirements.Review of the 12/2024 number 2.02 Standard Operating Procedures titled, Resident Incident Management, purpose was to ensure that the resident's incident report for the first phase of the investigation for Abuse resident/client mistreatment due to staff action was identified, protection of the resident/clients ensuring everyone is safe.Resident 38 Review of the medical record showed that the resident had been in the facility since 10/01/1996 with diagnoses which included severe intellectual disabilities (condition that involves limitations on intelligence, learning and everyday abilities to live independently), visual impairment and multiple mental health behavioral issues. The 03/11/2026 quarterly nursing assessment showed the resident was unable to communicate verbally but can state some words. Resident 38 required assistance with most Activities of Daily Living (ADL). The resident can get in and out of bed, transfer to and from a chair and walk short distances.Review of the 06/11/2026 behavior care plan showed behaviors due to intellectual disabilities interventions included were to redirect Resident 38 from approaching other residents and stay between Resident 38 and other residents if they are having behaviors. A list of familiar target behaviors exhibited include screaming and yelling, biting and scratching, physical aggression and dropping to the floor.Review of the 04/24/2026 incident report showed an allegation of abuse was called to a state agency and local law enforcement on 04/22/2026 by a community service contract provider of the facility. Staff L, Collateral Contact 1 (CC1), had contacted their supervisors about an incident with Resident 38 at the facility where Staff F Attendant Counselor/Nursing Assistant-certified (AC), and another Staff M, AC had abruptly and forcibly removed Resident 38 from holding Staff L's hand while walking to a window in the main activity/dining room. Staff L stated Staff F then placed their hands on Resident 38 forcibly redirecting the resident towards the resident's chair. Staff M then came on the left side of Resident 38 to hold the resident who was starting to fall and assist Staff F. Resident 38 was then resisting the move and yelling. Staff L stated Staff F had Resident 38's collar and pulled it while Resident 38 was arching their back and forcibly let Resident 38 fall hard into their chair.During an interview on 04/27/2026 at 3:34 PM, Staff L confirmed the incident and stated that Resident 38 had grabbed their hand to walk in the past and did not find it an aggressive act. Staff L stated Resident 38 was calm walking with them towards the window. Staff L stated that Staff F was aggressive and forced Resident 38 towards their chair and put hands on the resident to direct the resident to their chair. The resident was yelling and arching their back and almost fell until another Staff assisted Staff F into the chair where Resident 38 sat hard onto the chair. Staff L did not know the name of Staff M at the time of the complaint. Staff L later reported the incident to their supervisors who called the state agency and law enforcement. During the conversation the surveyor asked if Staff L had any orientation by the facility concerning reporting abuse and they stated no they had not. Staff L was unaware of the administration or the name of the Superintendent of the facility.During an interview on 04/27/2026 at 11:30 AM, Staff G, AC, who worked with Resident 38 on 04/22/2026 stated they did not witness the initial contact with Staff L and Staff F with the resident but did witness Staff F and Staff M turn Resident 38 while Resident 38 was resisting them by arching their back and yelling. Staff F let Resident 38 fall onto the chair with a loud thump. Staff G stated that Resident would hold their wrist and hand at times. Staff G did not report the incident they observed and was not aware of the potential mistreatment of Resident 38.During an interview on 04/27/2026 at 11:45 AM, Staff M stated they saw Staff F directing Resident 38 back to the chair by placing hands on the resident's shoulder and hip. Resident 38 was resisting and arching their back while yelling. Staff M stated Resident 38 fell towards their left side and they went to assist Staff and the resident so they would not fall. Staff M stated they directed Resident 38 to the chair and the resident sat down hard due to resisting by arching their back. Staff M stated that they did not think it was abuse.During an interview on 04/28/2026 at 3:00 PM, Staff F stated that on 04/22/2026 at 9:30 AM, along with Staff B, Director of Nursing Services (DNS), Staff F showed how they handled Resident 38's grabbing Staff L's wrist/hand and peeled Resident 38's fingers from the wrist of Staff L's wrist. Staff F stated they thought Resident 38 would hurt Staff L. Staff F then added that another resident was seated in their chair against the wall of where Resident 38 and Staff L were walking nearby and was afraid of a resident outburst since the two residents do not like each other. Staff F showed how they placed their hands on Resident 38's shoulder and waist forcing Resident 38 back to their chair. Staff F stated Staff M had to assist them back to their chair and Resident 38 sat hard onto the chair. Staff B also did suspend Staff F to the main building away from resident contact but failed to identify Staff M who was part of the potential mistreatment of Resident 38. Staff M continued to work from 04/22/2026 through 04/30/2026 and were not removed from working with residents until the investigation was finalized.During an interview on 04/30/2026 at 4:21 PM, Staff A, Superintendent, stated that they did not orient contracted agencies on mandated reporting of abuse and was unaware Staff M was involved in the incident with Resident 38 and failed to remove them from resident contact pending investigation. Additionally, staff did not consider the 04/22/2026 Resident 38 incident as potential abuse/mistreatment and failed to document Resident 38's behavior responds and report the incident.Reference: WAC 388-97-0640(2)

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program that ensured, A) the Legionella (a waterborne bacteria that can cause a severe respiratory disease) Water Management Program (WMP) identification and monitoring of control measures within acceptable ranges and what ways to intervene when control measures were not met for 1 of 1 WMP, reviewed for infection control and B) the facility staff implemented the cleaning/disinfecting of the general environmental surfaces and resident rooms with an Environmental Protection Agency (EPA) registered disinfectant 3 of 4 staff (Staff AA, CC, BB), reviewed for environmental cleaning/disinfection. This failure increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases.Findings included .Review of the facility's WMP, dated March 2026, showed where control measures should be applied and required to be monitored for the facility's seven sets of cottages (a small house that a limited number of residents reside within) and main building. The WMP showed that examples of chemical and physical control measures were testing chlorine levels, maintaining water heaters at regulated temperatures, and decorative fountains were not allowed. The WMP showed control measures parameters (limits or acceptable ranges) would be ensured through monitoring and action taken when outside parameters. The WMP showed the water management team had chosen to monitor control measures by flushing the three unoccupied cottages every Wednesday and in the event that systems performed outside of control limits, action would be taken. The WMP did not show how the other set of four resident occupied cottages/main buildings control measures were to be monitored, when they were monitored, the frequency of monitoring, acceptable ranges of the implemented control measures, nor the actions that would be taken when control measures were not with acceptable ranges for any of the cottages/main building. Review of the facility's policy titled, Legionella Water Management Program, revised March 2026 showed the WMP would include Specific control measures used to control the introduction and/or spread of Legionella. Acceptable ranges for each control point that were being monitored and a system to monitor control limits and ethe effectiveness of the control measures. A plan for when identified control measures were not being met (outside of acceptable ranges) or not effective.Additionally, the policy showed the WMP team included the Infection Preventionist (IP), Maintenance Supervisor and Superintendent. Review of the facility's policy titled, Cleaning and Disinfecting, revised January 2025, showed the cleaning and disinfecting of the living environments. The policy showed that environmental surfaces within resident cottage such as walls, floors and other surfaces would be properly cleaned/disinfected with an EPA registered disinfectant. Additionally, the manufacturer instructions were to be followed when using an EPA registered disinfectant.WMPDuring an interview on 04/29/2026 at 7:52 AM, Staff Z, Maintenance Supervisor, stated the WMP control measures they were monitoring/documenting for all the cottages/main building was chlorine (a chemical element) and potential for Hydrogen (pH, a specific scale measurement for water solutions). Staff Z stated they did not have acceptable ranges or parameters for the chlorine or pH levels, .just writing down the levels. Staff Z stated they were unsure of what actions/steps would be needed if the control measures were outside of the acceptable ranges.During a concurrent observation and follow-up interview on 04/29/2026 at 9:05 AM, showed Staff Z displaying the process for testing the chlorine levels. Staff Z tested the water from the main building lower basement office sink. The chlorine levels showed 0.11 milligrams (a unit of measure) per milliliter (a unit of measure). Staff Z was unsure if the chlorine level was within acceptable ranges or not.During an interview on 04/29/2026 at 10:26 AM, Staff EE, IP, after reviewed the facility's WMP document, stated they did not see specifics (like when being monitored or the frequency of monitoring) on control measure for the set of four resident occupied cottages/main building, .might being missing a paragraph. Staff DD stated they could not find acceptable ranges for control measures on the WMP or what actions would be taken if the control measures were not within acceptable parameters. Staff DD stated the identification/monitoring of the control measures, acceptable ranges, ways to intervene when control measures were not met should be on the WMP. Staff DD stated staff would need to know the control measure parameters so when they are outside of that it could be communicated and actions could be taken. Staff DD stated the WMP did not have the correct information and needed to be updated. During an interview on 04/29/2026 at 1:50 PM, Staff A, Superintendent, stated they would have expected the WMP to have the specific control measures, how they were to be monitored, the frequency of monitoring, acceptable ranges of the implemented control measures and the actions that would be taken when control measures were not with acceptable ranges. Environmental CleaningDuring a concurrent observation and interview on 04/29/2026 at 7:30 AM, showed Staff AA, Custodian, in the main building of the facility cleaning the general environment. Staff AA stated they cleaned the main building and would also be cleaning resident cottages 405 and 406. Staff AA stated they utilized three main chemicals to clean/disinfect environmental surface within the facility's cottages and buildings. Staff AA showed the surveyor the chemicals they used and noted a Waxie (a specific company) pink colored 330 odor controller/degreaser solution, a Waxie blue colored 730 Hydrogen Peroxide (HP, a chemical compound) disinfectant cleaner solution and a Waxie yellow colored 210 neutral floor cleaner solution within the custodial closet. Staff AA stated they used the 330 solution within resident rooms on all the surface areas, the 210 solution was used on all the resident room floors and throughout the facility, and the 730 solution was utilized for surfaces within the resident kitchen areas, dining areas and family areas of the cottages. Staff AA stated when using the 730 chemical they would spray the chemical on wipe of right away.Record review of Waxie Solutions Station production sheets, dated 2023, showed the Waxie 330 chemical solution was an odor controller/degreaser and not a registered disinfectant. The Waxie 730 HP chemical solution was an EPA registered disinfectant and required a contact time (a term used for the duration a disinfectant must remain visibly wet on a surface to effectively kill a specific bacteria or virus) that ranged from one minute to five minutes to kill viruses and ten minutes for bacteria. The Waxie 210 chemical solution was a daily floor cleaner and not a registered disinfectant.During an interview on 04/29/2026 at 8:36 AM, Staff CC, Custodian, stated they used the Waxie 210 chemical solution on all floors within the resident cottages and throughout the facility. Staff CC stated they did not change the 210 chemical solution used for the floors when cleaning/disinfection a resident Transmission Base Precautions (TBP, safeguards put in place for a resident with a known or suspected infectious disease to help prevent cross contamination) room.During a concurrent observation and follow-up interview on 04/29/2026 at 11:56 AM, showed Staff AA in cottage 406 wiping down handrails/doors outside of resident room with the Waxie 330 chemical solution. During an interview on 05/01/2026 at 7:22 AM, Staff BB, Custodian, stated they used the Waxie 210 chemical solution on all floors within the resident cottages and throughout the facility. Staff BB stated they utilized the Waxie 730 chemical solution for disinfecting high touch surface areas by spraying on the chemical on the surface and wipe it up right away.During an interview on 05/01/2026 at 7:47 AM, Staff EE, IP, stated the facility's process was to utilize the Waxie 730 HP chemical solution to disinfect all resident rooms, floors, surfaces and all the high touched surface areas throughout the facility. Staff EE stated that facility staff should be using the Waxie 730 HP chemical solution to disinfect all floor within resident cottages. Staff EE stated that using the Waxie 210 floor cleaner, which was not an EPA registered disinfectant, was not the correct process for environmental surface disinfection of the resident rooms. Reference: WAC 388-97-1320(1)(a)(2)(b)(5)(c)

Based on observation, interview, and record review, the facility failed to ensure nurses consistently documented the condition of a pressure injury (PI, localized damage to the skin as well as underlying soft tissue that occurs due to sustained pressure, often over bony areas) that included an initial wound assessment and periodic follow up assessments for 1 of 2 residents (Resident 15) reviewed for PI. In addition, the facility failed to open a plan of care that included specific interventions to promote healing of the PI. This failure placed Resident 15 at risk of delayed healing having unevaluated changes to their pressure injury to inform the provider for assessment and treatment orders. Findings included. Record review of the facility's policy titled, Pressure Sore-Decubitus Ulcer (PI) care and prevention dated 08/29/2025, showed the purpose of the policy was to prevent and treat further pressure injuries, the licensed nurse (LN) was responsible to document the condition of the wound including stage, size, site, depth, color, drainage, and odor as well as the treatment provided. A wound assessment in resident record would be completed by a LN when a pressure injury was first noted. The description of pressure injury stages included: - Stage 1: a persistent area of skin redness that does not disappear when pressure is relieved or does not turn white when pressure is applied, - Stage 2: a partial thickness of skin is lost may present as blistering surrounded by an area of redness, - Stage 3: a full thickness of skin is lost, exposing the subcutaneous (deepest skin layer contains fat cells) tissues, - Stage 4 a full thickness of skin and subcutaneous tissue is lost, exposing muscle and/or bone Resident 15 Review of Resident 15's medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include cerebral palsy (a group of conditions that affect movement and posture. It's caused by damage that occurs to the developing brain, most often before birth), quadriplegia (paralysis of all four limbs), diabetes mellites (DM, metabolic disorder in which the body has high sugar levels for prolonged periods of time) and anxiety disorder. Review of a 02/23/2026 comprehensive assessment showed Resident 15 had moderate impaired cognition, a suprapubic catheter (device that drains urine from the bladder through a tube inserted into the lower abdomen), a colostomy (an opening in the abdomen that connects the end of the large intestine to the skin where stool is passed) and was dependent on staff for their bed mobility and transfers. Resident 15 was at risk for PIs and none present at the time. During an interview and observation on 04/27/2026 at 3:20 PM, Resident 15 was observed lying on their bed with an alternating air mattress (a mattress that utilize air bladders that constantly inflate and deflate, which helps to reduce pressure on the skin and promote blood flow), stated they had a small open area on their bottom. During an observation on 04/28/2026 at 9:00 AM, Resident 15 had their pressure injury dressings changed by Collateral Contact 2 (CC 2 -contract wound provider) with the assistance of two Attendant Counselor (AC, Nursing Assistant-Certified) staff and Staff O, Licensed Practical Nurse (LPN). Staff O stated that Resident 15 did not have wounds on their buttocks when they were admitted to the facility. They stated that Resident 15's wound on their right buttock started a few months ago and the wound on the left buttock started about two to three weeks ago. Resident 15 often refused to lay down during the day and preferred to stay up in their wheelchair. The wounds were observed to be free of drainage and odor, the resident denied discomfort. Record review of the 02/18/2026 care plan, in the medical record, showed Resident 15 had potential/actual for impaired skin integrity related to DM Type 2, quadriplegic cerebral palsy, history of rashes, dermatitis due to bodily fluids, scar from chest to abdomen, scars on hands from pushing wheelchair through doors, extreme self-neglect. Resident 15's PIs with interventions were not included in the care plan. Record review of a 03/07/2026 24-hour shift report showed a temporary problem (TP, designated what and how often to chart) was opened for Resident 15's skin bleeding right backside between buttock and thigh. Record review of a 03/08/2026 at 3:28 AM progress note (PN) showed the resident had scar tissue between the right buttocks and thigh that appeared macerated (skin that has become soft, wrinkled, and weakened due to prolonged exposure to moisture) and was bleeding. Record review of a 03/12/2026 at 1:03 PM PN showed the open area to right lower buttock continued, no bleeding or signs of infection (no measurements or stage identified). Record review of a 03/16/2026 facility provider initial 30-day assessment showed no nurses report of the open wound on Resident 15's right buttock. Record review of a 03/18/2026 at 9:15 PM PN showed the right lower buttock crease was improving without signs of infection (no measurements or stage identified). Record review of a 03/20/2026 at 12:08 PM PN showed the open area to right lateral upper thigh continued without signs of infection but continued with raw skin. A new order was noted and processed, betadine (an antiseptic solution used to treat wounds) applied (no measurements or stage identified). Record review of a 03/22/2026 at 8:37 PM PN showed betadine was applied to right lower buttock upper thigh area, no drainage or signs of infection (no measurements or stage identified). Record review of a 03/24/2026 at 1:13 PM PN by Staff O showed the area to right lower buttock was approximately 6 centimeters (cm) by 4 cm, no drainage or signs of infection (first measurement 17 days after skin opened, no depth or stage identified). Record review of a 03/28/2026 at 9:24 PM PN by Staff C, LPN, showed open area remained on right lower buttock, no bleeding or signs of infection (no measurements or stage identified). Record review of a 03/31/2026 at 1:11 PM PN showed betadine was applied to right thigh open area, measured 6 cm by 4 cm, no signs of infection, a small amount of blood was noted. On calendar for 04/01/2026 for provider to reassess (review of provider calendar and medical record showed no note the provider reassessed Resident 15's PI on 04/01/2026). Record review of a 04/09/2026 at 1:12 PM PN showed the open area to right lower buttocks had a small amount of light green drainage on the dressing, the wound base was moist, no active drainage, no complaints of pain or discomfort (no measurements or stage identified). Record review of a 04/10/2026 facility provider 30 day assessment showed Staff reports [Resident 15] has a non-healing pressure sore (injury) to right ischial tuberosity (a rounded bump on the back part of the pelvis bone that supports body weight when sitting) The provider documented the wound bed was clean and the dressing had a foul smell, no redness, swelling, no slough (dead skin tissue that appears yellow or white and can cover parts or the entire wound bed), no granulation (specialized connective tissue that emerges during wound healing phase), and the wound bed was pale (34 days after wound first documented by nursing). Record review of a related nursing 04/10/2026 PN showed the provider planned to refer Resident 15 to wound care specialist. Record review of a 04/14/2026 at 12:59 PM PN by Staff O showed the open areas to right lower buttock had no signs of infection (no measurements or stage identified). Record review of a 04/17/2026 initial wound evaluation by CC 2 showed the wound to the right buttock measured 3 cm by 2 cm by 0.2 cm and was a stage 3 PI. The plan included the wound would be evaluated and treated every five days by CC 2 and the facility staff were instructed to reinforce the dressing as needed. Record review of a 04/20/2026 at 12:51 PM PN showed the dressing to the right buttock was in place and a new 2.5 cm by 1 cm open area noted on left buttock. Record review of a 04/22/2026 at 12:58 PM PN by Staff O showed the open wound to the left buttock was approximately 3 cm by 3 cm and they expected provider CC-2 to see the resident later that day. Record review of a 04/22/2026 wound report by CC 2 showed that the right buttock wound was 2.5 cm by 2.0 cm by 0.2 cm with 100% granulation, no odor and skin around the wound was dry. No description of the left buttock wound; however, directions were written to leave the dressings to the left and right buttock until next visit in five days. Record review of a 04/23/2026 at 1:21 PM PN by Staff O showed the dressing to the right lower buttock was intact, clean and dry. The dressing to the lower left buttock came off, was redressed and minimal amount of light green drainage was noted on the dressing. Record review of a 04/28/2026 dressing change and wound evaluation by CC 2 showed the right buttock wound bed measured 2.0 cm by 2.0 cm by 0.2 cm and had 100% granulation tissue. The left buttock wound bed measured 2.5 cm by 2.0 cm by 0.1 cm with 100% granulation. Both wounds were estimated to heal in three months. During an interview on 04/30/2026 at 11:00 AM, Staff K, Registered Nurse/Resident Care Coordinator (RN/RCC), stated that Resident 15 was admitted without pressure injuries and was a risk, so they had an alternating air mattress placed on their bed. Staff K stated that Resident 15 should have an acute care plan in their paper record that included interventions. New problems were usually added to the care plan during their quarterly review; however, the PIs probably should have been added to the care plan. During an interview and record review on 04/30/2026 at 12:00 PM, Staff Q, RN, opened Resident 15's paper chart under the care plan tab and stated that was where the acute care plans were written, and they could not find one for Resident 15's PI. During an interview on 04/30/2026 at 12:50 PM Staff R, RN, stated they were the day shift charge nurse, and they were not aware Resident 15 had a stage 3 PI. Staff R stated there should be a care plan in the medical record. They stated the unit nurses provided the residents treatments, and they rotated to a new unit every 30 days. During an interview on 05/01/2026 at 8:00 AM, Staff C stated that they rotated through Resident 15's unit last month and documented on the open wound on their buttocks. They stated that the wound was on the right buttocks and did not change much. They stated they did not measure the wound, probably should have, and was surprised there was not wound assessment opened and stated, the nurse who identified the wound should have opened an assessment. During an interview on 05/01/2026 at 9:48 AM, Staff B, Director of Nursing Services, stated that when Resident 15's wound first opened there should have been an incident report, a wound assessment opened and a care plan opened with interventions. Staff B stated Resident 15's wounds were the first facility acquired PIs that they ever had, the few PIs here were admitted with them. Reference: WAC 388-97-1060 (3)(b)

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse for 1 of 3 residents (Resident 38) reviewed for abuse/neglect. This failure placed the residents at risk of experiencing fear, intimidation, mental anguish, and emotional distress. Findings included . Resident 38 Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses which included severe intellectual disabilities (condition that involves limitations on intelligence, learning and everyday abilities to live independently), osteoarthritis (changes in bone shape and cartilage that causes inflammation which results in pain in joints, stiffness and loss of mobility), obsessive compulsive disorder (a pattern of unwanted thoughts and fears known as obsessions that lead to repetitive behaviors called compulsive acts that interfere with daily living). The 03/11/2026 quarterly nursing assessment showed the resident was unable to communicate verbally but can state some words. Resident 38 required assistance with most Activities of Daily Living (ADL). The resident can get in and out of bed and used a wheelchair for outside activities. Resident 38 is visually impaired with impairment of vision in their left eye and visual cloudiness in their right eye due to cataracts (cloudy area in the lens of the eye). The resident had a decline in vision which staff were to monitor for ability to participate in activities. Resident 38's care plan showed that they could state simple words like pop but was not able to write or participate in social conversations or voice opinions. The resident will yell at the presence of pain with screams and tears. During cares the staff were to communicate using soothing voices, use favorite music when stabilizing for nursing treatment of a part of their body, (example treatment of a skin tear).Review of the 06/11/2026 behavior care plan showed behaviors due to intellectual disabilities interventions included to redirect the resident if rummaging in other resident's rooms. Redirect Resident 38 from approaching other residents and stay between Resident 38 and other residents if they were experiencing behaviors. A list of familiar target behaviors exhibited include screaming and yelling, biting and scratching, physical aggression and dropping to the floor. Resident 38 would threaten to bite and have bitten staff in the past and would attempt to scratch another person. The direction was to not approach the Resident or try to redirect, stay back and give the resident some space and time to calm down and ensure the resident was safe. Additionally, Therapeutic Options techniques were to be followed by staff. Therapeutic positive behavior supported in knowing the individual and their way of responding to staff for their wants and needs.Review of a 04/22/2026 incident showed Resident 38 was visited by Staff L, Collateral Contact 1 (CC1), who was contracted with the facility to provide additional community service activities to the residents at the facility. On 04/22/2026 at 9:15 AM CC1 entered Cottage 403 to visit Resident 38 who had been seated in their chair at their table. Staff F Attendant Counselor (AC, a nursing assistant-certified), forcefully removed Resident 38's hand from Staff L's hand and forcefully made Resident 38 go back to their chair across the room. Staff F had placed their hands on Resident 38's shoulder and waist while the resident was screaming and resisting Staff F. Staff L stated in the investigation that another Staff M, AC, came to assist Staff F, and they forced Resident 38 onto the chair and Resident 38 sat down hard on the chair.During an interview on 04/27/2026 at 3:34 PM, Staff L stated on 04/22/2026 at 9:30 AM, Staff F came to the table where they were seated and stated that Staff L should be aware that Resident 38 had a bad morning and did not sit next to Resident 38. Staff L sat across the table from Resident 38 and brought out a large, pieced puzzle for the resident to put together. Resident 38 stood up from the table and was not interested in the puzzle. Staff L then stood up and Resident 38 reached to hold Staff L's wrist to walk with them without any struggle or outburst. Staff L had had many previous contacts with Resident 38 in the past and this was not an unusual action by the resident. Staff L stated Staff F immediately and forcefully grabbed Resident 38's hand and removed it from Staff L's wrist and forcefully placed their hands on Resident 38 shoulder and waist and had forced Resident 38 back towards the resident's chair. Resident 38 was screaming and resisting Staff F's forcing Resident 38 back to their chair. Staff L stated Resident 38 arched their back and tried to get away from Staff F and began to fall when Staff M came up on the left side of Resident 38 and forcefully held Resident 38's shirt collar along with Staff F to the resident's chair and forcefully plopped (a sound made like something falling or dropping) Resident 38 in their chair.During the same interview Staff L reported they then sat across from Resident 38 and brought out the puzzle for the resident which they played for a few seconds then became uninterested along with a magazine Staff L tried to interest Resident 38 with to divert Resident 38's anxiety. Staff L then played music on their cell phone for Resident 38. Resident 38 eventually left the table and Staff L left the building. Staff L met with their supervisors on 04/22/2026 at 12:15 PM, Staff L's supervisors reported the incident with Resident 38 to a state division and law enforcement. Staff L stated there was no report of Resident 38's incident to the facility staff or administration.During an interview on 04/27/2026 at 11:30 AM, Staff G, AC, who worked with Resident 38 on 04/22/2026 stated they did not witness the initial contact with Staff L and Staff F with the resident but did witness Staff F and Staff M turned Resident 38 while Resident 38 was resisting them by arching their back and yelling. Staff F let Resident 38 fall onto the chair with a loud thump. Staff G stated that the Resident would hold their wrist and hand at times. During an interview on 04/27/2026 at 11:45 AM, Staff M stated they saw Staff F directing Resident 38 back to the chair by placing hands on the resident's shoulder and hip. Resident 38 was resisting and arching their back while yelling. Staff M stated Resident 38 fell towards their left side and they went to assist Staff and the resident so they would not fall. Staff M stated they directed Resident 38 to the chair and the resident sat down hard due to resisting by arching their back.During an interview on 04/28/2026 at 3:00 PM, Staff F stated that on 04/22/2026 at 9:30 AM, Staff L had entered the facility Cottage 403 where Resident 38 lives and stated they wanted to take the resident out. Staff F stated Resident 38 had a bad morning and was taking their clothing off and putting other clothing on themselves. Since it was raining outside Staff L sat with Resident 38 and pulled out a puzzle. Staff F stated they instructed Staff L not to sit close to Resident 38. Staff F stated Resident 38 was not interested in the puzzle and stood up then Staff L stood up from across the resident's table and took Staff L's wrist/hand and started walking from the resident's table toward the window on the opposite side of the room. Staff F stated they immediately went towards Resident 38 and quickly removed the resident hand from Staff L's hand. Staff F immediately placed their right hand on resident 38's shoulder and Staff F placed their left hand on Resident 38's left hip and moved the resident toward the resident's chair. Staff F stated the resident was screaming and resisting them by arching their back. Staff M came to help Staff F when Resident 38 was leaning towards their left side and began to fall. Staff F stated they got Resident 38 to their chair and the resident fell into the chair. Additionally, Staff F stated they thought Resident 38 was going to injure Staff L and stated they were walking towards another resident who could have acted out because those two don't get along. Staff F stated they did not consider the act of abrupt removal of resident's hand from Staff L's wrist/hand when there was no danger, placing hands on and forcibly redirecting Resident 38 while they were yelling and resisting and act of abuse or mistreatment. Staff G and M did not report the incident to their supervisor.During an interview on 04/29/2026 at 11:00 AM, Staff DD, Therapeutic Options Supervisor, (instruction required for all staff a comprehensive approach to reducing violence and the use of restraints. The purpose of training is to be a source of healing, encouragement and safety). Staff DD stated that all staff at the facility were trained on hire and every two years on how to recognize and approach residents with behaviors and teaching intervention skills that are designed to prevent injury to staff and people receiving services. During the interview with Staff DD, they recommended looking at why the resident/client would grab a wrist or hand was usually not an attack but an attempt to communicate. Staff DD stated if there was no immediacy or danger and the other individual did not perceive it as a danger the act of abruptly removing a hand and forcibly redirecting a resident would trigger negative behaviors.During an interview on 04/30/2026 at 1:03 PM, Staff C, Licensed Practical Nurse (LPN), stated that they were on duty on 04/22/2026 and had heard something about the incident but did not chart anything.During an observation on 04/30/2026 at 1:15 PM, Staff H, AC, was standing by Resident 38 when the resident grabbed Staff H's arm and walked with Staff H to the window across the floor to the other side of the room. Resident 38 while holding Staff H's hand opened the window curtain looked out and closed the curtain. Staff H and Resident 38 calmly walked back to Resident 38's chair and the resident sat down.During an interview on 04/27/2026 at 3:00 PM, Staff B, Director of Nursing Services, was unaware of the 04/22/2026 incident with Resident 38 until law enforcement called them on 04/24/2026 and informed them of the incident.Reference: WAC 388-97-0640(1)

Based on interview and record review, the facility failed to ensure residents were given the opportunity to formulate advanced directives (AD, a legal document in which an individual person specifies what actions should be taken for their health care and/or finances in the event they were no longer are able to make decisions for themselves because of illness or incapacity) nor notify a resident of their right to formulate an AD when the resident was able to make the decision regarding their rights for 1 of 3 residents (Resident 44) reviewed for AD. This failure denied the resident the right to make an informed decision regarding formulation of an AD and placed residents at risk for losing the right to have their preferences and choices honored regarding emergent/end-of-life care.Findings included .Review of the facility's policy titled, Resident Rights, revised January 2025, showed the facility resident had the right .to participate in the development of the plan for services and medical treatment, including the right to formulate Advance Directives, and to approve or reject any parts .Review of the facility's policy titled, Resident Participation in Medical Treatment and Advance Directives, revised October 2025, showed the facility would provide written information to adult residents concerning their legal right to participate in decisions regarding their medical care, including the right to formulate AD. The policy showed the advanced directives would be honored only for a resident who was 18 years or older. The policy showed that if a resident was unable to make a decision regarding their care and treatment but later becomes able to, the facility would discuss AD at that time. Additionally, AD included Physician's Orders for Life Sustaining Treatment (POLST, a medical order form that summarized a resident's wishes regarding treatment) and a living will. Review of Resident 44's medical record showed they were admitted to the facility on [DATE] with diagnoses including Autistic Disorder (a condition related to the brains development which can affect and individuals' communication, social interaction and can cause behaviors), Attention-Deficit Hyperactivity Disorder (a developmental disorder characterized by inattention, hyperactivity, and impulsivity [to act on a whim without reflecting on consequences] that interferes with daily functioning) and intermittent explosive disorder (a mental health condition characterized by recurrent, sudden, uncontrollable outburst of aggression that are inappropriate and lack justification) and problem related to education and literacy (the ability to read, write and use information). The 03/04/2026 comprehensive assessment showed the resident was cognitively intact and able to make their needs known. Additionally, the medical records showed the resident became their own responsible person/decision maker in January 2026 and no AD were noted. Record review of a social service questionnaire showed that on 03/05/2026 Resident 44's representatives signed/completed the documents questions regarding AD choices and elected No to all ADs.During an interview on 04/28/2026 at 2:25 PM, Staff B, Director of Nursing Services (DNS), and Staff K, Registered Nurse/Resident Care Coordinator, stated Resident 44 was cognitively intact, able to make their own decisions and was their own responsibility party since they had become an adult.During an interview on 04/29/2026 at 11:36 AM, Resident 44 stated that facility staff had started approaching the resident for decisions regarding resident choices and plan of care now and they no longer had a guardian in place since they turned [AGE] years old. Resident 44 stated they were unaware of what an AD was and no staff had asked them if they had wanted to fill out a POLST form or formulate other AD. Resident 44 stated they would like some more information/education on ADs so they could decide on whether to formulate one or not.During an interview on 04/29/2026 2:53 PM, Staff I, Social Services, stated their process for offering AD was to send out an AD questionnaire document annually, the document was also in the admission documents, and Staff K, Resident Care Manager, offered to formulate AD during the quarterly care conferences. Staff I stated they send the AD questionnaire document to resident representatives/guardians and do not send/review the AD questionnaire document with the residents. Staff I stated that if someone wanted an AD, they would give the individual more AD information but did not provide assistance in completing AD. Staff I stated they did not send, review or educate on formulating AD with Resident 44 and sent out the AD questionnaire document to Resident 44 previous guardian. Staff I stated Resident 44 was cognitively intact, was their own responsible person and able to make their own decisions.During an interview on 04/29/2026 at 3:20 PM, Staff K stated they were charged with reviewing the POLST form quarterly, with the resident representatives/guardians, during the care conference. Staff K stated Staff I went over all the other AD forms. Staff K stated that Resident 44 was cognitively intact, was their own responsible person and able to make their own decisions but had not reviewed the POLST form with Resident 44. Staff K stated that Resident 44 had the right to formulate an AD, facility staff should be educating/offering on AD to the resident, and assisting the resident in the process if they were to choose to formulate an AD.During an interview on 04/30/2026 at 10:32 AM, Staff B stated that facility staff should be offering to assist in formulating AD with Resident 44. Staff B stated when Resident 44 became an adult they could make their own decisions and AD should have been reviewed at that time. Staff B stated the correct process was not followed for providing Resident 44 with the opportunity to make a choice on formulating AD documents or notifying the resident of their right to formulate an AD when the resident became able to make the decision regarding their rights.Reference: WAC 388-97-0280(1)(3)(c)(d)

Based on observation, interview and record review, the facility failed to ensure a resident who had expressed the need/desire to work, had previously worked and agreed to the work arrangements, was given the choice to perform voluntary services at the facility for 1 of 2 residents (Resident 44) reviewed for resident rights. This failure placed the resident at risk of confusion/frustration with facility staff and an increased risk of behaviors regarding their choice/arrangement to work.Finding included .Review of the facility's policy titled, Resident Rights, revised January 2025, showed the facility resident had the right to participate in the development of their plan of care and they would be .permitted successive degrees of freedom of movement and opportunities/responsibility for self-management and independent decision making. Review of Resident 44's medical record showed they were admitted to the facility on [DATE] with diagnoses including Autistic Disorder (a condition related to the brains development which can affect and individuals' communication, social interaction and can cause behaviors), Attention-Deficit Hyperactivity Disorder (ADHD, a developmental disorder characterized by inattention, hyperactivity, and impulsivity [to act on a whim without reflecting on consequences] that interferes with daily functioning) and Intermittent Explosive Disorder (a mental health condition characterized by recurrent, sudden, uncontrollable outburst of aggression that are inappropriate and lack justification) and problems related to education and literacy (the ability to read, write and use information). The 03/04/2026 comprehensive assessment showed the resident was cognitively intact and able to make their needs known. Additionally, the medical records showed the resident became an adult and their own responsible person/decision maker in January 2026.During a concurrent observation and interview on 04/27/2026 at 10:45 AM showed Resident 44 in their room, lying on their bed, playing video games. Resident 44 had a one-on-one (one facility staff member designated to supervise just Resident 44, in order to prevent danger/harm to the resident from themselves and/or other residents) staff watching over them. When asking about activities, the resident stated they liked mowing lawns (using a lawn [NAME] to cut grass), and had been mowing the facility's lawns/working with the ground's keeper staff last year in 2025. Resident 44 stated they wanted to keep working and [NAME] lawns, but the facility was no longer allowing them to. The resident stated, they cannot pay me or something, and was still unsure of why they could not continue mowing the lawns like last year.Review of Resident 44's care plan, dated 03/05/2026 showed the resident had a one-to-one staff supervision throughout the day inside and outside the cottage (a small house that a limited number of residents reside in). The care plan showed that due to Resident 44's autistic disorder and ADHD, diversional activities (engaging recreational tasks designed to distract from stress, pain, or boredom while also stimulating the mind, body and emotions) were to be implemented. The goal was to provide the resident .with preferred leisure/recreational activities on the living unit at least twice daily. The care plan showed the resident liked activities that included video games, watching TV, building/fixing things, yard work (gardening, mowing lawns), and lawnmowers. The plan was to have the resident actively participate in gardening and yard activities.Review of Resident 44's quarterly recreation activities from 08/27/2025 to 12/02/2025 showed: On 09/08/2025 the resident participated in lawn mowing with staff and enjoyed activity. On 09/15/2025 the resident participated in mowing the lawn with staff and was alert and sociable (a person who is friendly and interacting with others). On 09/30/2025 the resident participated in lawn mowing independently and was alert during the activity.During an interview on 04/28/2026 at 12:54 PM, Staff T, Attendant Counselor (AC, a Nursing Assistant-Certified) and Staff U, AC, were both familiar with Resident 44. Staff U stated that Resident 44 used to have a program where they would [NAME] the lawns around the facility, but was now on hold, and Staff U was unable to state the reason why. Staff T stated that last year (2025) the facility had bought the resident a lawnmower to utilize and Resident 44 was mowing the front grass/lawn area outside of cottages 405/406. Staff T was unsure of why Resident 44 had not been able to [NAME] the lawn yet this year. Both Staff T and Staff U stated that a committee had been formed around Resident 44 wanting to work/[NAME] lawns and Staff V, Psychology Associate/Licensed Provider would know more about what was happening.During an interview on 04/28/2026 at 2:25 PM, Staff B, Director of Nursing Services and Staff K, Registered Nurse/Resident Care Coordinator, stated that Resident 44 was cognitively intact, able to make their own decisions and was their own responsibility party since they had become an adult. Staff K stated the resident had stable behaviors with some outburst when overly frustrated and enjoyed activities that were hands on like taking care of the greenhouse garden and mowing lawns the past 2025 year. During a concurrent observation and interview on 04/29/2026 at 11:36 AM, in cottage 405, Resident 44 showed the surveyor a realistic, metal black rose they had created during a shop class at school. Resident 44 stated they had not been allowed to [NAME] yet this year (2026) and inquired about if the surveyor had heard if the facility was going to let the resident [NAME] again or not. The resident stated they saw that mowing the lawn and yard work was voluntary as an activity, I really want to [NAME] the yard on the other side of the fences . as the resident pointed to the back of the 405/406 cottages. During an interview on 04/30/2026 at 7:40 AM, Staff V, Psychology Associate/Licensed Provider, stated they had been working with Resident 44 since that had admitted to the facility and the resident was a highly capable individual, who was cognitively intact and had typical teenage behaviors. Staff V stated that Resident 44 took pleasure in doing activities with their own hands, to gain skills for the future, like mowing the lawn and so a plan had been made for the resident to work with the Maintenance and Operations Division (MOD) staff to get the resident involved in activities that the resident enjoyed. Staff V stated that the resident was mowing lawns with one-on-one staff supervision and MOD staff towards the end of the 2025 summer season, before the MOD staff would normally cease for the fall/winter seasons. Staff V stated the resident preferred activities that were hands on and found mowing the lawn to be relaxing, but some staff brought up safety concerns, before the 2026 spring season of mowing, around the resident behaviors, training on [NAME] equipment and safety with landscaping work. Staff V stated that was when a committee was formed and a work safety agreement was developed for Resident 44. Staff V stated the work agreement addressed resident specific safety rules, responsibilities and education that were to be completed in order for Resident 44 to volunteer for work that involved mowing lawns and other landscaping tasks. Staff V stated that Resident 44 and Staff V had worked together to meet/complete the requirements of the work safety agreement, but then MOD changed their minds and put a stop to the agreement.Record review of Resident 44 work safety agreement showed that on 03/27/2026 an agreement was made between the volunteering Resident 44, Staff V and Staff W, MOD Facility Manager. The record showed, .the purpose of this agreement is to ensure that all work is performed safely and responsibly. The Volunteer understands that the work involves available outdoor lawn car, landscaping, and related tasks. The agreement stipulated the safety rules/responsibilities that included following instructions, use of equipment properly, the wearing of safety gear, how to work safely and outdoor safety practices, respecting others/property, and the safety/training videos to be completed. The work agreement was signed by Resident 44, Staff V and Staff W, on 03/27/2026.During an interview on 04/30/2026 at 9:25 AM, Staff W and Staff Y, MOD Regional Manager, were aware that Resident 44 had expressed interest in mowing lawns at the facility. Staff W stated they had signed the volunteer work safety agreement when Resident 44 and Staff V had come to the main building on 03/27/2026, the kid is very smart. Staff W stated that after making the agreement they reached out to Staff Y and that was when they had put a hold on it. Both staff stated they had concerns about ensuring the resident's safety, with using a gas-powered [NAME], and who would be liable if Resident 44 was injured. Staff W stated that in 2025, Resident 44 had worked with MOD staff on mowing, raking leaves, washing cars and other landscaping tasks along with the resident's one-on-one AC staff supervision. When asked what had changed from the resident working with MOD staff in 2025 to now, regarding the safety/accident liability, Staff W stated the concerns raised after the 03/27/2026 work safety agreement had come from the resident taking on landscaping tasks more frequently in 2025, along with who was liable for injuries and Resident 44 education on using a lawn [NAME]. Staff W stated the nursing home staff ensured Resident 44's safety, supervision, accident liability and education when Resident 44 had previously performed mowing/landscaping tasks in 2025. Record review of a late entry progress note (PN) for 03/31/2026 entered 04/02/2026 at 9:54 AM showed that Resident 44 had volunteered to work with MOD which would allow the resident to complete tasks and keep busy while helping around the facility's campus. The PN stated the resident had watched all of the safety/training videos and had .signed contracts agreeing to the specific terms for the volunteer program . The PN stated the resident have been previously cleared/performed mowing of the lawns which was .one task (Resident 44) especially enjoys . but had not been approved yet. The PN showed that Resident 44 had mention to staff the resident was expecting the program to start and was .upset that others had mowed the lawn that (the resident) was to [NAME] . During an interview on 04/30/2026 at 10:50 AM, Staff B stated that Resident 44 enjoyed mowing the lawn. Staff B stated the resident, and MOD had signed an agreement, but MOD staff were concerned about safety and .went back on the agreement. Staff B stated that Resident 44 had behaviors, but the resident was cognitively intact, had the ability to understand/learn, was receptive towards education, had already previously expressed interest in working with MOD and been safe mowing and had one-on-one AC staff supervision. Staff B stated the resident had the right to perform voluntary work regarding mowing lawns and that it had already been implemented int the resident's care plan.During a follow-up interview on 04/30/2026 at 11:52 AM, Staff V stated that Resident 44's program development regarding mowing/performing yard work with MOD had begun back in February 2026, before the spring season started. Staff V stated they had a heart to heart (a serious and honest conversation between two people) about the regulation of the resident's behaviors/emotions, acting respectful towards other people/property and showing responsibility in the preparation for working with MOD on mowing/landscaping around the facility. Staff V stated Resident 44 volunteered because they wanted to understand and see what it would be like to have a job, and to gain knowledge from the experience, which was why both Staff V and Resident 44 had completed all the work safety agreement requirements before signing the document on 03/27/2026. Staff V stated the work safety agreement was an opportunity for the regulation of Resident 44s emotions, not even give the opportunity to fail.During an interview on 04/30/2026 at 1:13 PM, Staff A, Superintendent, stated that Resident 44 had been completing mowing and other tasks last year (2025) and very positive experience. Staff A stated there had been some miscommunication and misunderstanding of the work safety agreement completed on 03/27/2026 between MOD, Staff V and Resident 44. Staff A stated the facility did not provide for the resident to perform the work services like they had chosen and had been planned for in the work safety agreement. Staff A stated, We failed (Resident 44) in that situation.Reference: WAC 388-97-0420(2)(a)(b)(d)

Based on observation, interview, and record review, the facility failed to ensure the nurse staffing information postings were posted on daily basis at the beginning of each shift in prominent locations readily accessible to residents and visitors for 4 of 4 units (203/4, 401/2, 403/4, 405/6), reviewed for Nurse Staffing Information. These failures placed residents, family members and visitors at risk of not being fully informed of current nurse staffing levels and resident census information.Findings included.The nurse staffing data was observed posted on the second floor of the Main Building (MB) across from the Director of Nursing Services (DNS) office on 04/27/2026, 04/28/2026, 04/29/2026, 04/30/2026 and 05/01/2026. There were no staff posting observed on the six living units where residents and visitors would have access during the dates listed. During an interview and observation on 04/28/2026 at12:31 PM Staff B, DNS, stated the staff posting was updated at the beginning of each shift and posted outside their office. Review of a sign dated June 2016 hung outside the DNS office showed Yakima Valley School maintains a current, daily posting in a uniform manner, in a clearly visible place on 2 North outside room [ROOM NUMBER] (DNS office) Staff B stated these signs were posted on the units to inform visitors where to find the staff information. During an interview and observation on 04/29/2026 at 10:10 AM on unit 203/4 showed no sign posted that staffing data was available in the MB on the second floor. Staff FF, Registered Nurse, stated they had not seen any signs that directed visitors and families to find the staff posting, for a long time. During an interview on 05/01/2026 at 10:05 AM Staff A, Superintendent/NH Administrator, stated the staff data postings were only on the second floor of the MB (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.Reference: WAC 388-97-1620(2)(b)(i)

The facility failed to ensure consistent one to one supervision for 2 of 4 residents (Resident 2, Resident 1) reviewed for accidents, when Resident 2 experienced a superficial scalp laceration of unknown origin and Resident 1 was left on the toilet for an unknown about of time without staff supervision at the door. This failure placed the residents at risk for accidents, injuries and diminished quality of life.Findings included Record review of the facility's policy titled, Level of Supervision, LOS, dated 10/07/2024, showed that a LOS was assigned to provide an appropriate degree of supervision for each resident to promote the free exercise of a resident's rights while also ensuring the safety of residents and staff. LOS level 4 was one-to-one supervision allowing as much social space as possible. Supervision must be positioned in a manner to prevent danger or harm to self or others.Resident 2Record review showed Resident 2 was admitted to the facility on [DATE] with diagnoses to include autistic disorder (a condition related to brain development that impacts how a person perceives and socializes with others), conduct disorder (a serious behavioral and emotional disorder in children and adolescents characterized by aggressive and destructive behavior), aphasia (condition characterized by either partial or total loss of the ability to communicate verbally or using written words) and seizure disorder (the brain's electrical activity is periodically disturbed, resulting in some degree of temporary brain dysfunction).Review of a comprehensive assessment dated [DATE] showed Resident 2 had severe cognitive impairment and had behavior towards self and others that put them at significant risk for physical injury.Review of a 03/07/2025 care plan showed Resident 2 required LOS level 4 staffing.During a telephone interview on 04/01/2026 at 8:00 AM, Resident 2's Representative (RR2) stated that the evening of 03/24/2026, Resident 2 was found to have a two-centimeter (cm) laceration (a torn or jagged wound to the skin and soft tissue underneath) on the top of their head. The facility staff could not identify how or where the injury happened. Resident 2 had one-to-one staff assigned to them 24 hours a day, seven days a week. RR2 stated How could [Resident 2] have an unknown injury with one-to-one staff always present? I want to know how this happened.Review of a 03/25/2026 at 1:37 AM progress note by Staff C, Licensed Practical Nurse, showed that at 10:13 PM the previous evening, Resident 2 had a two cm by 0.25 cm laceration to the top of their head, the area was cleaned and left open to the air. Resident 2 smiled and laughed during the assessment and did not show signs of discomfort when cleaned.Review of a 04/02/2026 Statewide Investigation Unit ([NAME], performs impartial abuse and neglect investigations in state residential facilities) report showed that four direct care staff that were present on evening shift 03/24/2026 were reassigned to non-resident work duties during the investigation. The investigation showed that none of the staff assigned to Resident 2 and or in the immediate vicinity saw or heard anything that could have caused the resident's injury. Staff interviews showed that Resident 2 had no falls, no destructive or aggressive behaviors. Review of a statement by Staff D, Registered Nurse, showed they searched the soiled laundry on 03/25/2026 at 3:15 AM and found a bag with a fitted sheet, comforter, pullup brief, shorts and a shirt with Resident 2's name on the tag. The comforter had a red 12 cm by 12 cm circle that was dried blood. The previous evening shift staff reported changing urine-soaked sheets around 9:30 PM on 03/24/2026 and did not report seeing blood. The investigation concluded that Resident 2's scalp laceration remained an injury of unknown origin. During an interview on 04/07/2026 at 2:20 PM, Staff C stated they assessed Resident 2's injury when it was first found. Staff C stated the wound was fresh, no active bleeding, swelling or bruising noted in the area. The laceration was neither deep nor wide enough that would suggest need for stitches. Resident 2's movement and behavior were at baseline; they did not appear in pain. There was no blood on the residents' clothing.During an interview on 04/07/2026 at 3:30 PM, Staff B, Director of Nursing, stated that no staff that day reported seeing the blood on the comforter or any blood in the environment. The staff maintained that they did not know how Resident 2 could have received the laceration. Staff B stated staff did find one sharp area on [Resident 2's] closet; however, there was no evidence of an impact on the closet frame.During an interview on 04/07/2026 at 4:00 PM, Staff A, Administrator, stated that Resident 2's laceration had remained an injury of unknown origin and should not occur for residents that have one to one staff assigned to them. Resident 1Record review showed Resident 1 was admitted to the facility in 1969 with diagnoses to include profound intellectual disability (significant limitations in both intellectual functioning and adaptive behavior with the inability to live independently, being in need of close supervision, limited communication, and physical restrictions), and anxiety disorder (the mind and body's reaction to stressful, dangerous, or unfamiliar situations).Review of a comprehensive assessment dated [DATE] showed Resident 1 required extensive staff assistance to walk, sit, stand and use the toilet.Review of the 08/07/2025 care plan showed Resident 1 could sit on the toilet, should be toileted every two hours, do not leave unattended, and ensured the door was closed for privacy. Resident 1 had a history of eating toilet paper and leaving the bathroom unclothed from the waist down.During an observation and interview on 04/07/2026 at 12:00 PM, Resident 1 was observed on the toilet with the door closed and no staff standing by for five minutes. The surveyor entered cottage 204 at 12:00 PM and observed Staff E, Nursing Assistant (NA) and Staff F, NA, out front in the kitchen/living area. The recliner that Resident 1 sat in was empty. Looking through the back of the cottage, Resident 1 was not in their bedroom and there was a toilet door shut with the light on. At 12:05 PM, Staff E came out of the staff bathroom and began gathering supplies to enter the bathroom. When asked, Staff E stated that they assisted Resident 1 on the toilet at 11:50 AM.During an interview on 04/07/2026 at 12:15 PM, Staff F stated that Resident 1 was assisted to the toilet every two hours and staff were to stand outside the door because the resident could try and get up on their own. Resident 1 could fall or come out of the bathroom undressed.Record review of a 10/08/2026 staff training showed staff were to ensure the door was closed for privacy when residents were utilizing the toilet, and staff stayed with or stood outside the door to assist the resident when they were done.During an interview on 04/07/2026 at 1:25 PM, Staff E stated they were aware they should stay with Resident 1 while they used the toilet, however they did not implement that during the resident's toileting that day.During a telephone interview on 04/07/2026 at 2:35 PM, Collateral Contact (CC), stated that they were in cottage 204 about two or three weeks ago around lunchtime and believed Resident 1 was left on the toilet with no staff near for a minimum of 30 minutes. During an interview on 04/07/2026 at 4:00 PM, Staff A stated there had not been any reports regarding Resident 1's toileting supervision care plan not being followed. Reference: WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR, a screening required to be completed prior to admission to a nursing home that looked for indicators that one may have a mental disorder or intellectual disability) were completed for 1 of 3 sampled residents (Resident 4), reviewed for PASRR's. This failure placed residents at risk for receiving inadequate mental health interventions, an increase in avoidable behaviors, and a diminished quality of life. Findings included .Record review of facility's policy titled, Admissions 1.08, dated 08/2025, showed that a PASRR Level 1 form would be completed prior to a resident's admission to the facility. Record review of facility's policy titled, Residential Habilitation Center Admissions, 17.01.02, dated 08/2024, showed that before a resident's admission for nursing facility services, the facility must ensure the Level 1 PASRR was complete and accurate. Resident 4 Record review of Resident 4's medical record showed they were admitted to the facility on [DATE]. Review of Resident 4's 09/19/2025 comprehensive assessment showed the resident had diagnoses to include moderate intellectual disability (a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently), autistic disorder (a condition related to brain development that impacts how a person perceives and socializes with others) and epilepsy (a brain condition that causes repeated episodes of sudden, brief changes in the brain's electrical activity). The assessment showed that Resident 4 had moderate cognitive impairment and would reject care from staff. Review of Resident 4's medical record showed no PASARR documents were received by the facility prior to Resident 4's 09/19/2025 admission. During an interview on 10/31/2025 at 10:40 AM, Staff C, Admissions Coordinator, stated they had a process to ensure each resident's documents included PASRR prior to admission; however, they could not find any PASRR documents for Resident 4's 09/19/2025 admission and I thought we had one, but did not and I missed it. On 10/31/2025 at 2:45 PM, Staff A, Administrator, was informed and acknowledged their failure to ensure the PASRR process for Resident 4. Reference: WAC 388-97-1915 (1) (4)

Based on interview and record review the facility failed to ensure supervision for 1 of 4 residents (Resident 1) reviewed for dental sedation. The failure to follow post sedation safety protocol resulted in Resident 1 to have an unwitnessed fall that caused a 10-centimeter (cm) laceration mid forehead that required 11 staples at the hospital. Findings included.Record review of facility's policy titled, Level of Supervision (LOS) 1.08, dated 10/2024, showed that a LOS would be assigned to provide an appropriate degree of supervision for each resident. Direct care staff would check the LOS assigned in the resident's record daily. Definition for LOS 3 was supervision must be positioned in a manner to protect the resident from or deter danger. Enhanced staffing [was] required.Record review of facility's policy titled, Nursing Standard Operating Procedure IV.A.17 Sedation, dated 02/2024, showed that after receiving sedation, the Attendant Counselor (AC, a nursing assistant) would maintain close observation of the resident (LOS 3), maintain safety precautions as directed by the nurse and the resident would not be allowed to lay down in bed until released by the nurse.Resident 1Resident 1 was admitted to the facility on [DATE] for a short-term respite stay and discharged back home on [DATE].Review of the resident's 07/31/2025 comprehensive assessment showed Resident 1 had severe intellectual disabilities (a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently), anxiety disorder (the mind and body's reaction to stressful, dangerous, or unfamiliar situations) and was blind. The resident was dependent on staff for their activities of daily living (dressing, toileting and bathing); however, they were independent with walking around in the cottage.Review of the 07/24/2025 care plan showed the resident would receive sedation prior to going to dental and upon return to the cottage the resident would be monitored by staff for drowsiness, eating problems and discomfort.Review of the 07/31/2025 facility investigation showed Resident 1 received Lorazepam (a medication that has sedative and antianxiety effects) three milligrams (mg) on 07/29/2025 at 8:30 AM for a dental appointment. Later that day, Resident 1 had an unwitnessed fall in the cottage at 1:15 PM that caused a laceration to their forehead and required medical care at the hospital.Record review of the 07/29/2025 Sedation Protocol Checklist showed Resident 1 was to remain in the wheelchair with a positioning belt and stay in the line of sight of staff until released by the nurse. The resident's vital signs were attempted prior to the sedation and every 30 minutes after until the resident returned to their baseline. Resident 1 would not allow their pulse or blood pressure to be measured; however, their level of consciousness and respiratory rate was monitored by the unit nurse and were within stable parameters. Resident 1 was drowsy and had not been released by the nurse prior to their injury.Review of statements included in the 07/31/2025 facility investigation showed that Staff D, AC, was working with Resident 1 just prior to the incident on 07/29/2025. Staff D transferred Resident 1 to their bed due to falling asleep in their wheelchair around 1:00 PM. Staff D watched Resident 1 from the bedroom door for about 10 minutes until Resident 1 appeared asleep. Staff D then went to the front of the cottage to wash their hands and chart. When done washing their hands, they heard a noise in the back of the cottage and found Resident 1 bleeding from their forehead, while standing in the hallway.Review of statements included in the 07/31/2025 facility investigation showed that Staff C, Licensed Practical Nurse, was the nurse on duty when Resident 1 was found with a laceration on their forehead. They reported they had not released Resident 1 from sedation observation and were not notified prior to the resident's transfer to bed.Review of the 07/31/2025 facility investigation conclusion showed Staff D failed to follow the sedation protocols to maintain line of sight of the resident.Review of a 07/29/2025 at 2:49 PM progress note showed Staff C was called to attend Resident 1 at 1:14 PM after staff heard a loud thud in the back hall. Resident 1 was standing near their bedroom door with a bleeding laceration to their forehead. The laceration was measured 10 cm long by 2 cm wide and 0.5 cm deep. Pressure was applied and the resident was transported by ambulance to the hospital.During a telephone interview on 08/18/2025 at 12:45 PM, Resident 1's Representative (RR) stated the facility reached them by phone by the time Resident 1 was in transport to the hospital. The staff stated they thought Resident 1 fell in the back hall and hit their head on a hard surface. The RR stated, the wound was horrific and was very upset this happened. The RR stated after returning home, they took Resident 1 to the hospital on [DATE] to have the staples removed. The RR stated the hospital staff instructed them to clean the wound two to three times a day and it would take a while to heal. The RR stated Resident 1 was very resistant to having the wound cleaned and it had become a fight.During an interview on 08/18/2025 at 1:20 PM, Staff D stated they knew Resident 1 was LOS 3 and thought they could leave the resident's bedside after they fell asleep. Staff D stated they did not know that LOS 3 with sedation required continuous line of sight until the nurse released the resident from monitoring. Staff D stated they should not have left Resident 1 alone in their room.During an interview on 08/20/2025 at 10:15 AM, Staff A, Superintendent/NH Administrator, stated their investigation showed Staff C was new to day shift and had not been trained on the sedation protocol. We should have done a better job to protect [Resident 1].Reference: WAC 388-97-1060 (3)(g)This is a repeat citation from the Statement of Deficiencies dated 05/28/2025.

Based on observation, interview, and record review, the facility failed to ensure there were optimal nursing staff in order to provide appropriate supervision and individualized care needed based on the acuity (the level of severity of residents' illnesses, physical, mental, cognitive limitations, and conditions) level of care required for 6 of 10 residents (Residents 2, 6, 23, 10, 15, and 17) reviewed for staffing. This failed practice placed residents at risk for unmet care needs, not receiving care planned interventions, and negative outcomes. Findings included . Review of a policy dated 10/2024, titled Level of Supervision (LOS), showed that a LOS was to be assigned to each resident to provide an appropriate degree of supervision to protect their rights, keep them safe, and to staff to the maximum extent reasonable. The LOS showed: • LOS 1- staff should have general knowledge of where residents are and what they are doing. • LOS 2- staff were to have knowledge of where the residents were at, at all times, who they were with, and what they were doing. • LOS 3- staff supervision must be positioned in a manner to protect from or deter danger. • LOS 4- staff provided one-to-one supervision allowing as much social space as possible. <Resident 2> Review of the resident's medical record showed they admitted with a diagnosis of Intellectual Disabilities (ID, limitations in cognitive functioning and skills, including conceptual, social, and practical skills) and mixed receptive-expressive language disorder (a communication disorder that affects both understanding and producing/expressing language). The 05/13/2025 comprehensive assessment showed Resident 2's cognition was severely impaired and were dependent on staff for all of their care needs. Additionally, Resident 2 required a LOS 1, and staff needed to anticipate (foresee and prepared to meet the resident ' s needs in advance since they could not communicate that themselves) their needs due to their inability to communicate verbally. <Resident 6> Review of the resident's medical records showed they admitted with a diagnosis of ID and mixed receptive-expressive language disorder. The 05/26/2025 comprehensive assessment showed Resident 6's cognition was severely impaired and required extensive assistance from staff for all of their care needs. Additionally, Resident 6 required a LOS 1, and their needs were to be anticipated by staff due to them not being able to communicate verbally. <Resident 23> Review of the resident's medical records showed they admitted with a diagnosis to include ID and mixed receptive-expressive language disorder (a communication disorder that affects both understanding and producing/expressing language). The 04/09/2025 comprehensive assessment showed Resident 23's cognition was severely impaired and was dependent on staff for eating. Additionally, the record showed Resident 23 required LOS 2 and staff were to anticipate their needs due to their limited ability (four words) to communicate verbally. An observation on 06/02/2025 at 11:56 AM, showed Resident 6 sitting in their wheelchair (w/c) with their plate of food sitting in front of them on the table. Resident 23 was sitting in a recliner waiting for their food to be served. Residents 6 and 23 both required the assistance of staff to eat but the staff were busy assisting the other two residents. At 11:59 AM, Residents 6 and 23 were assisted with their lunch, after the other two residents that required assistance had eaten. An observation on 06/03/2025 at 5:09 PM showed two staff members, Staff H, Registered Nurse, and Staff I, Nursing Assistant (NA), that were available to assist residents with their meals. Residents 2, 6, and 23 had not had their dinner served and all three residents required staff assistance with eating. Staff H was assisting a fourth resident who required assistance with eating. Staff H stated they were helping Staff I assist the residents to eat because they were short-handed (not enough staff). Staff I stated when they were short staffed the residents are the ones to suffer, because look at [Resident 6], they haven't eaten yet and the residents had to wait until one of the staff were finished with the residents they were currently assisting. Staff I stated Resident 23 had not eaten yet either. An observation on 06/04/2025 at 11:38 AM, showed Resident 2 sitting at the table without their meal. Resident 6 sat in their w/c in between the two dining room tables, and Resident 23 walked out into the dining area, from the back of the cottage (out of eyesight of staff), both residents were not served their meals. Staff R, NA, was sitting at one of the tables assisting another resident with their meal. There were no other staff observed. Staff R stated the other NA had gone on their lunch break. Staff R stated there were two NA staff assigned to the cottage, and another one would float from one cottage to the other to help. At 11:55 AM, Staff K, NA, returned from lunch and assisted Resident 6 with their meal. Then, at 12:16 PM, Staff R sat down at the table to assist Resident 2 with their meal (38 minutes after the first resident was observed assisted with their lunch) and at 12:36 PM, Resident 23 received assistance with their meal (58 minutes after the first resident was observed being assisted with their lunch). Staff R stated there were four residents that required assistance with eating and even if they were not short of staff, they still would not have enough staff for all the residents to eat their meals together. <Resident 10> Review of the resident's medical records showed they admitted with diagnoses to include ID. The 03/11/2025 comprehensive assessment showed Resident 10's cognition was moderately impaired and had inattentive (not paying attention to something) behaviors. Additionally, the record showed Resident 10 required a LOS 3 and the staff needed to anticipate their needs due to their limited verbal skills and use of body language. The record showed Resident 10 did not like the bathroom door closed all the way, so staff were to stand in the doorway while Resident 10 was toileted. <Resident 15> Review of the resident's medical records showed they admitted with diagnoses to include ID and mixed receptive-expressive language disorder. The 03/13/2025 showed Resident 15's cognition was severely impaired and required extensive assistance from staff for eating. The assessment showed Resident 15 had wandering behaviors. Additional review of the record showed Resident 15 required a LOS 4. <Resident 17> Review of the resident's medical records showed they admitted with diagnoses to include ID and PICA (an eating disorder where a person compulsively eats things that aren't food and don't have any nutritional value or purpose). The 03/15/2025 comprehensive assessment showed Resident 17's cognition was moderately impaired and required partial to moderate assistance of staff for toileting. Additionally, review of the record showed Resident 17 required a LOS 2 and their care needed to be anticipated due to their non-verbal and body language communication. An observation on 06/02/2025 at 10:48 AM showed Staff V, NA, was one on one with Resident 15 who was exit seeking. Staff T, NA, and Staff P, NA, were at the back of the cottage assisting with a mechanical lift transfer, and there was a volunteer reading to a resident in the dining room area. Resident 17 waited until staff walked out of their sight and jumped up from the table and walked quickly to the refrigerator, took out a black condiment container, scooped out a big bite with their finger and put it in their mouth. In the container was fry sauce (mayonnaise mixed with ketchup). The volunteer yelled out for the staff and Staff T ran to the refrigerator to intercept Resident 17 from eating the remainder of the container. During an interview on 06/03/2025 at 4:25 PM, Staff M, NA, stated they were short staffed because two of the NAs scheduled for this cottage were sent over to cottages 405 and 406 because they were also short staffed. Staff M stated when they were short staffed it could make providing care very challenging, especially during mealtimes. Staff M stated it was not an ideal situation because you had to prioritize and choose who was going to receive care first. Staff M stated when they were short staffed and needed to provide care to another resident, they would have to leave a LOS 2 resident without supervision until they were finished. During an interview on 06/03/2025 at 4:50 PM, Staff W, NA, stated the normal staffing pattern was to have six NAs, but most of the time they only had five NAs. Staff W stated that day (06/03/2025) the maximum staff was four and they would float back and forth from cottage to cottage to cover lunches, breaks, or help if they needed it. Staff W stated having four staff instead of six meant it would take longer to get to the needs of the residents because they would have to wait until someone was available from another cottage to help or if the other cottage called for help, they would have to wait until someone returned from their break. During an interview on 06/04/2025 at 10:19 AM, Staff L, Licensed Practical Nurse, stated they had one NA scheduled in cottage 402 with five residents who required being transferred with a mechanical lift (a device used to raise or lower people using mechanical systems like hydraulics, pulleys, or gears). The NA would have to go and prepare the residents to transfer to and from their bed and wheelchair and then the resident would have to sit there and wait for a NA to come from the other cottage to help transfer them (when using a mechanical lift, they require two staff for safety). Staff L stated they had quite a few NAs off work for injuries they had sustained while working in another cottage that housed residents with severe combative (ready or eager to fight)/physical behaviors (cottages 405 and 406) when that cottage is short staffed, the NAs were pulled from all the other ones to ensure they had the staff they needed, which made the rest of us have to work short staffed. Review of a list provided by the facility on 06/04/2025 titled OJI (on the job injury)/Out list, showed 15 NAs and one Registered Nurse were currently out or injured and not working. Review of the list showed 12 of the 15 NAs were from the day shift, one was from the swing shift, and two were from the night shift. An observation on 06/04/2025 at 11:08 AM showed Staff S, NA, and Staff P, NA, were the available assigned staff and Staff T, NA, was at lunch. Staff S was one on one with Resident 15, who had exit seeking behaviors and was actively seeking an exit. Staff S was walking in and out of resident rooms with Resident 15 and up and down the hallways in the back of the cottage. Staff P prepared residents for lunch at the front of the cottage and assisted Resident 17 in the restroom at the back of the cottage. Resident 10 assisted themselves to the restroom at the opposite end of the hall at the back of the cottage, pulled their pants down, and sat on the toilet. The door to the restroom was left open. While Resident 10 was sitting on the toilet, Resident 15 was walking out of the room right outside of the restroom and looked into the restroom at Resident 10. Resident 15 then continued up and down the hallway outside of the restroom where they could visibly see Resident 10 in the restroom. Resident 10 then stood up, pulled up their pants without wiping, and walked back to the dining area for lunch. Additional observation at 11:14 AM showed Staff T had returned from lunch and assisted Resident 10 to the restroom again in an attempt to clean them up from the previous trip to the restroom. Resident 10 had escalated behaviors of screaming and yelling and Staff T was attempting to redirect them. There were loud noises of someone yelling (possibly another resident alerting staff) at the front of the cottage when Resident 17, who had been sitting at the table in the dining area waited until Staff T walked out of their sight and quickly walked to the refrigerator and took out a white Styrofoam container, took the lid off, and scooped their finger into the dish and put it into their mouth. Staff T quickly walked away from Resident 10 who was sitting on the toilet, with the door open, to go and intercept Resident 17 from the refrigerator. Staff P and Staff S had assisted other residents during this time. Staff T stated Resident 17 needed to be a higher level of care because of their history of eating everything in sight and because they waited until the staff were not in their sight and would hurry and get into things. An observation on 06/05/2025 at 12:13 PM, showed Resident 17 walked to the restroom from the dining area, pulled their pants down, sat on the toilet, with the door open while Resident 10 (the opposite sex) walked up and down the hallways in visible sight of Resident 17 sitting on the toilet. While Resident 10 was walking towards the bathroom door, Resident 17 stood up, pulled up their shorts, and walked back to the dining room. The other NA assisted other residents with lunch and Resident 15 was outside one on one with a NA. During an interview on 06/06/2025 at 1:38 PM, Staff B, Director of Nursing Services, stated their process was to staff the cottages with the LOS required for the residents specific to that cottage and not the level of care each resident required. Staff B stated they had not been made aware that Resident 17 should have had their LOS assessed and changed. Staff B stated they had five NA vacancies and several on the job injured staff that were not working.

Based on interview, and record review, the facility failed to ensure that physical restraints (any manual method, physical or mechanical device, equipment or material, attached or adjacent to the residents body, that cannot be removed by the resident and restricts the resident's freedom of movement) were implemented in a safe manner, had the required resident specific medical symptoms (which warranted the use of physical restraints) identified, medical provider orders for the use of the specific type of physical restraint were obtained, nor that least restrictive measures were utilized to treat a resident's medical symptoms for 3 of 3 residents (Residents 20, 3 and 15), reviewed for physical restraints. This failure placed residents at an increased risk for injury, a loss of their freedom of movement and adverse mental health effects regarding their well-being, independence and self-direction. Findings included . Review of the facility's policy titled, Use of Restrictive Procedures, revised December 2024, showed that a medical professional would place an order for medically necessary mechanical restrictions/restraints to .protect a client's physical health and treat a medical condition . The policy showed that if medically necessary treatments were planned by an interdisciplinary team (IDT, a collaborative group of healthcare staff from various fields of work within a facility) for a resident to have restrictions/restraints the protocol and procedure would be on the Restraint Orders and Monitoring form. The policy showed that when physical restraints were used to complete a medical or dental procedure a medical professional would document medical necessity (refers to a determination that a treatment or procedure is essential to treat a diagnosed medical condition) and include the purpose of the restraint, and that lesser restrictive interventions (the choosing of interventions that limits a residents freedom, independence, or rights as little as possible) were tried but ineffective. Additionally, the policy showed the medical professional must document in the resident's medical record using the restraint orders and monitoring form, which included the type of physical restraint, the resident's response to the physical restraint and the emotional and behavioral state of the resident upon release of the restraint. Review of the facility's protocol form titled, Restraint Orders and Monitoring, revised March 2022, showed the restraint orders section needed to be fill out completely or to look at the physician's order and that the form would be used for all restraint checks and monitoring. The form has sections for the type of restraint order, type of restraint, description of restraints used, physicians order, restraint alternatives tried, and the reason for the resident's restraint. Review of the Center for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument (a tool used to facilitate accurate and effective resident assessment practices), Section P, Restraints and Alarms, dated 10/01/2024, showed, Any manual method or physical or mechanical device, material, or equipment that meets the definition of a physical restraint must have: physician documentation of a medical symptom that supports the use of the restraint, a physician's order for the type of restraint and parameter of use, and a care plan and a process in place for systematic and gradual restraint reduction (and/or elimination, if possible), as appropriate. Additionally, identification of medical symptoms could assist the facility in determining what less restrictive measure to utilize and that facility's should perform all due diligence (extensive evaluation before implementation) in documenting this process to ensure that they had exhausted alternative treatments and less restrictive measures before a physical restraint was employed to treat a resident's medical symptom. <Resident 20> Review of the resident's medical records showed they were admitted to the facility intellectual disabilities (ID, limitations in cognitive functioning and skills, including conceptual, social, and practical skills), hearing loss, anxiety and expressive language disorder (a communication challenge that affects a person's ability to express thoughts, ideas or feelings clearly and effectively). The 04/18/2025 comprehensive assessment showed the resident had severely impaired cognition and no physical restraints were documented being used. The 10/18/2024 comprehensive assessment showed that physical restraints were documented as used less than daily. Review of Resident 20's care plan, reviewed 06/06/2025 showed the resident would receive safe quality oral health care. The care plan showed, (Resident 20) is very resistant to oral health care. Restraint and/or oral sedation (the process of making a resident more relaxed through administration of medication) needed for safety during dental treatment. Review of Resident 20's dental progress notes showed: • on 07/16/2024, Resident 20 was .adequately sedated and tolerated the procedure well. (Resident 20) was very cooperative. (Resident 20) was treated in the dental chair; hand restraints and leg wrap (applied 10:34 AM, removed 10:54 AM) . No documentation was noted on Resident 20's specific medical symptoms identified, which warranted the use of the physical restraints, the medical providers orders for implementation of the physical restraint, nor that least restrictive measures were utilized for Resident 20 prior to implementation of physical hand/leg restraints. • on 10/17/2024 Resident 20 was .adequately sedated and tolerated the procedure well. (Resident 20) was very cooperative. (Resident 20) was treated in the dental chair; hand restraints and leg wrap (applied 09:44 AM, removed 10:13 AM) . Again, no documentation was noted on the specific medical symptoms identified for the use of physical hand/leg restraints, the provider orders for implementation of the physical hand/leg restraints, nor that lesser restrictive intervention were attempted before using the hand and leg restraints. Review of Resident 20's provider orders for July 2024 and October 2024, showed no documentation of orders for specific medical symptoms that warranted the use of physical restraints had been completed. Review of the facility's restraint orders and monitoring form showed no documentation of the form being completed for Resident 20's dental appointments/physical restraint implementation. <Resident 3> Review of the resident's medical records showed they were admitted to the facility with diagnoses including ID, cerebral palsy (a neurological disorder that permanently affects body movement and muscle coordination) and expressive language disorder. The 05/10/2025 comprehensive assessment showed the resident had a severely impaired cognition and physical restraints were documented as used less than daily. Review of Resident 3's care plan, reviewed 06/04/2025 showed the resident would receive safe quality oral health care. The care plan showed that Resident 3 was very resistant to oral health care and that restraints/oral sedation may be needed for their safety during dental treatments. Review of Resident 3's dental progress notes showed that on 05/08/2025 at 10:27 AM, the resident was treated in their wheelchair .right hand restraint applied 9:47 AM/removed 10:04 AM . No documentation was noted with the specific medical symptoms identified for the use of the physical hand restraint, the provider orders for implementation of the physical hand restraint, nor that lesser restrictive intervention were attempted before implementing the hand restraint. Review of Resident 3's provider orders for May 2025, showed no documentation of orders for specific medical symptoms that warranted the use of physical restraints had been completed. Review of the facility's restraint orders and monitoring form showed no documentation of the form being completed for Resident 3's dental appointments/physical restraint implementation.<Resident 15> Review of the resident's medical record showed they were admitted to the facility with diagnoses including ID and epilepsy (a brain condition that causes recurring seizures, which are abnormal electrical brain activities). The 03/13/2025 comprehensive assessment showed Resident 15's cognition was severely impaired and received anxiety (excessive, persistent, and uncontrollable worry and fear about everyday situations) medications. Review of Resident 15's dental progress notes showed: • on 01/29/2025, Resident 15 was seen for a dental appointment. Resident 15 was given anxiety medications for sedation prior to the appointment. Upon arriving to the dental department, Resident 15 was awake and alert. Resident 15 was transferred from their wheelchair to the dental chair and placed into protective stabilization a body wrap (a temporary restraining device that immobilizes a subject's body and restricts their ability to kick or do harm) restraint. The note showed Resident 15 was resistive at times but cooperative enough to treat. • on 02/06/2025, Resident 15 was seen for a dental appointment and provided the same medications and body wrap restraint as on 01/29/2025. Additionally, physical assistance was provided to stabilize the head. Resident 15 was very cooperative and tolerated the procedure well. • on 02/19/2025, Resident 15 was seen for dental appointments and provided the same medications and wrap as on 01/29/2025. Resident 15 was awake and alert throughout the dental visit. • on 03/19/2025, Resident 15 was seen for dental appointments and provided the same medications and wrap as on 01/29/2025. Resident was awake and alert through the dental visit. • on 04/09/2025 Resident 15 was seen for dental appointments and provided the same medications and wrap as on 01/29/2025. Resident was awake and alert through the dental visit. • on 05/15/2025 Resident 15 was seen for a dental appointment and provided the same medications and restraints as on 02/06/2025. Resident 15 was very cooperative and tolerated the procedure well. The notes showed no documentation that Resident 15 experienced any behaviors prior to being placed into the body wrap restraint or that they attempted to use a least restrictive option. The notes showed Resident 15 was taken from their cottage after being provided medication sedation and transferred from their wheelchair directly into the dental chair into a body wrap restraint. During an interview on 06/05/2025 at 3:55 PM, Staff B, Director of Nursing Services, stated the facility's process with physical restraints was to get a provider order for the restraint and how the restraint would be applied, obtain consents from the resident representative, complete assessments/care planning all before a restraint would be utilized for the resident. Staff B stated that they were not aware of physical restraints currently being needed for facility residents and that they would have received a notification from the nursing staff if they needed to apply a physical restraint. When asked about physical restraints during dental appointment, Staff B stated that dental staff were responsible for obtaining restraint consents, assessments and documentation of least restrictive measures being utilized. During an interview on 06/06/2025 at 9:47 AM, Staff B stated they were aware of facility residents having physical restraints applied during dental procedures. Staff B stated that it was not the facility's process to obtain provider orders for the implementation of physical restraints on residents during dental procedures. Staff B stated the restraint orders and monitoring form should be documented and would show a resident's orders, assessments, monitoring, and the lesser restrictive measures used before implementing physical restraints. Staff B stated they did not see that the facility's dental staff was completing the form when restraints were implemented during resident dental procedures. During an interview on 06/06/2025 at 10:30 AM, Staff B and Staff G, Dental Hygienist, stated they were familiar with the facility's resident population with intellectual disabilities, and dental procedures conducted. Staff G stated that during resident dental procedures, sedation/physical restraints were applied when a resident was starting to pull at the dentist's arm or when a resident would move their arms up to their mouth. Staff G stated that physical restraints were not utilized during every dental procedure. Staff G stated they did not put in a provider order when implementing physical restraints, but that a consent was obtained annually from resident representatives for implementation of physical restraints during dental procedures. Staff G stated that least restrictive measures were not conducted every time physical restraints were to be implemented for a resident and that they should have been. Staff G stated they document a dental progress note for residents, but that the note did not include all the required information that was on the restraint orders and monitoring form. Staff G stated they had not been completing the restraint orders and monitoring form for restraints implemented during the residents' dental procedures. Staff B stated the correct process was not being followed for the implementation of physical restraints with residents' dental procedures. During an interview on 06/06/2025 at 1:06 PM, Staff A, Administrator, stated that implementation of physical restraints during resident dental procedures was not being completed correctly. Staff A stated that least restrictive measures should be conducted with residents before moving to the application of physical restraints. Staff A stated that a provider order should be obtained, and dental staff should be completing the restraint orders and monitoring form when implementing physical restraints. Staff A stated that facility staff were not following the correct process for the implementation of physical restraints with residents during dental procedures.

Based on interview and record review, the facility failed to ensure residents and/or their representative were offered/educated on the COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing that could result in severe impairment or death) immunization (the action of taking a vaccine for a particular infectious disease) for 1 of 5 sampled residents (Residents 38) reviewed for immunization status. This failure placed the resident at risk of making an uninformed decision and contracting the COVID-19 virus. Findings included . Review of the facility's policy titled, COVID-19 Response, revised January 2025, showed the facility would offer residents or their representative the COVID-19 vaccine, educate on the risk/benefits of the immunization and obtain consent. <Resident 38> Review of the resident's medical record showed they were admitted to the facility on [DATE], with diagnosis including Autism (a developmental disorder characterized by differences in social interactions/communication and restricted or repetitive patterns of behavior/interests), anxiety and intellectual disabilities. The comprehensive assessment dated [DATE] showed the resident had a severely impaired cognition. Review of Resident 26's immunization records for years 2024 and 2025 showed no documentation of a COVID-19 immunization assessment, education or a signed consent/declination form completed for the resident. During an interview on 06/06/2025 at 4:00 PM, Staff C, Registered Nurse/Infection Preventionist, stated they did not have documentation of Resident 38's representative (RR) consent or education on the benefits/potential side effects of the COVID-19 immunization. Staff C stated the procedure was to send out letters to the facility RR about immunization information and had not received a response back from Resident 38's RR. Staff Q stated when a RR did not respond to the letter, that facility staff would contact the RR to offer and educated on the COVID-19 immunization. Staff Q stated that the correct process was not followed and Resident 38's RR was not contacted about the COVID-19 immunization. During an interview on 06/06/2025 at 4:16 PM, Staff A, Administrator, stated the correct process for offering/educating on the risk versus benefits and potential side effects of the COVID-19 was not followed for Resident 38.

Based on observation, interview and record review, the facility failed to provide care and services in a dignified manner when they served other residents their meals before everyone else seated in the dining area for 3 of 4 residents (Residents 2, 6, and 23) reviewed for dignity. This failure placed residents at risk for lack of inclusion and decreased dignity. Findings included . <Resident 2> Review of the resident's medical record showed they admitted with diagnoses to include Intellectual Disabilities (ID, limitations in cognitive functioning and skills, including conceptual, social, and practical skills) and mixed receptive-expressive language disorder (a communication disorder that affects both understanding and producing/expressing language). The 05/13/2025 comprehensive assessment showed Resident 2's cognition was severely impaired and was dependent on staff for eating their meals. <Resident 6> Review of the resident's medical records showed they admitted with diagnoses to include ID and epilepsy (a brain condition that causes recurring seizures, which are abnormal electrical brain activities). The 05/26/2025 comprehensive assessment showed Resident 6's cognition was severely impaired and was dependent upon staff for eating their meals. <Resident 23> Review of the resident's medical records showed they admitted to the facility with diagnoses to include ID and epilepsy. The 04/09/2025 comprehensive assessment showed Resident 23's cognition was severely impaired and was dependent upon staff for eating their meals. During an observation on 06/02/2025 at 11:56 AM, showed Resident 6 sitting in their wheelchair (w/c), looking downwards to their right side. Resident 6's meal had been served onto a plate and was waiting for staff to assist them with eating. Resident 23 was sitting in the recliner closest to the front door waiting for their meal. Observations showed all other residents had been served their meals or were being assisted with their meals while these two residents waited for staff to assist them. NAs began to assist Residents 6 and 23 at 11:59 AM. There were two other residents that required staff assistance with their meals that had already been assisted. A concurrent observation and interview on 06/03/2025 at 5:09 PM, showed Residents 2, 6, and 23 had not been served their dinner. The living room area and the dining area are both in a combined space. At one table there was Staff H, Registered Nurse, assisting another resident with their meal and on a side table, there was a resident eating unassisted, and only required cueing. Resident 2 was sitting at a different table with their eyes closed, mouth opened, and their dinner plate was sitting in front of them, but staff clarified they had already eaten even though their food had not looked like it had been touched. Resident 6 was sitting in the dining room area, in between the tables, with a side table beside their w/c, waiting to be assisted to eat, and Resident 23 was walking back and forth from their room to the dining room. Staff H stated they were helping staff out because they were short-handed [not enough staff] today. Staff I, Nursing Assistant (NA), stated when they were short staffed, the residents were the ones who suffer, because look at [Resident 6], they haven't eaten yet. Staff I further confirmed that Resident 23 had not been assisted to eat either (exited the building at 5:23 PM and neither resident 6 nor 23 had been served or assisted with their meal. 14 minutes after the other residents had been observed being assisted). A concurrent observation and interview on 06/04/2025 at 11:38 AM, showed Staff R, NA, sitting at one table in the dining area assisting a resident with their meal. Resident 2 was sitting at the 2nd table with no food and directly across the table from Resident 2 was another resident who had been served their meal and was eating. Observations showed Resident 6 sitting in between the two tables in the dining room area, in their w/c, waiting for their meal and assistance, and Resident 23 stood by the two tables, walking back and forth from table to table. Additionally, Resident 2 blankly stared at the resident eating across from them, and at times would wrinkle their forehead and scowl (an angry or bad-tempered expression). Staff R stated they were the only NA at the time and the other NA had been on their lunch break. Observations at 11:55 AM, showed Staff K, NA, had returned from their lunch break and assisted Resident 6 with their meal. Resident 2 and Resident 23 were waiting for their meal and staff assistance. Resident 2 continued watching the resident across from them eating. An observation at 12:16 PM, showed Resident 2 received their lunch with staff assistance (38 minutes after the first resident was being observed being assisted). Observations at 12:36 PM (58 minutes after all other residents) showed Resident 23 received their lunch with staff assistance. Staff K stated they had four residents out of the seven they were assigned that required staff assistance with their meals and they just had to prioritize who to assist first. During an interview on 06/06/2025 at 1:38 PM, Staff B, Director of Nursing Services, stated they felt they had enough staff for the level of supervision the residents required, not the amount of assistance they needed. Staff B stated they would have expected the NAs to call for additional assistance if they did not have enough staff to assist with feeding all the assisted residents at the same time.

Based on observation, interview, and record review the facility failed to follow physician's orders to obtain specialized services for 1 of 2 residents (Resident 15) reviewed for pain. This failed practice placed residents at risk of not receiving needed specialized care and services and a decline in health and/or mobility. Findings included . <Resident 15> Review of the resident's medical records showed they admitted with diagnoses of Intellectual Disabilities (limitations in cognitive functioning and skills, including conceptual, social, and practical skills) and autism (when a person has trouble communicating and understanding what people think and feel). Review of the 03/13/2025 comprehensive assessment showed Resident 15's cognition was severely impaired and was independent for transfers and ambulation. During an observation and concurrent interview on 06/02/2025 at 3:00 PM, Resident 15 was sitting in a chair in the dining room, stood up, and walked towards the back patio door. When Resident 15 walked, they had a slight limp to their left leg. Resident 15 was wearing shorts, and the left knee showed some mild swelling compared to the visualization of the bones from the right knee to the left knee. Staff P, Nursing Assistant, stated Resident 15 had limped on their left leg for the past few months, off and on. Staff P stated they went to have imaging but for some reason that could not be completed. Staff P stated Resident 15 had been put on a pain medication for their left leg. Review of Resident 15's care plan dated 06/14/2024 through 09/13/2024, showed no care plan to reflect Resident 15's left leg limping or increased pain. Review of the Orthopedic (Ortho, a specialist who diagnoses and treats conditions affecting the bones, muscles, and joints) specialist's note, dated 03/06/2025, showed Resident 15 was being seen for left knee pain and the symptoms were gradually worsening. The plan was to obtain further imaging for concerns that Resident 15 experienced internal derangement (internal damage to the knee caused due to trauma) to their left knee. The note showed Resident 15 would require intravenous (IV, medication provided into the vein) sedation due to the resident's diagnoses. Further, Resident 15 was to have rest and activity modification to prevent increased stress to the knee, ice alternating with heat, and possible topical pain-relieving creams and ointments. Review of a follow-up note, dated 03/06/2025, sent to the facility from the Ortho showed; Ordering MRI (Magnetic Resonance Imaging, a medical imaging technique that uses a powerful magnet, radiation waves, and a computer to create detailed images of the inside of the body) with IV sedation of the left knee and to follow-up after the imaging was completed. Review of a follow-up note, dated 04/04/2025 sent to the local hospital, showed IV is not done at our facility and the provider was called and asked to prescribe oral sedation. The note had no other documentation or who signed or sent the note. Review of Resident 15 progress notes, showed: • 03/17/2025 - the RR reached out to inquire about an imaging appointment and was told one had not been made yet and would reach out to the Ortho. • 04/04/2025 - Resident 15 went to the local hospital for scheduled imaging of their left knee. Staff that assisted Resident 15 was told they did not perform imaging under general anesthesia (a medical treatment that induces a sleep-like state by administering medications through an IV) so the imaging was not completed. • 04/04/2025 - the RR called the facility to see what the next steps were and informed the facility they wanted the provider, or the Medical Director consulted with for the next steps and requested the possibility of finding another facility for the imaging. The note showed they followed up with the provider and they were told to locate another facility that would perform the imaging. • 04/08/2025, 04/27/2025, 05/01/2025, 05/05/22025, and 5/15/2025 - Resident 15 continued with limping to their left leg. Review of Resident 15's 06/2025 physician orders showed an order initiated on 04/29/2025 for ibuprofen (a brand of medication used for pain and swelling) 600 milligrams (a unit of measure) twice daily for diagnosis of Osteoarthritis (breakdown of cartilage in the joints, leading to pain, stiffness, and limited movement) of knee (which knee is not specified). Review of a 03/06/2025 Physician's note, showed Resident 15 was followed up by the Ortho and had orders for imaging for further evaluation. Another note dated 05/05/2025, showed Resident 15 had on-going left knee pain with limping and had a referral to an Ortho for imaging. The note showed blood tests were ordered via verbal order due to the Resident Representative's (RR) concern for Rheumatoid Arthritis (RA, a chronic inflammatory disorder that can affect more than just your joints) and for Resident 15 to continue with the use of the ibuprofen. Review of Resident 15's blood test results showed no blood tests had been obtained to rule out RA as the RR had requested and the provider had verbally ordered on 05/05/2025. During an interview on 06/06/2025 at 8:21 AM, Staff D, Resident Care Coordinator (RCC), stated the facility waited for the Ortho to make Resident 15 an appointment for the imaging (63 days later). Staff D stated their attempts to reach the Ortho had not been successful and had left requests for a return call. Staff D stated the RA blood tests were just ordered (32 days after verbal order) and were working on that. Staff D stated they had not reached out to Resident 15's primary provider because Resident 15 had been referred to a specialist and once, they were referred out, our hands don't do anything from that point, so we don't step on anyone's toes. Staff D stated they had reached out to the RR to request them to call the Ortho to see what the plan was. Staff D stated they thought they updated Resident 15's care plan but at times when they update it, stuff just disappears or doesn't go anywhere. Staff D stated they did not follow up with Ortho's plan for ice and heat and activity modifications because they must have overlooked those directions. A concurrent observation and interview on 06/06/2025 at 12:46 PM, Staff Q, Recreation Nursing Assistant, stated they attended the imaging appointment with Resident 15 for their left knee. Staff Q stated when they arrived, they were told by the local hospital that when the appointment was made, they informed the caller they did not do imaging under general anesthesia, so refused to see them. During this interview, Staff Q was walking with Resident 15 outside in the parking lot, Staff Q let go of Resident 15's hand to allow them to walk on their own. Resident 15 walked without a limp, but when taking a step with their left leg, they would swing the left leg slightly outwards, as if not to bend it all of the way. Staff Q stated they had noticed that as well. Resident 15's left knee showed mild swelling compared to the right knee. During an interview on 06/06/2025 at 1:38 PM, Staff B, Director of Nursing Services, stated they would have expected Staff D to have followed up with Resident 15's primary provider for additional imaging orders or at least a plan of action to ensure the imaging ordered had been completed. Staff B stated the RCC's should continue to do all they can, even when a resident was referred out to another provider, to ensure they get done what they need. Staff B stated they did not know why the blood work ordered had not been completed but it should have been. Staff B stated notes from providers should be read when a resident returned from an appointment and additional interventions put into place if that is what was ordered. Staff B stated that did not happen with Resident 15. Additionally, Staff B stated Staff D should not have reached out to Resident 15's RR for assistance in obtaining the imaging ordered.

Based on interview and record review, the facility failed to issue a written notice of bed hold (holding or reserving a resident's bed while the resident was absent from the facility) and provide a written notice to the resident and/or their representative of a hospital transfer for 1 of 2 residents (Residents 15) reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed and any monetary charges associated with the bed hold and lack of discharge needs while in the hospital. Findings included . <Resident 15> Review of the resident ' s medical record showed they admitted to the facility with diagnoses to include Intellectual Disabilities (ID, limitations in cognitive functioning and skills, including conceptual, social, and practical skills) and epilepsy (a brain condition that causes recurring seizures, which are abnormal electrical brain activities). The 03/13/2025 comprehensive assessment showed Resident 15's cognition was severely impaired and had readmitted to the facility on after a hospital stay. Review of Resident 15's progress notes dated 02/12/2025 showed the resident experienced loose stools and an elevated temperature for three days. The provider was notified, and orders were given to send Resident 15 to the hospital. A follow-up progress notes on the same day showed the resident had sepsis (a serious condition in which the body responds improperly to an infection, causing organ damage and sometimes death) and was admitted to the hospital. Further review of the medical record showed Resident 15, nor their Resident Representative (RR) were offered a bed hold or were they given a notification of a hospital transfer. During an interview on 06/06/2025 at 3:04 PM, Staff N, Social Services Specialist, stated they normally received a notification by electronic mail (email) if a resident had been admitted to the hospital. Staff N stated they had not received that email or I missed it somehow and the bed hold, and transfer notification had not been done. During an interview on 06/06/2025 at 3:24 PM, Staff A, Administrator, stated they would have expected the bed hold and the notification of transfer to be completed per their policy. Staff A stated the process was to offer the bed hold and they were aware that got missed.

Based on interview and record review the facility failed to develop a base line care plan (BCP), for 3 of 3 residents (Resident's 43, 44 and 35) reviewed for base line care planning. The facility failed to provide the residents or their representatives with a written summary of the required information upon completion of the comprehensive care plan. The missing information included the resident's initial goals, physician's orders and current diet orders. This failure placed the residents at risk for adverse events and unmet care needs. Findings included . <Resident 43> Review of the resident's record showed they were admitted to the facility on [DATE] with diagnoses which included autism (a mental health condition that affects an individual's ability to communicate and react to the environment), and intellectual disability (limitations in cognitive functioning). The comprehensive assessment dated [DATE] showed Resident 43 had severe cognitive impairment and required two staff to support their activities of daily living (ADL's, basic tasks needed for self-care). Review of Resident 43's CP dated 01/23/2025 showed the required components were not included such as initial goals, physician or dietary orders. Additionally there was no documentation that a written copy had been given to the resident's representative once it had been completed. During an interview on 06/06/2025 at 2:40 PM, Staff E, Resident Care Coordinator (RCC) stated they did not include initial goals, physician orders or current diet orders on the CP. Staff E stated they were unaware of the required components to be included on the CP. <Resident 44> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses that included autism, intellectual disability and epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures). Review of the comprehensive assessment dated [DATE] showed the resident had severely impaired cognition and required supervision and minimal assistance from staff for ADL's. Record review of Resident 44's CP dated 03/06/2025 showed no initial goals, physician orders or dietary orders listed. <Resident 35> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses including cerebral palsy (a congenital (prior to birth) disorder of movement and muscle tone), osteomyelitis (inflammation of bone caused by infection) in the sacrum (a bone located at the base of the spine) and diabetes (too much sugar in the blood). Review of the comprehensive assessment dated [DATE] showed the resident was cognitively intact and required substantial to total assistance from staff for ADL's and mobility. Record review of Resident 35's CP dated 10/23/2024 showed no initial goals, physician or dietary orders identified. Additional review showed there was no documentation that the CP had been given to the resident after it had been completed. During an interview on 06/06/2025 at 11:44 AM, Staff D, RCC stated they had been responsible to develop the CP's for Resident's 43 and 35. Staff D stated the CP's did not include the required components for initial goals, physician or dietary orders. During an interview on 06/06/2025 at 1:12 PM, Staff B, Director of Nursing Services, stated they had not been aware of the requirement to develop a CP which included the resident's initial goals, physician and dietary orders. Staff B stated, We are working on a new process to develop a CP with the identified components as we did not have one before.

Based on interview and record review, the facility failed to validate the accuracy of a resident's Preadmission Screening and Resident Reviews ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) as required for 1 of 5 residents (Resident 35) reviewed for PASARR. This failure placed the residents at risk for not receiving the care and services appropriate to their needs. Findings included . <Resident 35> Review of Resident 35's medical record showed the resident was admitted to the facility on [DATE] with diagnoses including a bone infection of the lower spine, depression and anxiety. The comprehensive assessment, dated 05/05/2025, showed the resident was cognitively intact, could make their needs known and had active diagnoses of an anxiety disorder and depression. Review of Resident 35's PASARR, dated 11/01/2024, showed under section I, SMI/ID, had been marked for depression but was not marked for anxiety. During an interview on 06/06/2025 at 1:57 PM, Staff F, Social Service Director, stated they, along with the Resident Care Coordinators, reviewed resident PASARR's for accuracy before submitting a referral for positive Level 1 PASARR's. Staff F stated they were not aware that Resident 35 had a diagnosis of anxiety, and the resident PASARR was not accurate and needed to be corrected and resubmitted. During an interview on 06/06/2025 at 4:16 PM, Staff A, Administrator, stated the facility staff know the procedure for resident PASARR's and checking to make sure resident SMI diagnoses were accurate was a part of that. Staff A stated the correct process was no followed for Resident 35's PASARR.

Based on observation, interview, and record review, the facility failed to ensure care, the assessed level of supervision and assistance were consistently provided to prevent an avoidable accident for 1 of 3 residents (Resident 1) reviewed for falls with injury. Resident 1 experienced harm when they were left unsupervised, had an unwitnessed fall or contact with a firm surface and developed a hematoma (a localized collection of clotted blood that pools outside of the blood vessels, similar to a bruise) to the right eye. Findings included . Record review of facility's policy titled, Level of Supervision (LOS) 1.08, dated 10/2024, showed that a LOS would be assigned to provide an appropriate degree of supervision for each resident. Direct care staff will check the LOS assigned in the resident's record daily. Definition for LOS 3 was supervision must be positioned in a manner to protect the resident from or deter (prevent) danger. Enhanced staffing [was] required. <Resident 1> Record review showed Resident 1 was a long-term resident of the facility with a diagnosis that included severe intellectual disabilities (a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently), anxiety disorder (the mind and body's reaction to stressful, dangerous, or unfamiliar situations), Obsessive-compulsive disorder (a disorder that causes unwanted thoughts and fears [obsessions] and repetitive behaviors [compulsions] that interfere with daily life) and cataracts (a clouding of the lens of the eye that affects vision) in both eyes. Record review of a 03/11/2025 comprehensive assessment showed that Resident 1 walked independently and required some staff assistance for activities daily living, such as dressing and hygiene. The resident had a history of falls. Record review of the resident's 03/12/2025 care plan showed Resident 1 required LOS 3 to deter them from danger related to their lack of safety awareness, lack of coordination and impaired vision. Review of a 05/06/2025 at 6:30 AM progress note showed that staff heard a loud thud in the back hallway earlier that morning and Resident 1 was later found walking in the back hallway with a bump and swelling to their right eye and right cheek bone. Record review of the incident investigation, dated 05/13/2025, showed that Staff C, Attendant Counselor (AC, same as a nursing assistant) was assigned to Resident 1 the morning of 05/06/2025 and left the resident unsupervised in the back hallway to take out the garbage at 5:30 AM. Resident 1 was found at 5:40 AM walking out of the back hallway with swelling and bruising above and below their right eye. The possible cause was determined to be an unwitnessed fall and/or bumping into a firm surface while unsupervised. Record review of a 05/06/2025 at 12:39 PM nursing progress note showed a hematoma developed to the right eye that measured six centimeters (cm) by four cm. Observation on 05/27/2025 at 3:30 PM showed Resident 1 was leaving the bathroom after changing their pants and walked from the back hallway to the dining room with their assigned staff nearby. Resident 1 had resolving bruises above and below their right eye. Resident 1 smiled, clapped their hands and sat in a dining chair. During an interview on 05/27/2025 at 3:35 PM, Staff D, AC shift charge, stated that residents on LOS 3 have an assigned staff that needed to be able to always see the resident. Staff D stated that Resident 1 was at risk for falling and that was one reason the resident was LOS 3. During a telephone interview on 05/27/2025 at 11:00 PM, Staff E, AC, stated they worked the morning of 05/06/2025 and heard a loud thump come from the back hallway around 5:30 AM. They stated they were not aware Resident 1 was in the back hallway unsupervised when they heard the sound until they observed Staff C enter the front door after taking out the garbage. They stated they then went back to check on Resident 1 and observed them walking into their bedroom, however, they did not see Resident 1's face. During an interview on 05/28/2025 at 2:30 PM, Staff C stated they were assigned to Resident 1 the morning of 05/06/2025. Staff C stated they had just finished assisting their assigned residents to toilet and dress when they took the garbage from the back of the unit out the front door. Staff C stated before leaving the back hallway, they found Resident 1 standing in the clean linen room (the door was propped open). Staff C stated they guided Resident 1 out of the clean linen room, shut the door and proceeded to take the garbage to the front of the unit and went out of the front door. Staff C stated they saw the two other staff in the dining and living areas; however, they did not notify these staff that they were taking out the garbage and Resident 1 was alone in the back hallway. Staff C stated that when they returned to the unit, they went to the kitchen area to document on the resident sleep charts. Then at approximately 5:40 AM when heading to the back hallway, they observed Resident 1 walking down the hall with the injuries around their right eye. During an interview on 05/28/2025 at 3:55 PM, Staff B, Director of Nursing, stated that residents on LOS 3 should always be in a staff's line of sight. Staff C did not follow the resident's care plan and should not have left Resident 1 alone in the back hall. Reference: WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to protect 5 of 5 residents (Resident 1, 2, 3, 4, and 5) from misappropriation of controlled medications (narcotics) by 1 of 1 staff (Staff C, Registered Nurse [RN]), reviewed for drug diversion (transfer of medication from the resident it was prescribed for to another person for unlawful use). This failure placed the residents at risk for pain, unmet care needs, on-going misappropriation of medication, and a diminished quality of life. Findings included . Record review of the facility's policy titled Controlled Substance (Medication) Accountability, 7.08 dated 02/2025, showed that controlled substances would be strictly accounted for from acquisition through dispensing, and their disposal if necessary. An accurate inventory of all controlled substances would be conducted on the living unit by nursing staff. The pharmacist would review the controlled substance log monthly and sign the log. Each nursing unit would maintain a bound controlled substance logbook with consecutively numbered pages. The date, time, dosage, dosage remaining and the signature of the nurse would be documented each time a dose was removed from the controlled substance bingo card (a method of packaging medications in which a blister pack was enclosed in a folded-over card with foil backed blisters/bubbles, where medications were packaged in a seven day, 14 day, 30 dose or 60 dose card.) Controlled substances were double locked and counted each sift by two nurses. The Director of Nursing would investigate any significant loss of a controlled substance on the living unit. Review of a facility incident report dated 01/29/2025 showed that the Staff D, Clinical Pharmacist, had discovered oxycodone 5 milligram (mg) tablets (a controlled medication used for pain with a high potential for abuse and the potential to cause severe dependence if abused), had been replaced with loratadine 10 mg tablets (a medication used to treat allergy symptoms) for Resident 1 and Resident 3. The backs of the bingo card foil had a small cut, the tablets had been replaced, and the foil taped shut. Staff D reported to the facility administration and reviewed all schedule medications on the living unit. Three additional tampered bingo cards of oxycodone 5 mg were found, one bingo card each for Resident 2, Resident 4 and Resident 5. Staff E, RN / Acting Director of Nursing (DON), reviewed the impacted resident's records, found they were at baseline and placed the residents on ongoing monitoring. <Resident 1> Record review showed Resident 1 was a long-term resident with diagnoses that included profound intellectual disabilities (a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently), cerebral palsy (a group of conditions that affect movement and posture. Caused by damage that occurred to the developing brain, most often before birth), and dysmenorrhea (a condition that caused severe and frequent menstrual cramps and pain). Review of a 01/20/2025 comprehensive assessment showed that the resident had total dependence on staff for all their activities of daily living (ADL) and had severe cognitive impairment. Review of a 11/01/2024 care plan showed Resident 1 was treated for chronic pain caused by hip dislocation (when the ball-shaped head of the femur separates from its cup-shaped socket in the hip bone), and dysmenorrhea. Resident 1 would exhibit non-verbal signs of pain by crying, biting their hand and grimacing. Record review of Resident 1's January 2025 physician orders showed an order for oxycodone tab 5 mg prn (as needed) every eight hours for breakthrough pain after Tylenol and ibuprofen had been tried. On 02/11/2025 at 2:30 PM, an observation of the tampered bingo cards was made in the facility pharmacy with Staff F, Clinical Pharmacist. Review of Resident 1's bingo card of oxycodone tab 5 mg showed 30 tablets were filled by the facility pharmacy on 11/06/2024. Review of the front of the bingo card showed first dose of oxycodone 5 mg was given on 11/09/2024 (indicated by nurse initials and date). Review of the back of the bingo card showed doses 23 through 30 were not tampered with (had no cut foil). The cut foil was observed on the right side of the bingo card foil beginning with dose 22 through dose one. The last non-tampered dose was given on 12/02/2024 and the first tampered dose was given on 12/06/2024 (the tamper date window). Review of the corresponding controlled medication/narcotic record showed that Resident 1 received 14 doses of loratadine instead of the ordered oxycodone. The bingo card had eight taped foil bubbles of the loratadine tablets retained by the pharmacy on 01/29/2025. <Resident 2> Record review showed Resident 2 was a long-term resident with diagnoses that included profound intellectual disabilities, cerebral palsy and hip dislocation. Review of the 11/10/2024 comprehensive assessment showed that the resident had total dependence on staff for all their ADLs and had severe cognitive impairment. Review of a 11/19/2024 care plan showed Resident 2 would exhibit discomfort and pain by yelling and slapping themselves on the face. Record review of Resident 2's January 2025 physician orders showed an order for oxycodone tab 5 mg every eight hours prn pain, must try and fail Tylenol prior to each use. On 02/11/2025 at 2:30 PM, observation of Resident 2's bingo card of oxycodone tab 5 mg showed 20 tablets were dispensed by the pharmacy on 10/02/2024. Review of the back of the bingo card showed the foil was cut on all 20 doses and two doses (of loratadine) were given to Resident 2 on 12/27/2024 and 01/19/2025. <Resident 3> Record review showed Resident 3 was a long-term resident with diagnoses that included profound intellectual disabilities. Review of the 02/07/2025 comprehensive assessment showed that the resident had total dependence on staff for all their ADLs and had severe cognitive impairment. Review of a 08/07/2024 care plan showed Resident 3 would exhibit discomfort and pain by pacing, dropping to the floor, pulling their hair and hitting self in the face. Record review of Resident 3's January 2025 physician orders showed an order for oxycodone tab 5 mg every six hours prn for pain. On 02/11/2025 at 2:30 PM, an observation was made in the pharmacy with Staff F of Resident 3's bingo card of oxycodone 5 mg showed 60 tablets were dispensed by the facility pharmacy on 01/11/2024 (more than one year ago). Review of the back of the bingo card showed the foil was cut and taped on all 60 doses with the first dose given on 03/30/2024. Resident 3 received 25 doses administered of loratadine (instead of oxycodone), and 35 loratadine tablets remained on the bingo card when retained by the pharmacy. <Resident 4> Record review showed Resident 4 was a long-term resident with diagnoses that included profound intellectual disabilities, cerebral palsy and kidney stones (hard deposits of minerals develop inside the kidney and cause symptoms of pain and difficulty passing urine). Review of a 01/19/2025 comprehensive assessment showed that the resident had total dependence on staff for all their ADLs and had severe cognitive impairment. Review of a 07/19/2024 care plan showed Resident 4 would exhibit discomfort and pain by their increased frequency of vocalizations. Record review of Resident 4's January 2025 physician orders showed an order for oxycodone 5 mg tab two times a day prn for pain. On 02/11/2025 at 2:30 PM, an observation was made in the pharmacy of Resident 4's bingo card of oxycodone 5 mg that showed 30 tablets were dispensed by the facility pharmacy on 11/06/2024. Review of the back of the bingo card showed the foil was cut on bubbles 25 through one. The first tampered foil/bubble was given to Resident 4 on 12/06/2024. There were eight doses of loratadine given instead of the ordered oxycodone and 17 doses of loratadine tabs remained on the bingo card. <Resident 5> Record review showed Resident 5 was admitted on [DATE] with diagnoses that included cerebral palsy, and osteoarthritis (a long-term degenerative joint condition in which the joints gradually deteriorate, causing pain and stiff joints). Review of a 10/23/2024 care plan showed Resident 5 would verbally express their discomfort and pain, received routine and prn pain medication. Record review of Resident 5's January 2025 physician orders showed an order for oxycodone tab 5 mg two times a day as needed for pain. On 02/11/2025 at 2:30 PM, observation made with Staff F, of Resident 5's bingo card of oxycodone 5 mg showed 60 tablets were dispensed by the facility pharmacy on 12/18/2024. Review of the back of the bingo card showed all 60 foil/bubbles were tampered with and the remaining 38 tablets were loratadine. Resident 5 received 22 doses of loratadine between 12/22/2024 and 01/29/2025. During an interview on 02/10/2025 at 11:10 AM, Staff E, RN / Acting DON, stated they started their investigation after being notified by the pharmacist on 01/29/2025. They stated they narrowed down the dates the bingo cards were tampered with and by reviewing the nursing schedules, they identified three licensed nurses that had keys to the narcotic drawers during the tamper dates. These nurses were removed from direct nursing care the morning of 01/30/2025. Staff E stated 187 doses of oxycodone tab 5 mg foil/bubbles were cut and taped on the five bingo cards. Staff E stated they reviewed the five resident's charts during the dates they did not receive the oxycodone for pain and found the residents had a documented decrease in pain symptoms or voiced pain relief. On 02/11/2025 at 2:30 PM the five tampered bingo cards were observed in the facility pharmacy with Staff E, Staff F, and law enforcement. The foil cuts and tape were not visible unless the card was held up to a light source. Staff F stated the loratadine tablets were part of the stock supply on each medication cart and look like the oxycodone tablets. Staff F stated they had never seen narcotic diversion accomplished this way. On 03/12/2025 law enforcement had interviews scheduled with each of the three licensed nurses (including Staff C) who had worked during the bingo card tamper date windows. A Residential Care Services investigator sat in on the interviews. On 03/12/2025 at 11:30 AM, Staff C, RN, stated during the law enforcement interview (Residential Care Services Investigator was present and observing) that they switched out the oxycodone with the loratadine tablets by cutting the foil back with a paperclip and taping the window shut. During an interview on 03/12/2025 at 3:15 PM, Staff B, Assistant Administrator, stated they were saddened this diversion occurred and was thankful that the other two licensed nurses could now return to work. Staff B stated, this was so wrong for the residents, who cannot verbalize how they feel and not get the pain medication that was ordered for them. Reference: WAC 388-97-0640(2)(a), (3)(c)(d)

Based on interview and record review, the facility failed to ensure 7 of 11 staff (Staff M, O, Q, D, F, J, and H) immediately (not later than two hours after the allegation was made) reported allegations of abuse to the facility administration and State Agency (SA) and to implement timely interentions to protect 2 of 2 residents (Resident 1 and Resident 3) reviewed for abuse reporting. This failure placed the residents at risk for continued abuse, potential for harm, and diminished quality of life and constituted an immediate jeopardy (IJ). On 08/29/2024 the facility was notified of the noncompliance identified at the level of an IJ in F-Tag 609, 42 CFR S483.12(c)(1) Reporting of Alleged Violations, for failure to ensure staff reported alleged abuse immediately to both the facility Nursing Home Administrator (NHA) and Stage Agency (SA) abuse hotline that resulted in a delay of up to 17 days to remove the alleged perpetrators from direct resident care. The facility removed the immediacy on 08/30/2024 with an onsite verification from investigators. The facility provided all staff mandatory training on Abuse, Neglect, and Mandatory Reporting with a live instructor in a classroom setting prior to working with vulnerable adults. The staff training plan included on-call staff and new hires. Staff were provided with a small how to report card during the live training 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 24 hours, seven days a week. Findings included . Record review of the facility's policy titled, Resident Incident Management 2.02, dated 08/22/2023, showed that abuse and neglect of vulnerable adults was prohibited by law and would not be tolerated. All facility employees, contractors, volunteers, and students must report every incident observed, reported, or suspected abuse of residents to the Complaint Resolution Unit (CRU) (SA abuse hotline.) After fulfilling the duty as a Mandatory Reporter, they must also report the incident to the DNS and Superintendent (NHA) or Officer of the Day (designee). <Resident 1> Record review showed Resident 1 was admitted on [DATE] with multiple diagnoses including profound intellectual disabilities (a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently) and autism (a condition related to brain development that impacts how a person perceives and socializes with others). Review of the 06/01/2024 comprehensive assessment showed Resident 1 had no speech, highly impaired vision and moderate cognitive impairment. The resident had self-injurious behaviors (SIB) that put them at risk for injury to themselves. Review of Resident 1's care plan, dated 06/14/2024, showed that they exhibited severe SIB, such as slapping self, punching their head or pulling their hair. Staff had interventions to redirect the behavior by identifying what the resident needed and if not redirectable, the staff had a protective helmet and mitts they could apply with a physician order to protect the resident from injury. <Allegation 1> Record review of a 07/25/2024 witness statement written by Staff M, Nursing Assistant (NA), showed that on a day they worked evening shift in cottage 405/406 (shift log showed it was on 06/29/2024) they observed Staff N, NA, physically abuse Resident 1. They stated that they reported the incident the following day (06/30/2024) to their supervisor, Staff O, NA Supervisor. Staff M did not report to the facility NHA and the SA abuse hotline within the required time frame. Review of a 07/16/2024 Developmental Disabilities Administration (DDA) Statewide Investigation Unit ([NAME]- performs impartial abuse and neglect investigations in state residential facilities) report showed the facility administration was informed of an allegation that Staff N had hit Resident 1 on the head to stop their behaviors, no date or time of the alleged abuse was provided. The facility removed Staff N from resident care when the Administrator was made aware of the incident (17 days after alleged abuse). Review of a 07/29/2024 DDA [NAME] report showed that Staff O stated that Staff M reported to them on 06/30/2024 that the day prior, they observed Staff N hit Resident 1 in the head. Staff O reported they told Staff M that they needed to report the allegation to the SA abuse hotline and to Staff P, NA Manager. Staff O stated that they reported the 06/29/2024 allegation, to Staff Q, NA Charge, by telephone on 07/01/2024. Staff O stated that they reported the allegation during a meeting with Staff P on 07/23/2024. Staff O and Staff Q did not report the alleged abuse to the NHA or SA abuse hotline. Review of a 07/16/2024 DDA [NAME] report showed that based on the information available, there was insufficient evidence to conclude the allegation occurred. The investigation had been turned over to law enforcement on 07/10/2024. <Allegation 2> Review of a witness statement written by Staff D, NA, on 07/08/2024, showed that on 07/06/2024 at 10:00 PM, Resident 1 was lying down in bed and could be heard tapping on their head. [I] redirected to not hit [them]self and told [them] it's bedtime. [Staff C, NA] goes in and kicks [Resident 1] in the face. [I] told [Staff C] to leave, [Resident 1] had no response and went to bed. Review of Staff D's, statement from a 07/12/2024 at 11:00 AM interview, documented in a 07/10/2024 DDA [NAME] report, showed that they were confused and in shock and did not know what to do and they reported to their shift charge (Staff Q) after they had left work on 07/06/2024. Staff D did not report to the NHA and SA abuse hotline. Review of Staff F's, NA, statement from 07/15/2024 at 1:57 PM, documented in the 07/10/2024 DDA [NAME] report showed that they walked in directly behind Staff C and saw them lift their leg towards Resident 1. Staff F stated they then saw Staff C raise their arms over their head and bringing them down on Resident 1. Staff F stated they did not directly see where Staff C hit or kicked Resident 1 but heard the sound of making impact. Staff F did not report what they witnessed to the facility NHA and SA abuse hotline. Review of the 07/06/2024 facility initial incident report showed that Staff Y, Licensed Practical Nurse, was notified of the allegation of abuse at 10:47 PM, the DNS designee and the NHA designee were both notified at 11:00 PM. Review of a statement written by Staff R, Registered Nurse, dated 07/07/2024 at 9:23 PM, showed they were made aware of the allegation of abuse on 07/06/2024 at 11:00 PM. Staff R reported they went to cottage 405 and found [Staff C] was still working in the cottage and stocking the clean linen room. I asked [Staff C] to remove [them]self from the cottage to protect the residents. Record review of the State complaint tracking system showed the State Agency abuse hotline received an online/portal report of the abuse allegation on 07/07/2024 at 12:49 AM. <Resident 3> Record review showed Resident 3 was admitted on [DATE] with multiple diagnoses including cerebral palsy (a group of conditions that affect movement and posture. It's caused by damage that occurs to the developing brain, most often before birth), unspecified intellectual disabilities (a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently), and adjustment disorder (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior). Review of the 07/14/2024 comprehensive assessment showed Resident 3 had no speech, highly impaired vision, and moderate cognitive impairment. Review of Resident 3's care plan, dated 04/14/2024, showed they could be unsteady with walking, did not understand personal space, would get too close to others trying to touch or pinch, and was obsessive about taking their clothes off. Review of an 08/03/2024 facility incident report showed on 08/02/2024 at 2:25 PM, Staff J, NA, and Staff H, NA, observed Staff I drag Resident 3 across the floor to their bedroom. The NHA designee was notified on 08/03/2024 at 12:50 AM (10.5 hours after alleged abuse was witnessed). The SA abuse hotline was notified on 08/03/2024 at 1:21 AM (11 hours after alleged abuse). Review of an 08/03/2024 DDA [NAME] report showed on 08/09/2024 at 12:51 PM Staff J stated that they were shocked by what they witnessed Staff I do with Resident 3 and that they did not know what to do and reported the incident to Staff P, NA supervisor, on 08/02/2024 at 10:00 PM. During an interview on 08/14/2024 at 2:03 PM Staff I, NA, stated that they worked in cottage 203 on 08/02/2024 and denied they handled Resident 3 in a rough manner before the end of their shift. Staff I stated they started work at 6:00 AM on 08/03/2024 in cottage 203. They stated at 7:30 AM they were told by Staff V, Registered Nurse, to go up to the duty desk (a central staffing office) for the rest of the day and 08/04/2024. (17 hours after alleged abuse.) During an interview on 08/14/2024 at 2:40 PM, Staff H stated they witnessed Staff I drag Resident 3 to their bedroom on 08/02/2024. Staff H stated they knew Staff J reported what they witnessed to their supervisor, Staff P, NA. Staff H stated they had been trained to report abuse by calling the SA abuse hotline, notify the nurse and the NA Manager/supervisor, however they did not report because they knew Staff J had reported. During an interview on 08/15/2024 at 1:45 PM, Staff J stated that after the incident occurred, they did not say anything to any one until I reported to [Staff P], my supervisor, at 10:00 PM when they came to work. [Staff P] told me to call the state abuse hotline and found the phone number for me. During an interview on 08/30/2024 at 3:38 PM, Staff B, Assistant Superintendent (Assistant NHA), stated we should not have missed these reports of abuse, it was expected that all staff know how to report abuse allegations. Reference: WAC 388-97-0640(2)(b)(5)(a)(6)(b)(7)(a)

Based on interview and record review the facility failed to protect a resident's right to be free from physical abuse for 2 of 2 cognitively impaired residents (Resident 1 and Resident 3) reviewed for allegations of abuse. This failure resulted in physical harm when Resident 1 who had severe cognitive impairment, dependence on staff, and was unable to express discomfort, was kicked in the face. Resident 1 experienced psychosocial harm, applying the reasonable person concept when Resident 1 had a change in sleep behaviors and eating patterns and seemed more withdrawn. This failure placed the residents at risk for further abuse, injury, and diminished quality of life. Findings included . Review of the State Operations Manual (SOM), Psychosocial Outcome Severity Guide dated 10/24/2022, showed when a resident's reaction to a deficient practice (such as physical abuse) were markedly incongruent (or different) with the level of reaction a reasonable person in the resident's position would have to the physical abuse (such as the facility being their home with the expectation of safety and trust in the facility staff to protect them from harm). Record review of the facility's policy titled, Resident Rights 1.02, dated 06/30/2023, showed that residents have the right to legal protections from mental, physical, and sexual abuse. Record review of Developmental Disabilities Administration (DDA) policy titled, Protection from Abuse: Mandatory Reporting 5.13, dated 07/2024, showed abuse and neglect of vulnerable adults is prohibited by law and will not be tolerated. <Resident 1> A record review showed Resident 1 was admitted on [DATE] with multiple diagnoses including profound intellectual disabilities (a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently), autism (a condition related to brain development that impacts how a person perceives and socializes with others), insomnia (a sleep disorder characterized by difficulty falling asleep or staying asleep) and anxiety disorder (the mind and body's reaction to stressful, dangerous, or unfamiliar situations). Review of the 06/01/2024 comprehensive assessment showed Resident 1 had no speech, highly impaired vision and moderate cognitive impairment. The resident had self-injurious behaviors (SIB) that put them at risk for injury to themselves. Review of Resident 1's care plan dated 06/14/2024 showed that they exhibited severe self-injurious behaviors, such as slapping self, punching their head or pulling their hair. Staff had interventions to redirect the behavior by identifying what the resident needed and if not redirectable, the staff had a protective helmet and mitts they could apply with a physician order to protect the resident from injury. Further review of Resident 1's care plan showed that when awake, they were on a Level of Supervision (LOS) 4: One-to-one supervision, allowing as much social space as possible. Supervision must be positioned in a manner to prevent danger or harm to self or others. If the resident were in their room, staff were to be positioned outside the door, with the curtain pulled, staff were to be positioned outside their door and perform visual checks (eyes on Resident 1) every five minutes. When sleeping, the resident was on a LOS 3: supervision must be positioned in a manner to protect from or deter danger. Staff were to provide 15-minute checks when they were asleep, and the curtain was pulled. <Allegation 1> Record review of a 07/25/2024 witness statement written by Staff M, Attendant Counselor Nursing Assistant (NA) showed that on a day they worked evening shift in cottage 405/406 (shift log showed the date was 06/29/2024) while they were one-to-one supervision with Resident 1, they observed Staff N, NA, hit Resident 1 in the head around 5:30 PM. They stated that they took Resident 1 to the toilet and noticed they had a soiled incontinent brief. They asked Staff N to keep an eye on the resident while they got a new brief and disposed the soiled one. Staff M stated that when they returned to the bathroom, Staff N was telling Resident 1 that they needed to sit down (on the toilet) and push. Resident 1 began hitting themselves in the head and Staff N proceeded to also hit the resident in the head stating that was how to get Resident 1 to stop their SIB. Resident 1's SIB did not stop, and the nurse was notified and helped take Resident 1 to their room to apply their safety gear. Review of a 07/16/2024 DDA Statewide Investigation Unit ([NAME]- performs impartial abuse and neglect investigations in state residential facilities) report showed the facility was informed of an allegation that Staff N had hit Resident 1 in the head to stop their behaviors, no date, time or name of witness of the alleged abuse was provided. The facility removed Staff N from resident care. Based on the information available at the time, there was insufficient evidence to conclude the allegation occurred. The investigation had been turned over to law enforcement on 07/10/2024. Review of nursing progress notes from 06/29/2024 showed that Resident 1 had three episodes of SIB between 6:00 PM and 9:20 PM. The resident required application of their helmet and mitts due to Resident 1 pulling their hair, hitting their face/head with fists and biting their wrists. The nurse documented at 9:30 PM that there was no open skin on the resident's wrists nor other skin injuries observed from Resident 1's attempts at SIB. Review of Resident 1's sleep and meal consumption logs from 06/29/2024, 06/30/2024 and 07/01/2024 showed no changes to their usual sleeping and eating habits. <Allegation 2> Review of a 07/10/2024 DDA [NAME] report showed that through several witness reports and the change in Resident 1's sleep behavior, it was more likely than not that on 07/06/2024 Staff C, NA, kicked Resident 1 (in the face). Staff C was removed from direct resident care after the incident. Review of a witness statement written by Staff D, NA, on 07/08/2024, showed that on 07/06/2024 at 10:00 PM, Resident 1 was lying down in bed and could be heard tapping on their head. [I] redirected to not hit [them]self and told [them] it's bedtime. Staff C goes in and kicks [Resident 1] in the face. [I] told [Staff C] to leave, [Resident 1] had no response and went to bed. Review of a nursing progress note dated 07/07/2024 showed that on 07/06/2024 at 10:50 PM Resident 1 was examined from head to toe. The nurse observed the resident's right cheek was light red, no other injuries were found, and the resident went right back to sleep. Review of Staff E's, NA, statement from 07/11/2024 at 6:45 PM phone interview, documented in the 07/10/2024 DDA [NAME] report showed, Staff E was in the cottage 405 hall near Resident 1's bedroom, on 07/06/2024 at 10:00 PM. They could hear Resident 1 in the beginning stages of a behavior and asked Staff D if they needed help with Resident 1's safety gear (helmet/mitts). Staff E stated that Staff C started walking to Resident 1's room and stated 'oh, I want some of this' with Staff F, NA, behind them. Staff E stated within seconds, they (Staff C and Staff F) were walking out of the room giggling and there were no sounds coming from Resident 1's room. Staff E asked them 'what did you do to get [Resident 1] to stop the behavior' and they just ignored Staff E. Review of Staff G's, NA, statement from 07/15/2024 at 1:22 PM interview, documented in the 07/10/2024 DDA [NAME] report, showed that they were hanging around the hallway of cottage 405 by the bedrooms around 10:00 PM on 07/06/2024. Staff G stated they saw Staff C and Staff F enter Resident 1's bedroom. Staff G walked towards the room and stood by a short distance outside of the doorway. Staff G stated they saw Staff C pick up their right leg, like they were going to kick Resident 1, at the same time Staff F was closing the curtain. Staff G stated that they 'found it strange' that they were handling a behavior with the lights off and closing the curtain. Staff G stated they didn't hear Resident 1 after they closed the curtain only heard Staff C state you need to stop and go to sleep. Review of Staff F's statement from 07/15/2024 at 1:57 PM, documented in the 07/10/2024 DDA [NAME] report showed that they walked in directly behind Staff C and saw them lift their leg towards Resident 1. Staff F stated they then saw Staff C raise their arms over their head and bringing them down on Resident 1. Staff F stated they didn't directly see where Staff C hit or kicked Resident 1 but heard (the sounds of) making impact. During an interview on 08/07/2024 at 2:54 PM, Staff D refused to talk about what they witnessed on 07/06/2024 and stated, I don't want to talk, you can read my statement and ended the interview. During an interview on 08/07/2024 at 3:15 PM, Staff E, stated they were assigned one-to-one for a resident in the bedroom next to Resident 1 on 07/06/2024. Staff E stated they could hear Resident 1 start hitting themselves, I stated, is [Resident 1] going to SIB? Staff D, who was the assigned one-to-one, stood up, but Staff C headed for Resident 1's room and stated 'oh, I want some of this'. Staff F was behind Staff C, and they went into Resident 1's room with Staff D following. I heard the privacy curtain close. Staff D came out quick. I said, wow you got [Resident 1] to calm down fast. Staff D had a look of shock on their face and said, a yeah. Staff C and Staff F both came out of the room. I did not know what happened until the next day. I started my shift at 2:00 PM with Resident 1, they were sleeping and according to their sleep log had slept the whole day. Resident 1 woke up for dinner and then returned to bed and this was not normal for them. During an interview on 08/08/2024 at 4:35 PM, Staff L, NA, stated they worked evening shift in cottage 405 on 07/06/2024. Staff L stated they were in the back hallway around the time of the incident talking with Staff E and had their back to Resident 1's room. Staff L stated they heard a bit of a commotion from the room, then Resident 1 got quiet, the room got quiet. After Staff C and Staff F went to the front of the cottage, Staff D looked worried, anxious and was pacing. Staff L stated they followed Staff D into Resident 1's room and saw Staff D use their cell phone flashlight to check the right side of Resident 1's face. Staff D did not say what they were looking for. Staff L stated that the next day Resident 1 was really out of it, they slept a lot, skipped dinner and a snack, that was real unusual behavior. During an interview on 08/09/2024 at 3:05 PM, Staff K, NA, stated that they worked evening shift in cottage 405 on 07/07/2024. Staff K stated that Resident 1 was not their normal self, they seemed withdrawn and was sleeping more than usual. Staff K stated they looked at Resident 1's sleep log and they had slept all on day shift and on evening shift until 8:00 PM. <Resident 3> A record review showed Resident 3 was admitted on [DATE] with multiple diagnoses including cerebral palsy (a group of conditions that affect movement and posture. It's caused by damage that occurs to the developing brain, most often before birth), unspecified intellectual disabilities (a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently), and adjustment disorder (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior). Review of the 07/14/2024 comprehensive assessment showed Resident 3 had no speech, highly impaired vision and moderate cognitive impairment. Review of Resident 3's care plan dated 04/14/2024 showed they could be unsteady with ambulation, did not understand personal space, would get too close to others trying to touch or pinch and was obsessive about taking their clothes off. Further review of the care plan showed Resident 3 was a LOS 3 (supervision must be positioned in a manner to protect from or deter danger. Enhanced staffing was required) when the resident was awake. They were a LOS 2 (knowledge of where resident was at all times, whom they were with and what they were doing) when asleep. Review of an 08/03/2024 DDA [NAME] report showed that based on two staff witness statements, it was more likely than not that on 08/02/2024 Staff I, NA, drug Resident 3 across the floor from the living area to the resident's bedroom by dragging Resident 3's lower body as they held the top of the torso with their arm hooked under Resident 3's shoulder. Review of an 08/03/2024 at 11:01 AM nursing progress note showed that Resident 3 had a full body check with no injuries found. Review of an 08/03/2024 witness statement written by Staff H, NA, showed that on 08/02/2024 at 2:15 PM, they observed Resident 3 begin taking off their shoes while sitting in a recliner in the cottage 203 living area. They stated Staff I walked up to Resident 3, grabbed their shirt pulling them aggressively to the floor. Resident 3 then grabbed another resident's shirt who was also sitting on the floor. Staff H stated they got between the two residents, and Staff I then drug Resident 3 back to their bedroom. After Resident 3 got to their room, they started taking off their clothes and the privacy curtain was closed let Resident 3 cool down. Record review of an 08/03/2024 witness statement written by Staff J, NA, showed that on 08/02/2024 at 2:25 PM they observed Resident 3 throwing their shoes on the floor. Staff I told Resident 3 to take their shoes to their room three times. The third time, Staff I suddenly grabbed Resident 3's shirt and pulled them out of the recliner and when on the floor, Resident 3 grabbed another resident's shirt. During an interview on 08/14/2024 at 2:03 pm, Staff I stated they worked in cottage 203 on 08/02/2024. They stated that Resident 3 was sitting in a recliner in the living area and started to remove and toss their shoes. Staff I asked Resident 3 to grab their shoes and let's go to your room, the resident had no response. Staff I stated they gave the verbal que again, but the resident scooted forward in the chair, sat on the floor and grabbed another resident's shirt. Staff I stated that after a couple minutes, Resident 3 stood up on their own and were directed to their room by walking next to the resident. Staff I denied pulling the resident out of the recliner and denied dragging the resident across the floor back to their bedroom. During an interview on 08/14/2024 at 2:40 PM, Staff H stated they witnessed the incident in cottage 203 on 08/02/2024. Staff H stated Resident 3 was upset because they wanted to go on a walk and could not at that time. Resident 3 was sitting in a recliner and started to take off their shoe and tossed it. Staff I told Resident 3 to pick up your shoe and let's go to your room. Staff H stated, Resident 3 shook their head no and took off the other shoe. Then Staff I walked over to Resident 3 and grabbed the front of the resident's shirt and pulled them off the chair. Resident 3 was then laying on the floor and reached out to grab another resident's shirt. I got in the middle and pried Resident 3's fingers off the shirt. Staff H stated, [Staff I] was now grabbing Resident 3 by the wrists to get them up, but they would not stand, and while the resident was on their back, Staff I drug Resident 3 to the back hall with Staff J walking behind Staff I. Staff H stated they heard Resident 3 screaming after they were all out of sight around the corner. During an interview on 08/15/2024 at 1:45 PM, Staff J stated that on 08/02/2024 at shift overlap Resident 3 was seated in a recliner in the cottage 203 living area and had just returned from a recreation outing. They observed Resident 3 take off their shoe and toss it on the floor. Staff I told Resident 3 to put your shoe back in your room. Resident 3 then removed their other shoe and tossed it to the floor. Staff I said again put your shoes back in your room. The third time Staff I told Resident 3 to pick up their shoes, Staff I approached Resident 3 and hooked their arm under the resident's left arm making an upward motion. Resident 3 slid onto the floor and grabbed another resident's shirt. Resident 3, now laying on the floor, was grabbed by Staff I on to the left upper arm and front of the resident's shirt, and was drug across the floor by Staff I, who was walking backwards. Staff J stated they helped Staff I by lifting both of Resident 3's legs by holding their feet. Staff J stated Resident 3 was screaming and yelling when they got back to their bedroom. Resident 3 got up on their bed and removed all their clothing. Staff J stated they felt it was wrong and was in shock that Staff I did that. During an interview on 08/15/2024 at 2:45 PM, Staff B, Assistant Superintendent, stated that they were shocked at the abuse that had occurred and did not understand why this was happening. These residents do not deserve to be treated this way. Reference: WAC- 388-97-0640 (1), (3)(a)

Based on observation, interview and record review, the facility failed to provide care and services necessary to prevent an avoidable accident for one of one resident (#1) reviewed for [CONDITION(S)] when Staff C, Registered Nurse (RN) placed a warm pack (a wash cloth heated with an unknown temperature of water) on the resident's abdomen for an unknown length of time to relieve [CONDITION(S)]. This failure caused harm to Resident #1 resulting in first and second degree [CONDITION(S)] to their abdomen and left inner thigh, requiring medical treatment. Findings included . Record review of the facility's policy titled Hot Moist Pack, revised 02/08/2021, showed directions for using a hot moist pack for cystic and pustular [CONDITION(S)] (small, inflamed, pus-filled, blister-like sores on the skin) by wetting a washcloth in 108 degrees Fahrenheit water and applying to the [CONDITION(S)] for 15 minutes. Review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities (Rev. 11-22-17) showed: - First-degree [CONDITION(S)] involve the top layer of skin (e.g., minor sunburn). These may present as red and painful to touch, and the skin will show mild swelling. - Second-degree [CONDITION(S)] involve the first two layers of skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin. Review of Resident #1's medical record showed the resident was admitted to the facility on [DATE] with diagnoses of profound intellectual disabilities and spastic quadriplegic (loss of use of the whole body) [CONDITION(S)] (a neurological disorder caused by a non-progressive brain injury). Review of the 04/19/2021 comprehensive assessment showed the resident had severe cognitive impairment, was blind and required extensive assistance from two staff to reposition in bed. The resident was incontinent of bowel and bladder and wore briefs. Observation on 05/12/2021 at 11:00 AM with Staff H, RN, showed Resident #1 resting quietly in their bed. Staff H exposed the areas of the burn on the lower abdomen and left inner thigh. Skin was light pink with the 5 centimeter (cm) fluid filled blister intact on the left side of the abdomen. The blister to the left inner thigh had deflated. Staff H stated there were no doctor's orders to use a warm pack on the abdomen to help them urinate. There was only a policy to use warm packs on skin [CONDITION(S)] with a doctors order. Review of the 05/10/2021 Incident Report written by Staff C showed she received a report that Resident #1 had not voided (urinated) on B shift (1:45 PM to 10:15 PM) and had not voided halfway through C shift (approximately 2:00 AM). Staff C documented she placed a warm pack on the resident's lower abdomen, over the brief. Staff D, Attendant Counselor (AC) charge, assisted by providing an additional cloth barrier between the warm pack and brief (documentation did not include time applied or temperature of water used). Review of the 05/10/2021 witness statement by Staff D showed the warm pack was a washcloth that was held under running warm water (unknown temperature), and wrapped it in a flat, cloth barrier. During a telephone interview on 05/12/2021 at 10:20 PM, Staff G, AC charge, stated she was about to provide incontinent care for Resident #1 at approximately 4:55 AM and found a flat, cloth barrier wrapped around a plastic bagged wet washcloth that was cold to the touch. Upon removal, there were blisters on the left side of the resident's abdomen and upper left leg. Staff G stated she had never seen a warm pack used to get a resident to void. The resident's brief was still dry. Review of the 05/10/2021 5:10 AM Incident Report showed Resident #1 had a pink burned area on the mid abdomen measuring 13 centimeters (cm) long by 5 cm wide. There was a fluid filled blister measuring 5 cm by 3 cm on the left side of the abdomen in the pink burned area. There was also a pink burn with a blistered center measuring 5 cm by 2 cm on the left upper inner thigh. The report showed Staff F, Advanced Registered Nurse Practitioner (ARNP), ordered a cool cloth to cover the area, in addition to the application of Aloe Vera. Review of the 05/10/2021 12:17 PM Staff F's progress note showed when Staff F undressed the abdomen wounds and palpated the area, Resident #1 did appear to be in discomfort. The ARNP diagnosed the wounds as first and second degree [CONDITION(S)] and ordered [MEDICATION(S)] cream (a sulfonamide antibiotic used on the skin for second or third degree [CONDITION(S)]) twice a day and cover with a non-stick dressing. Additionally, the ARNP noted the resident did have a normal void at approximately 5:30 AM.

Based on observation, interview and record review, the facility failed to implement an effective infection control program related to Centers for Disease Control and Prevention (CDC), Local Health Department (LHD), and Washington Department of Health (DOH) guidance for: 1) Required screening of healthcare personnel for COVID-19 (a highly transmittable infectious disease). 2) Quarantine of staff who had close contact with a household member who tested positive for COVID-19. 3) Usage of Personal Protective Equipment (PPE) during a facility outbreak of COVID 19. These failed practices potentially resulted in nine residents (tested positive between 11/20/2020 and 11/28/2020) and 16 staff (tested positive between 11/19/2020 and 11/28/2020) with COVID-19 results. This failure resulted in an Immediate Jeopardy on 12/02/2020 at 4:15 PM as determined by: 1) Six of 11 staff (Staff C, D, E, F, G, H) had documented signs and symptoms consistent with COVID-19 on the facility's screening forms and were allowed to work with the residents. 2) One of one staff (Staff I) was allowed to work at the facility two days, after being informed a household member, who they had close contact with, had tested positive for COVID-19. Findings included . Review of the facility's policy Novel Coronavirus (COVID-19) Guidance for Active Screening of Employees at 24/7 State-Operated Facilities, dated August 14, 2020 showed that the Washington State Department of Health developed guidance to assist state-operated facilities in response to the 2019 COVID-19 outbreak. Review of the section Employee Screening showed employee screening questions listed examples of symptoms that you cannot attribute to another condition such as; fever or chills, fatigue, sore throat, diarrhea . Review of the section Criteria for Screening Out an Employee showed a temperature greater than or equal to 100.4 Fahrenheit . OR If an employee answers yes to having new onset of any symptoms other than fever . entry to the facility will be denied. Review of the section titled Secondary Screening showed that the purpose of secondary screening is to determine employee fitness for duty based on established protocols . Secondary screening will be performed as soon as possible . and secondary screening must be documented and maintained. Review of the undated facility's Covid-19 Staff Screening Form documented Steps 1-7 on a questionnaire and included a systematic disqualify or eligibility of Staff to work, based on responses. The form showed: .Step 2. Since your last day of work, have you experienced a new cough that you cannot attribute to another health condition? If YES, proceed to step 6 . Step 4. Since your last day of work, have you experienced any of the following that you cannot attribute to another health condition (check all that apply). The form then showed various symptoms that could be attributed to COVID. If YES, to at least two of these symptoms, proceed to step 6 . Step 5. Within the last 14 days, have you had close contact .with someone with confirmed COVID-19? If yes, self-monitor and proceed to step 7 . Step 6.any questions in Step 2 . at least two symptoms in Step 4, this is considered a positive screen. Advise the individual to return home . Step 7. If answered YES to Step 5, self-monitor for symptoms and report to your work station . During an interview on 11/ 0 at 2:50 PM, Staff B, Director of Nurses (DON) stated that the utilization of the screening tool and current process of staff screening began around May of 2020. She stated staff were educated that they would screen one another at shift change in their assigned cottage. The DON gave an example of a Nursing Assistant (NA) at shift end would screen the oncoming NA staff using the facility's screening form. She stated that the screening tool did not meet all of the facility's needs and that the facility added an additional step wherein if staff indicated symptoms, they were educated to immediately contact an on-call designated staff to be screened and either released to work or sent home. She stated that the secondary screening assessment should be documented, but she was unsure of what process the on-call staff were utilizing. Further, she stated that there were no additional steps in the screening process and that once the form was completed it was sent to the Safety Officer to be filed. No other staff reviewed or evaluated the contents of the screening forms, once completed. STAFF SCREENING Review of the record showed: Staff C, NA. On 11/25/2020, Staff C (worked in cottage 401/402) reported signs and symptoms of headache and fatigue on the facility's screening form (per screening form disqualification from work). However, Staff C worked an eight-hour shift and later that same day, 11/25/2020 tested positive for COVID. The record did not show that a secondary screening had occurred. Staff D, Licensed Nurse (LN). On 11/27/2020, Staff D (worked in cottage 401/402) reported symptoms of headache, fatigue and sore throat on the facility's screening form and again on 11/29/2020 reported symptoms of headache, fatigue and congestion. Then on 11/30/2020, Staff D reported symptoms of sore throat, muscle or body aches, fatigue, and congestion. Per facility's policy and screening forms, Staff D would have been disqualified from work on those three days. Review of the record showed the employee worked eight hours on each of the following days: 11/27/2020, 11/29/2020 and 11/30/2020. The record did not show that a secondary screening had occurred. Staff E, NA. On 11/22/2020, Staff E (worked in cottage 403/404) reported symptoms of headache and congestion (disqualification from work) . The record showed the employee worked her scheduled shift (8 hours). The record did not show that a secondary screening had occurred. Staff F, NA. On 11/20/2020 Staff F (worked in cottage 405/406) reported symptoms of sore throat, diarrhea, and congestion (disqualification from work). The record showed the employee worked her scheduled shift (8 hours). The record did not show that a secondary screening occurred. Staff G, NA. On 11/24/2020 Staff G (worked in cottage 401/402) reported a new cough and congestion (disqualification from work). The record showed the employee worked her scheduled shift (8 hours). The record did not show that a secondary screening occurred. Staff H, NA. On 11/03/2020, 11/06/2020, 11/07/2020, 11/09/2020 (worked in cottage 201/202) reported symptoms to include headache, fatigue, congestion (disqualification from work). The record showed the employee worked her scheduled shifts (8 hours). The record did not show that a secondary screening had occurred. During an interview on 12/03/2020 at 1:30 PM, Staff B, Director of Nurses (DON) stated that she had reviewed the record for Staff C, D, E, F, G and H and was not able to locate that an additional screening assessment had been conducted. She acknowledged that the facility's screening procedure was not being implemented and that staff had disclosed disqualifying symptoms on the screening forms. She stated she was unsure as to why the secondary screening did not take place. LACK OF QUARANTINE Review of Center's for Disease Control (CDC) quarantine guidance https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/quarantine.htm showed: Quarantine: keeps someone who might have been exposed to [MEDICAL CONDITION] away from others Isolation: keeps someone who is infected with [MEDICAL CONDITION] away from others, even in the home stay home (quarantine) for 14 days after your last contact with a person who tested positive for COVID-19. On 12/03/2020 the CDC updated the recommendation to include two additional options of when to stop quarantine: On day 10 without testing or on day 7 after receiving a negative test result. Review of the facility's November 2020 schedule, showed Staff Q, Maintenance worked on 11/20/2020 and began experiencing COVID symptoms on 11/21/2020. Review of the facility's November 2020 COVID listing showed that on 11/23/2020 Staff Q tested positive for COVID and was given the directive to quarantine at home. Review of the record further showed Staff Q's spouse, Staff I also worked at the facility. During an interview on 11/30/2020 at 3:00 PM, Staff B, DON stated that Staff I was allowed to continue to work after Staff Q tested positive because the facility had conducted daily rapid tests with negative results on 11/23/2020 and 11/24/2020 prior to her shift and that she was directed to self-monitor for symptoms. She stated that Staff I's job was primarily administrative and required her to enter cottages to complete paperwork and to interview residents, at times. During an interview on 12/03/2020 at 10:30 AM, Staff I stated that after notification that her spouse (Staff Q) tested positive for COVID-19 she began wearing a face mask at home and attempted to isolate but found it very difficult. She stated that on the two days she worked, she wore a surgical mask while at work and did not wear eye protection. She stated that on 11/24/2020 she felt symptoms (body aches and sore throat) and did not work her scheduled shift. She was notified by the Local Health Jurisdiction on 11/28/2020 that due to a positive test, she was to quarantine at home. During an interview on 12/03/2020 at 4:00 PM, Staff A, Administrator stated that the facility followed Developmental Disabilities Administration (DDA) guidance for staff screening and eligibility to work. She stated that the facility had tested Staff I daily (after Staff Q tested positive) and that she was self-monitoring. She stated that the facility's screening form (Step 5) showed that since Staff I was wearing a face mask at home, she was cleared to work and self-monitor for any symptoms that may develop. PERSONAL PROTECTIVE EQUIPMENT Review of the CDC's National Institute for Occupational Safety and Health (NIOSH) cdc.gov, showed: N95 respirators are approved by NIOSH, reduce the wearer's exposure to airborne particles, are tight fitting and filter out at least 95% of particles in the air. KN95 masks are not NIOSH approved, however, had been allowed by NIOSH for usage during critical N95 supply shortage. Facemasks (procedure masks/surgical masks) are loose-fitting and provide only barrier protection against droplets, including large respirator particles. Record review of the facility policy, Protective Clothing and Equipment, dated 03/19/2020, showed that staff were to wear personal protective clothing and equipment, such as, N95 respirator, KN95 mask and/or procedure mask, eye protection, gown, and gloves, when appropriate. Record review of an email addressed to all staff sent by Staff R, Infection Preventionist (IP), dated 11/23/2020, showed that cottage 403/404 was in quarantine with active transmission and staff were notified to wear KN95s and face shields at all times. During an observation in cottage 403 on 12/02/2020 at 1:48 PM, four staff (Staff L (NA) , N (LN), O (LN), P (NA)) were observed in procedure masks (not the KN95 masks as facility policy and email from IP had indicated). The staff were gathered and communicating with one another at shift change. Resident #1 (not wearing a mask) was observed seated in the entryway facing the staff who were communicating at shift change. The resident was repeatedly sticking his tongue out and making noise using his tongue against his lips. During an interview on 12/02/2020 at 1:50 PM, staff L NA, was asked about usage of surgical masks, he stated the surgical masks were worn in the common area and that when a resident required direct care and contact, staff were to change into a KN95 mask. He stated that Resident #1 was the only resident in cottage 403 who had not tested positive for COVID and that all other residents had tested positive for COVID and were moved to the COVID isolation cottage. On the same day, during a concurrent interview and observation from 1:50 PM to 2:05 PM, Staff N, LN, stated she was assigned to cottages 403/404 and 405/406 for the evening shift. While in cottage 403 (quarantined unit) she stated that she did not wear a KN-95 mask in the unit because she did not provide direct care to the residents. At approximately 2:00 PM, Staff N was observed in cottage 405/406 wearing a surgical mask. This cottage had not had an outbreak of COVID-19 to date. During an interview on 12/04/2020 at 1:00 PM, Staff R, IP, stated that all staff in Cottage 403/404 should be wearing KN95s at all times in the unit, as the cottage was in quarantine status due to high risk of transmission of [MEDICAL CONDITION]. When asked how staff were made aware of the requirement, she said that an email was sent to all staff. She stated that the procedure to notify staff of PPE requirements did not require a face to face meeting with staff in the cottage and they should be aware from email. Additionally, she stated there must have been a miscommunication we do not want them donning and doffing masks in the cottages as it increased the risk of the spread of COVID. Review of the facility 12/09/2020 Complaint Resolution Reporting log showed Resident #1 tested positive for COVID on 12/08/2020 and was moved into the COVID isolation unit. The immediacy of the Immediate Jeopardy was removed on 12/10/2020 when observations, interviews and record review determined the facility had implemented the following interventions: 1) Ensured the new screening process met Local Health Jurisdiction (LHJ), Centers for Disease Control and Prevention (CDC) recommendations and Federal regulations. 2) Assigned and trained designated staff members to perform COVID-19 screenings at centralized location with designated staff to screen clinical personnel. 3) Implemented a screening process for staff who disclosed symptoms consistent with COVID-19 were disallowed to work 4) Provided oversight and monitored the new screening process to ensure sustained compliance Reference (WAC) 388-97-1320(1)(a)(b)(2)(a)

Based on observation, interview, and record review, facility failed to consistently provide resident care in a respectful manner that promoted the resident's dignity and maintained their quality of life. Deficient practice was identified for 1 of 3 sampled residents (#1) during an episode of intense behavioral escalation. Staff C intervened and told Resident #1 he would not be able to see his family members, the stated reason for his behavioral outburst. As a result, the resident escalated further due to his emotional distress and broke a safety glass window out with a chair. Resident #1 sustained a cut on his right wrist. Findings included: Resident #1: Review of the medical record showed the resident had multiple [DIAGNOSES REDACTED]. The resident's care plan entitled, Behavior Symptoms, last reviewed on 09/27/18, noted the resident had multiple maladaptive behaviors that require 1:1 (one-on-one staff) supervision to prevent injury to himself and others. His behavioral history included throwing heavy furniture and appliances at staff, tantrums and emotional outbursts, being uncooperative, being agitated and over-reactive, and demonstrating physical and verbal aggression. He will also exit seek and elope (run away) when he is upset. Staff were to refer to Therapeutic Options (training provided to staff) techniques to prevent and manage behavioral emergencies. When the resident's behavior escalated and the resident was at risk of harming himself or others, Call ACTION STAT, request additional staff from other cottages notify AC (Attendant Counselor/Nursing Assistant) in charge and report immediately to nursing . According to the behavior care plan, staff were to avoid telling him No, and keep him busy and involved in activities of his choice. There was a history of family visits/phone calls triggering aggression. The resident would focus on going home. Discussion about going home should be re-directed by staff providing distraction activities .Due to history of physical aggression towards staff attempt to Provide (sic) 2 staff to accompany (the resident) on his visits .If this is not possible staff are to take the cottage cell phone or walkie talkie to call for assistance if needed. Review of a 10/17/18 nursing entry at 8:00 PM showed staff had reported the resident was on the second floor of the administrative building at approximately 7:00 PM and he was destroying furniture and had thrown a chair into the safety glass in the nursing break/report room. Resident #1 sustained a cut to the fifth digit (finger). The AC staff had called 911/police to report the resident's physical violence/property destruction, and bleeding hand. Resident #1 was transported to the hospital for an evaluation. The 10/17/18 night shift nursing entry showed the resident had returned from the hospital and said, I feel real sad, he was crying with a saddened facial expression. A full body check identified a small cut approximately 1.5 centimeters ( more than a half inch) long cut to his right wrist area. According to a 10/18/18 day shift entry, the resident was irritable all shift saying he wanted to see mom and grandma, wanted to leave, said he was sad, and looked like he was about to cry. The resident refused to meet with his counselor. On 10/18/18 during the evening shift the nursing entry stated the resident was hollering about grandma, got upset, and pulled the fire alarm. A social service entry, dated 10/18/18, showed Resident #1 was on psycho/social alert due to a report of staff provoking him during an incident on 10/17/18 that resulted in him breaking a window and going to the emergency room . When interviewed, Resident #1 stated he just wanted her (Staff C, AC) to leave him alone and stop bothering him. The entry further stated, (Resident #1) had a very rough week. He is still not at baseline. Has had two trips to the ER this week because of behaviors around wanting to see mom and grandma. A social service entry on 10/19/18 stated, He is still not at his baseline but appears more relaxed than yesterday. Review of the investigative report for the facility, pertaining to the 10/17/18 allegation of Staff C verbally abusing/taunting Resident #1, stated Staff C had allegedly told the resident he was not going to be able to see grandma or mom. Staff C had also allegedly told the resident to hit the window harder and it resulted in him hitting the window with the chair and breaking it. The investigative analysis showed the resident had lived at the facility since 09/01/17 and was well know to all staff who were interviewed. The (cognitively impaired) resident reported Staff C was bugging him during the incident on 10/17/18. Staff C, and three interviewed AC staff reported (some were told later by Staff C in the cottage) that Staff C told (Resident #1) he was not going to see his family. Staff C stated the comment about not seeing his family was after the resident had broken the window, but the other witness to the incident stated it was three minutes prior to him breaking the window. All of the interviewed staff agreed telling (the resident) he is not going to see his family is harmful to him, emotionally abusive, and/or would result in escalated behaviors. It is universally agreed it would not be helpful for deescalating (the resident). Staff C, a charge AC, stated she would not train her staff to tell him he was not going to see his family in hopes of assisting with escalated behaviors. This evidence indicated staff are aware it is emotionally harmful to (the resident) to be told he cannot see his Grandma and Mom .Based upon testimonial and documentary evidence, it does appear emotional harm was done to (Resident's name), Resident (sic) based upon being told he could not see his Grandma and Mom. It cannot be determined that he was told to hit the window harder. Observations in room [ROOM NUMBER], the report room, on 11/07/18 at approximately 2:05 PM, showed the interior safety glass window (broken out by the resident) was approximately four feet by four feet in size. The room also had a large conference table surrounded by chairs and a full sized refrigerator. Refer to F689 for complete details of Resident #1's condition and subsequent behavioral outburst on 10/17/18 in the administrative building. On 11/07/18 at approximately 3:40 PM an interview was conducted with Staff A, AC. Staff A stated she was working in the unit on 10/17/18 during the evening shift. The resident had anxiety that day. He liked the idea of going to the administrative building. Staff A took a walkie talkie and they walked up to the second floor. Staff A and Resident #1 then entered the report room and the resident closed the room. He wanted to buy airplane tickets to return home (to see his mom and grandma). They sat at the large conference table to write a list related to getting the airplane tickets. Resident #1 had an expression change and demanded she buy the tickets now. When it didn't happen he requested another caregiver. Staff A then called the AC Charge, Staff C, via the walkie talkie, and conveyed the resident's wishes for a new one-on-one caregiver. Staff C said she was unable to arrange a change of caregivers at that time. The resident appeared mad and stated he was not leaving until he got a airplane ticket. He then flipped over the large conference room table and the refrigerator onto its face. Staff A exited the room and called Staff C for assistance. Staff A heard items being thrown around in the room. About five minutes later, Staff C arrived to help. Staff C tried to talk with the resident and offer alternate items but he cussed at her. Resident #1 demanded she buy him a plane ticket. Staff A stated she heard Staff C tell the resident, I'm sorry you are not going to see your mom. He stomped toward the door and Staff C ran out of the room. Resident #1 further escalated further and began hitting at the safety glass window with his hand and then later broke the window out with a chair. Staff C called 911 to obtain assistance with the resident. On 11/07/18 at approximately 4:38 PM, Resident #1 was observed seated on the front porch area of his cottage with a one-on-one AC/caregiver. The resident had mumbled speech. On 11/07/18 at approximately 9:30 PM a telephone interview was conducted with Staff E, AC. Staff E recalled working on the unit on 10/17/18 during the evening shift. Staff C, the Charge AC, had asked her (Staff E) to notify the nurse, Staff D, of Resident #1's behavioral incident occurring in the administrative building. When Staff C returned to the cottage she told Staff E about the details of the resident's incident with property damage. She stated he was flipping over tables. Staff C further stated she had told him that he wasn't going to see his mom or his grandma, which was what he was upset about, and now he finally knew the truth. After that the resident picked up a chair and broke the window. Staff C was interviewed on 11/08/18 at approximately 11:35 AM. She stated on 10/17/18 she had received a report from the day shift that the resident had been agitated all day. He was fixated on mom and grandma. Staff A had taken Resident #1 over to the main building. Staff A had called Staff C for help. I took off running. When Staff C arrived the table and refrigerator were tipped over. Staff C attempted to calm the resident but he cursed at her and threw a chair at the outside window. Staff C stated she was tired of lying and giving him false hope. She told the resident he couldn't have contact with mom or grandma now. The resident broke the safety glass out of the other window (facing the inside hallway).

Based on observation, interview, and record review, the facility failed to ensure 1 of 5 sampled residents (#1) was free from physical restraint use and treated with appropriate dignity/respect during an incident of behavioral escalation. There was no clearly identified medical symptom(s) necessitating the use of a physical restraint and the resident's care plan did not include the use of a physical restraint. A facility Licensed Nurse restrained Resident #1 to the floor on his back, both with and without the use of a mat. Resident #1 experienced psychosocial distress/harm, a serious affront to his dignity and increased behaviors, as a result of the imposed physical restraint. Findings included: Review of facility policy YVS (Yakima Valley School) 16-04 entitled, Resident Rights and revised on 01/17 documented the resident had: the right to request, refuse, and/or discontinue treatment. The document had a place for the resident, legal representative, and/or case manager to sign, acknowledging they had received a copy of the resident's rights. Additionally, the Employee Standard Operating Procedure 1.02, dated 06/12/17, also documented: IV. Standard: All staff members, volunteers and contracted service providers must not violate the rights of residents. Resident rights include, but are not limited to: Freedom from unnecessary medications, restraints, and restrictions. The YVS Employee Standard Operating Procedure 4.21 effective (MONTH) 23, (YEAR) addressed, Protective Mat Use addressed, When and How are Mats Not Used? 2. Mats are never used to push, pin, or hold a person unless there is a specific approved Positive Behavior Support Plan in place to do so. When mats are put in closed (sic) proximity to an aggressive person, it does not mean the mat is touching the person. No one may be pinned to the floor, bed, or wall, etc with mats. Close proximity does does not mean controlling all body movement. A person displaying aggression may be separated from others, and protected from surface impact .Mats separate and cushion. But mats do not force a person's (resident's) movement to stop. He/she stops. 3. Mats are used to provide a safe space and time to allow the person behaving in (a) dangerous manner to self-calm. Resident #1: Review of the medical record revealed the resident was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. According to the resident's Self-Care Deficit/Cognitive Loss care plan, with a facility review date of 06/01/18, the resident Takes medications whole followed by a small sip of water. History of medication refusals, allow a few attempts to take his medication prior to documenting refusal per physicians (sic) order. The Behavior Symptoms care plan, with a facility review date of 06/01/18, showed the resident had a history of [REDACTED]. Approaches included the use of protective mats in accordance with the facility protocol, YVS SOP (Standard Operating Procedure) 4.21. The resident had a history of [REDACTED]. Staff were to avoid touching the resident if his behavior was escalating. Staff were to refer to Therapeutic Options to prevent and manage behavioral emergencies (training provided to staff to deflect and de-escalate a resident's behavior). The resident's Impaired Communication care plan, with a facility review date of 06/01/18, noted the resident spoke in 1-3 word sentences and would repetitively ask the same question. Review of a 06/25/18 nursing entry by Staff A, Registered Nurse, revealed Resident #1 was approached with his bedtime medications. At the time of the first approach, the resident stated, No! I don't want them. During the second approach, the resident slapped the medications away, stood up from the chair, and attempted to strike the nurse with the I-Pad. The nursing assistants responded using therapeutic options and mat training to assist resident in de-escalating. As attention was focused toward Staff A, he stepped away from the situation. The resident did not take his medication. According to the 5-Day Investigation Report provided by the facility, on 06/29/18 it was reported to Staff B, Director of Nursing, that the incident involving Resident #1 and Staff A on 06/25/18 actually involved physical contact between Staff A and the resident. Resident #1 was lying on his back on the living room floor and Staff A was laying across the resident's chest and holding the resident's head down by placing his forearm across the resident's forehead. The responders to the Action Stat (a call for additional staff assistance) witnessed some of these events and may have participated in assisting with the alleged improper restraint. The alleged improper physical restraint was not immediately reported. Per the investigative analysis, staff interviews indicated the 06/25/18 incident appeared to have happened between 7:55 PM and 8:05 PM. Five of six direct witnesses present between the noted timeframe reported seeing Staff A laying over Resident #1 while the resident was on his back on the floor, with or without a mat between Staff A and the resident (dependent on each witness's time of entry). The sixth witness reported the resident was in a supine position on the floor with Staff A lying on his side next to the resident. Two witnesses stated Staff A was holding down the resident's left arm/hand. The seventh witness recalled entering the room as Resident #1 was getting up off the floor around 8:05 PM. Additional information contained in the investigative analysis included: It is reasonably certain that (Resident #1) was in a supine position (on his back) on the floor for at least 7 minutes. It is reasonably certain that (Staff A) completed an improper physical restraint by not removing himself from the floor and per his own statement, choosing to move closer to (the resident) and blocking (the resident) .Two direct witnesses stated they heard (Resident #1) tell (Staff A) to Stop, you are choking me! Additionally, the investigative analysis noted a review of the TO (Therapeutic Options) manual indicates there are no holds or restraints that are permitted for use at (the facility) that match the description of what may have been utilized with (Resident #1). DDA (Developmental Disability Administration) Policy 5/17 prohibits any physical restraint while resident is in a supine position. The resident's care plan indicated to avoid touching (Resident #1) if his behavior is escalating. A Positive Behavioral Support Plan was not in place for the resident on 06/25/18. Due to inaccurate and late reporting, it does not appear a physical and psychosocial assessment was completed in a timely manner on or around (MONTH) 25, (YEAR). On 07/17/18 at approximately 10:35 AM, an interview was conducted with Staff B, Director of Nursing, about the incident on 06/25/18 involving Resident #1, Staff A, and the other staff. Staff A had called Staff B on 06/25/18 to report a behavioral escalation directed against Staff A. Staff B suggested contacting Staff G, the Supervising Nurse. When Staff G entered the cottage, he saw two staff members using mats like a shield and he directed staff to put down the mats and the resident calmed. If staff are unable to manage a resident's behavior (with appropriate interventions) then the police were to be called for assistance. There had been no police involvement on 06/25/18. On 06/29/18 (four days later) Staff B was notified of the details surrounding the 06/25/18 incident. Staff B stated they still don't know how Resident #1 got to the floor and she was unaware of any physical assessment directly following the 06/25/18 occurrence. The resident continued to have [MEDICAL CONDITION] activity, a chronic condition evidenced before and after the 06/25/18 occurrence. The resident sent to the hospital (once after a [MEDICAL CONDITION] with head and facial injuries) and then later in the week resulting in the resident's medication(s) being adjusted. An interview was conducted with Staff A on 07/17/18 at approximately 12:00 PM. Staff A recalled on 06/25/18 Resident #1 had refused his bedtime medication. Staff A left and reproached the resident later. The resident again stated he didn't want the medications. Staff A attempted to offer the medication, stating he only had one pill for him. The resident then slapped the medication and juice out of his hands. Resident #1 was swinging at the nurse with his I-Pad. Staff A reportedly fell on the floor (related to the liquid on the floor) and the resident was then kicking at the nurse. Staff A moved in closer to the resident. He recalled staff placed a mat between them. Staff A stated he never held the resident down. Staff A left the cottage because the resident seemed to be targeting him. Staff G, the Supervising Nurse, was called and the resident then calmed down. Staff A initiated an incident report thereafter. Staff A recalled working on the same unit on 06/26/18 and 06/27/18. On 07/17/18 an interview was conducted with Staff C, Nursing Assistant, at approximately 1:45 PM. Staff C stated on 06/25/18 she heard an intercom announcement of an Action Stat and responded to the identified cottage. When she arrived at the cottage she observed Resident #1 laying on his back. Staff A (the nurse) was on his knees beside him holding the resident down. Resident #1 was saying he was going to kill the nurse. The resident was also trying to grab the nurse's clothes. Staff C and another staff member were positioned at the resident's feet. Staff A asked for a mat and when he received it, he put it between him and the resident. Staff C stated she was unsure how much hand pressure the nurse was applying to the mat on the resident and how far over the resident's face the mat was applied. The nurse stated., As soon as you calm down, I'll let you up. Staff C was unable to see the resident's head but heard him say, Get off me. You're choking me. Staff D, Nursing Assistant, was interviewed on 07/17/18 at approximately 2:05 PM. Staff D also heard the Action Stat on 06/25/18 and responded to assist. When she entered the cottage she saw Staff A on top of Resident #1 with a mat between them. Staff A was using his body and laying on the resident. The mat extended halfway up the resident's face. The resident was swinging at staff and stating he was going to kill them. Staff D also recalled two staff at the resident's feet as well. She was relieved by another staff member (Staff E) in less than two minutes. An interview was conducted with Staff E, Nursing Assistant, on 07/17/18 at approximately 2:15 PM. Staff E recalled responding to an Action Stat on 06/25/18. When he arrived Resident #1 was on the ground and a mat was across him. Staff A was leaning over the resident with one of the mats and using his forearms to hold him down. The resident was stating he was going to kill the nurse by slitting his throat. Staff E was there about 10 minutes. Staff E stated the resident was agitated by so many staff. It was too stimulating for him. Observations on 07/17/18 at approximately 4:05 PM showed Resident #1 was calmly moving around the cottage between the living room and the back area of the cottage with a staff member directly supervising and following the resident. Staff F, Nursing Assistant, was interviewed on 7/20/18 at approximately 1:55 PM. Staff F stated she heard the Action Stat and responded to the identified cottage. When she arrived on 06/25/18 she looked to the right and saw Resident #1 on his back and Staff A's left arm was on the resident's forehead and his right arm was holding the resident's arm. The nurse's stomach was pushed against Resident #1. No mat was present at that time. The resident was yelling and cussing. Resident #1 stated he was going to kill the nurse and stated, Get off me. Staff A was asking the resident if he had calmed down yet and was ready to get up. Then Staff A stated, it sounds like you are not ready. Staff C helped with the resident's legs and Staff F was managing the resident's legs and was holding his hand(s). Staff A asked for a mat and then put it across the resident's body and face. Staff A held the mat by one hand strap and by his forearm and was pushing against it while on the resident. Staff F was unable to see much of the resident's face because it was covered by the mat. The resident stated, You are choking me and stated he couldn't breathe. Then the nurse stopped pushing so much but the resident was not able to move. When the nurse was about ready to release the resident he asked for more mats. More people were there when the resident was released. Staff were in a circle around him (with mats) and the resident was punching at the mats. Staff A gave Staff F a mat and then left the area. The resident dropped to the floor and began to calm. Staff F was then released to return to her assigned cottage. This is a repeat deficiency from a Statement of Deficiencies dated 05/04/17.

Based on record review and interview, the facility failed to ensure all residents were free of abuse by staff. Deficient practice was identified for 1 of 4 sampled residents (#18) when a facility Registered Nurse (RN) engaged in physical abuse and verbal taunting. Resident #18 experienced skin injuries and voiced recall and displeasure with the treatment he had received. Findings included: Resident #18. Review of the medical record revealed the resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's 09/01/17 care plan, entitled ineffective airway clearance, documented the resident had additional medical conditions including recurrent aspiration (food and/or fluids entering the resident's lungs) pneumonia, [MEDICAL CONDITION], and sleep apnea. The resident received multiple respiratory treatments and oxygen to maintain adequate oxygen saturation levels (blood oxygen levels). The resident had behavioral issues. Resident #18 was not always compliant with his medications and treatments. On occasion, Resident #18 requested to go to the hospital or called 911 for assistance. He also demonstrated some physical and verbal aggression. A nursing entry on 12/28/17 documented the resident was complaining of his lungs hurting. Additionally, the resident's oxygen saturation level was below normal and he was sent to the hospital emergency department for an evaluation. The resident was admitted to the hospital with [REDACTED]. The 12/29/17 nursing entry noted the resident returned back to the facility at 2:45 PM. At 3:50 PM the resident experienced a ground level fall. He complained of pain to his right ankle and left wrist. He was sent back to the emergency department and they diagnosed the resident with a mild left ankle sprain and a contusion to the left wrist. The resident returned and was documented as ambulating without apparent pain. According to the 12/31/17 nursing entry the resident had no complaints of ankle or wrist pain and there was no evidence of swelling or bruising. See F760 for information related to the medication error(s) surrounding the resident's treatment after returning to the facility. A 01/02/18 nursing entry at 3:35 AM documented the nurse had been called to the cottage regarding scratches and the resident's complaints of his lungs hurting. The resident's oxygen saturation level was low but raised with a deep breath when cued. Also documented was: a scratch to the right palm, 0.5 centimeters (cm) by 0.5 cm, a scratch to the left 3rd finger measuring 0.5 cm by 0.3 cm that appeared recent. Resident #18 reported, She scratched me and confirmed he referenced an altercation already reported to a nurse/Director of Nursing between himself and staff. There was also a 4 cm by 1.5 cm bruise to the resident's left forearm. On 01/19/18 at approximately 10:25 PM, a telephone interview was conducted with Staff P, Nursing Assistant (NA). Staff P stated she was working night shift on 01/02/18 on Resident #18's unit. Resident #18 was sleeping in a recliner in the living room. Staff P was in the back hallway with Staff Q, another NA, and heard the resident say, No, No, Stop! Staff P entered the living room to check on what was happening and saw Staff J, RN, on top of Resident #18. Her knees were on top of his knees and she had ahold of his wrists. When Staff J saw the staff members enter she put her feet on the floor but continued to hold the resident's wrists/arms down. The resident got one arm free and he swung at the RN. She then swung at the resident and stepped back with both hands up like in a boxing pose. The resident then hit the RN and also struck Staff P on the ear (accidentally). Another staff member entered the cottage and attempted to intervene as the resident had pinned the RN and was hitting her. When the resident calmed the RN made comments to the resident about him breathing pneumonia germs and getting them all sick. She also stated he was going to have to go to jail. An Action Stat was called for additional staff assistance when the resident pinned the RN against the door. Staff asked the RN to leave the area. Thereafter, Staff P and Staff Q located another nurse at the facility and then reported the details of the incident involving Staff J and Resident #18. Staff P returned to the cottage. Resident #18 was crying and apologized to her for hitting her. She told Resident #18 that Staff J was gone. The resident had scratches on his hands and seemed to have a bruise appearing on his wrist. On 01/20/18 at approximately 9:50 AM Staff Q, NA, was interviewed via telephone about her observations on 01/02/18 on the night shift. Staff Q stated she was sitting in the back hallway. Resident #18 was sleeping in the recliner in the living room. Staff J was trying to get him to his room. The resident yelled no. He was mad when awakened. The RN needed to do a breathing treatment. She heard the RN say, don't swing at me. When Staff Q entered the living room she saw that Staff J's knees were up on the resident's knees with her feet off the floor and the RN was holding his arms. It was startling to see. The resident got his arm free and swung at the nurse. Staff J then got in a fighting pose. Staff Q tried to step in to intervene to protect the RN but then realized she was protecting the resident. Staff P was also present. Resident #18 was really distraught after going after the RN and hitting Staff P. He apologized to both. After the RN left, the resident commented about her being on top of him. He also brought it up to Staff Q the next day when she worked. According to a day shift nursing entry on 01/02/18, the resident asked the nurse if he had heard what happened last night. The scratches were noted as previously described. There was a purple bruise on the left mid forearm about 6 cm by 4 cm and a 1 1/2 cm bruise on the back of the right mid-forearm. A 01/03/18 nursing entry noted the resident stated that he and his guardian were very upset about what happened. Review of a 01/06/18 nursing entry revealed the resident spoke with his mother and talked to her about being held down by a nurse and about the bruises and scratches. The medical record documented the resident discharged from the facility on 01/10/18. On 01/22/18 an interview was conducted with Staff O, Social Worker. Staff O stated she visited the resident following the 01/02/18 incident with the nurse. Resident #18 spoke of how the nurse (Staff J) put her boots on the ends of his feet. She woke him up. He had told her no but the nurse persistently got in his face. There were bruises or marks on his hand or arm. The resident also stated that his guardian and mom were also mad about the incident. The resident had a plan to move to his new placement and he was excited about that. According to the 01/02/18 facility investigative conclusion, Staff J, RN, engaged in non-approved physical intervention techniques that resulted in physical restraint. Resident #18 suffered bruising and scratches that appeared to be related to a physical altercation involving Staff J. The bruising was consistent with reports that Staff J restrained the resident's arm against the arm of the chair. Resident #18 expressed emotional distress in the form of statements of fear and anger as well as episodes of tearfulness.

Based on observation, record review, and interview, the facility failed to prevent a resident elopement for 1 of 2 sampled residents (#17) with exiting seeking behaviors. Staff failed to provide immediate supervision to monitor Resident #17's actions and failed to ensure a mobility sensor alarm was turned on/functioning. Resident #17, a resident with impaired cognition, was significantly compromised when he exited the facility window and eloped at night, without shoes or a coat to protect him from the winter weather conditions. His whereabouts were unknown for more than two hours and he was found near the interstate by the police. Resident #17 sustained skin injuries as a result of the elopement event and/or follow-up actions consisting of transport by police officers and ambulances and a hospital evaluation. Findings included: Resident #17. Review of the medical record revealed the resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. According to the resident's care plan for behavioral symptoms, first dated 11/14/16, the resident's personal safety was jeopardized by impulsive high risk behaviors such was elopement from the home/cottage. He had a history of [REDACTED]. The resident was on LOS 4 (level of supervision) - One-to-one supervision allowing as much social space as possible. Supervision must be positioned in a manner to prevent danger or harm to self or others. One-to-one staffing at bedside if to maintain a medical treatment. Additionally, a motion sensor is attached to the window outside the building near the bedroom window that will alert staff should (the resident) attempt to go out the window. The sensor control box and alarm mechanism was located in the kitchen area. The resident's care plan also noted the resident had recently been discharged on [DATE] due to severe behaviors and property destruction, aggression, and elopement. The resident returned to the facility on [DATE]. The resident received physician services to manage his medications and monitor laboratory tests. On 12/13/17 the physician evaluated the resident. He reviewed the resident's behavioral episodes including frequency of the target behaviors of elopement/exit seeking, self-injurious behaviors (hitting his chest), physical aggression, and other behaviors. The physician reviewed the resident's medications and increased specifc anti-psychotic medications. The medication regimen also included orders for emergency medication options that were recommended and were to be reviewed with the on-call medical provider prior to being given. Documentation included a statement that the resident's severe, dangerous target behaviors were fueled by an all-consuming obsession to return to (a named location), an inability to related consequences to behavior . Review of a 12/18/17 day shift nursing entry revealed that Staff F, the Director of Nursing Services (DNS), had reduced the resident's level of supervision to LOS 3. Review of facility policy documented LOS 3, Supervision must be positioned in a manner to protect from or deter danger. Enhanced staffing required. According to a late entry for 12/18/17 by Staff G, Licensed Practical Nurse (LPN), Resident #17 exited the cottage without shoes at 3:00 PM but staff were able to redirect him. The resident went on an outing but when he returned he took off out of the cottage. An Action Stat was called to obtain additional staff assistance. The resident was picked up in the facility van and returned to the cottage. The resident was changed to LOS 4 (increased supervision) and an additional staff member was called in to do a one-on-one assignment with Resident #17. On 01/20/18 a telephone interview was conducted with Staff Member G at approximately 10:10 AM. Staff G recalled she had worked on Resident #17's cottage for a portion of the evening shift, between 2:00 PM and 6:30 PM. Staff G stated Resident #17 had left twice (attempted to leave the facility) during the timeframe she worked on 12/18/17. The DNS was called and the resident's supervision level was changed back to LOS 4 about 6:00 PM. Staff G stated she notified all the cottage staff of the change of the resident's supervision level but she failed to document the change and that was a mistake. Staff G stated she did not convey the change in the resident's supervision level to the staff member assigned as the one-on-one, Staff H, Nursing Assistant (NA). Staff H had already left to escort the resident as he was trying to leave the premises and Staff H did not have a cell phone. Staff G stated she was surprised they had assigned Staff H to the Resident #17 because she never works the cottage. Staff I, Registered Nurse (RN) Supervisor, had been notified about the resident's exit from the cottage and he drove his car to pick up the resident in an attempt to return him to his cottage. Review of a 12/18/17 nursing entry by Staff Member J, RN, noted the resident was administered emergency medications to address his agitation including screaming and charging behaviors. Resident #17 then went to his room and drew his privacy curtain around his bed. Staff believed him to have gone to bed and watching TV. When staff noticed complete quiet of (greater than) 10 minuted (sic) she went in moved the curtain and noted the window open (and) the resident had eloped. He had no shoes or coat, was dressed in cover alls (sic) (and) a reflective vest. An all staff emergency call was made over the radio. The police were notified. The DNS was notified and she notified the family members. Further review of the nursing entry noted the resident was found at 10:45 PM on 12/18/17 at the mini-mart near the freeway entrance. The resident was returned to the cottage via police vehicle. While in the cottage, the resident was in the cottage and was charging the police officers. Four police officers were present. After consulting with the the DNS and the on-call medical provider, the resident was sent to the hospital on a gurney in restraints. According to a 24 hour Unit Report (not the medical record), dated 12/19/17, the resident returned from the hospital at 2:40 AM and fell asleep. A nursing entry by Staff K, LPN, for the 12/19/17 day shift documented the resident slept in until 11:45 AM and then had lunch followed by a shower. During the shower, Staff K assessed the resident to have a 6 centimeter (cm) area by 3 cm (about 2 1/3 inches by 1 1/4 inches) of petechiae (red or purple spots showing through the skin caused by minor bleeds from broken blood capillaries or blood vessels) on the front aspect of the left shoulder, a 3 cm by 2 1/2 cm purple bruise on the right bicep, and front petechiae on rt. (right) shoulder .All bruising r/t (related to) incident that happened 12/8/19 (sic) (and) last night (SIB, self injurious behavior, + physical aggression). See prev. (previous) documentation. Review of the facility investigation associated with the 12/18/17 elopement event showed the weather was around 43 degrees Fahrenheit during the resident's elopement period. It was cloudy with some light misting of rain. The resident walked a distance of 4.1 miles from the facility to the gas station near the freeway. The resident returned to the facility around 10:40 PM on 12/18/17 wearing his jeans, tee-shirt, the orange vest, and was barefoot. The resident had been discovered missing at around 8:15 PM on 12/18/17. On 01/08/18 at approximately 3:30 PM, Resident #17 was observed walking in the cul-de-sac in front of the cottage. A male individual was walking with him as he ambulated up the hill to the west. On 01/20/18 at approximately 10:30 PM a telephone interview was conducted with Staff H. Staff H stated she was called in to work on 12/18/17. When she arrived at the cottage she was directed to follow Resident #17. He had exited the cottage and was walking fast, in an agitated manner. He made it about two blocks off campus. Staff I, the Supervisor, brought his car to meet the resident and Resident #17 agreed to get in the car. The resident finally re-entered the cottage. Staff H stated she had never worked with Resident #17 before. She did not have time to read the resident's care directives. Staff H, the assigned one-on-one caregiver, was verbally told the resident had been lowered to a LOS 3 supervision level. She stated that LOS 3 allowed for privacy. Resident #17 was in his room with the privacy curtain pulled around his bed. Staff H was seated in front of Resident #17's door and another NA was watching another resident nearby. The other resident had his radio on. Things were quiet in Resident #17's room and she thought he had gone to sleep. It was less than 5 minutes since she had last visualized him. When Staff H opened the curtain she observed the window was open and the resident was gone. She immediately reported the resident was missing. Staff L, the lead NA, asked Staff H about the alarm and Staff H stated she didn't know about the alarm. Staff L checked and the sensor alarm was not turned on (to signal if the resident attempted to exit the window). On 1/23/18 at approximately 10:45 AM an interview was conducted with Staff K, LPN. Staff K had worked on 12/19/17 during the following day shift. He described the skin injuries identified on 12/19/17 as noted above. Staff K stated there would not have been any reason to turn off the sensor. The resident had tried to go out the window in the past. The sensor, positioned outside the window, would sound an alarm in the cottage to signal staff if the resident exited the window. Resident #17 did not want to be at the facility. He was set on returning to his destination (a named town) where family members had resided. The resident developed tunnel vision when he was escalated and was at risk of being hit by a car due to his lack of safety awareness. Observations of the resident's room on 01/23/18 at approximately 11:30 AM revealed the resident's bed was positioned next to the east wall and the window was on the wall above. The vinyl wrapped window opened smoothly without much noise. The sensor was place on the exterior wall adjacent to the window. The sensor base was housed on the microwave in the kitchen area.

Based on observation, record review, and interview, the facility failed to ensure each resident was free of neglect and/or mistreatment. Deficient practice was identified for 2 of 5 sampled residents (#1 & #2). Resident #1 experienced harm when a hair dryer was placed and left running adjacent to her body, as a warming measure, resulting in second [MEDICAL CONDITION] multiple areas on her body. Resident #2 was handled roughly during a transfer resulting in scratches and bruising during a fire and evacuation drill. Findings include but were not limited to: Resident #1: Review of the medical record revealed the resident had multiple [DIAGNOSES REDACTED]. The resident's 7/24/94 care plan documented she had impaired communication and required total staff assistance for her basic care. An 8/23/02 care plan noted the resident had impaired physical mobility. She was able to bear some weight but otherwise used a wheelchair for mobility. In addition, the 2/26/07 care plan revealed the resident had [MEDICAL CONDITION]. Medication was prescribed to address the condition. Direct care staff were to monitor the resident for cool skin, pale, dusky or bluish color, lethargic or temperature 97 degrees or below. Report to nursing. LN (Licensed Nurse) to instruct AC (Attendant Counselor, Nursing Assistant, NA) about warming procedures per (facility's name) policy II.B.3a(.) Review of the facility policy's II.B.3a identified permissible warming equipment that included temperature taking equipment, warm clothing (such as hat, stockings, etc.), blankets, and warm fluids. Direct care staff were to monitor for symptoms, take the resident's temperature, and report to the Licensed Nurse (LN). The LN was responsible for developing a care plan for any resident developing hypothermia (low body temperature) and documenting the temperature(s) in the medical record. The LN was to document nursing orders for hypothermia on the NA care directives. The LN documentation was also to include assessments and the number of occurrences and how long it took to elevate the resident's temperature to 98 degrees Fahrenheit (F). Nursing orders for prevention and protection included measures for appropriate clothing for the weather with special precautions for transporting in the cold weather, use of warm fluids when appropriate for the resident, additional clothing and blankets, encouraging the resident to move their extremities and change position frequently to increase circulation and help raise their temperature. The resident was to be protected against exposure to cold or drafts. Bath water was to be between 105 and 108 degrees F with immediate and thorough drying. The resident's hair was to be blown dry immediately following a bath. Hypothermic residents were not to lie on the floor. Additionally, a deep immersion, warming bath (105-108 degrees F) for 15-20 minutes was permissible if staff were unable to raise the resident's temperature after 1-2 hours on warming procedure with extra clothing, blankets, etc. There was also a directive to follow any special physician's orders or individual orders on the resident's plan of care. The resident's medical record noted that following a lab study for [MEDICAL CONDITION] function, the medical practitioner wrote an order to increase the resident's [MEDICAL CONDITION] medication on 5/05/17. According to the 5/2017 Medication Administration Record (MAR), the new dose began on 5/06/17. According to a 5/08/17 evening shift nursing entry by Staff Member A, a LN, the resident's temperature was very low at 93.3 A (axillary, taken in the arm pit). Warming procedures were initiated at 6:30 p.m. The resident's temperature was 97.4 A at 8:40 p.m. more alert. The following 5/08/17 nursing entry by Staff Member A documented the LN was called to the resident's room at 9:15 p.m. by the NA (Staff Member B). Per the 5/08/17 documentation, Staff Member B stated, I burned her. Resident #1 had reddened areas to her left upper anterior thigh 11.4 centimeters (cm) by 5 cm (approximately 4 1/2 inches by 2 inches), left lower abdomen 7.5 cm by 4 cm (approximately 3 inches by 1 1/2 inches), left forearm blister 3 cm by 1.5 cm (approximately 1 1/4 inches by 5/8 inches), and left outer thigh (4 cm by 1.6 cm (approximately 1 1/2 inches by 5/8 inches). Staff Member A called the Nurse Practitioner (ARNP) and reported the resident's condition. ARNP directed that pictures be taken and the resident was to be sent to the hospital for evaluation. The following nursing entry by Staff Member A on 5/08/17 revealed that Resident #1 had been hypothermic and was covered by blankets. Staff Member B had put a hair dryer on top of the resident's pants. When getting the resident ready for bed Staff Member B had noted the reddened areas. (The resident) had her pants on and I laid it on her outer pants, pointing toward her Body (sic). She must have moved (and) the dryer slipped. Review of the hospital records revealed the resident had first [MEDICAL CONDITION] approximately 1% of her body surface, on the left leg, left arm, and left abdomen and second [MEDICAL CONDITION] approximately 2% of her total body surface area, on the left leg, left arm, and abdomen. A medicated cream was ordered to be applied every every 12 hours with dressing changes. On 5/10/17 the ARNP ordered Zinc to be administered twice daily (to aid in wound healing) for two weeks. Review of the 5/2017 MAR and Treatment records revealed the resident had also received five doses of as needed [MEDICATION NAME] (Tylenol) to address discomfort between 5/08/17-5/11/17. According to a 5/08/17 facility investigative document, Staff Member A stated Resident #1 was hypothermic and several blankets were placed on her. Staff Member B stated she had put a hair dyer on the resident to warm her up. I put it in the hole between her legs. Staff Member A documented she thought the NA had put the hair dryer on top of blankets, where in fact she he had laid it on top of her pants, (and the resident) had moved, causing the dryer to fall sideways. The plan to use the hair dryer to warm the resident had been mentioned to the LN while she was administering medications. The LN documented she thought Staff Member B was going to use on her hair to help (with) hypothermia to decrease hypothermia. Also contained in the investigative documentation was a statement that Staff Member A reported that the use of the hair dryer (in that manner) was not a part of the facility's warming procedure. A 5/08/17 written investigative statement from Staff Member B documented she had transferred Resident #1 into her recliner and placed a hair dryer between her pant legs and under her blankets. She went back to check the resident about five minutes later and the blankets were warm so she turned off the hair dryer. When she went to put the resident to bed at 9:15 p.m., Staff Member B observed [MEDICAL CONDITION] the resident's leg and arm and immediately notified the nurse. On 5/11/17 at approximately 4:00 p.m. an interview was conducted with Staff Member C, the LN Supervisor on 5/08/17. Staff Member C stated that on 5/08/17 he heard on overhead page from Staff Member A. He responded to the unit and was met by Staff Member A. Staff Member C was notified that Resident #1 had been hypothermic and was placed in the recliner. A hair dryer was laid on top of the resident's clothing and directed toward her abdomen. The resident was able to move herself some. The hair dryer was running for approximately five minutes and [MEDICAL CONDITION] the resident. Staff Member C directed that necessary telephone calls were made. Involved staff were subsequently reassigned pending investigative findings with regards to the resident's burn injuries. Observations of Resident #1'[MEDICAL CONDITION] conducted on 5/11/17 at approximately 9:00 a.m. when two LNs, Staff Members D and E, performed dressing changes and applied the medicated cream to the three burn sites. Multiple blisters were observed on the left anterior thigh burn site and on the left lower abdomen burn site. The left inner forearm site was open with a superficial crater appearance and a light yellowish base. The resident had received Tylenol prior to the dressing change according to Staff Member D. Resident #2: Review of the medical record revealed the resident had multiple [DIAGNOSES REDACTED]. According to the resident's 5/12/94 care plan the resident required total basic care assistance from staff. When transferred between surfaces, staff were to use a gait belt (a belt placed around the resident's waist for staff to grasp instead of the resident's extremities or body parts) with 1-2 staff members. The resident had impaired communication related to a visual impairment, hearing impairment, and expressive/receptive deficit (without speech). The resident used a wheelchair for mobility and a love seat for alternate seating. According to a 5/08/17 nursing entry at 8:10 p.m., the resident was assessed to have a superficial abraded area on her left outer arm about 4 cm by 1 cm (approximately 1 1/2 inches by 1/3 inch) and a 2 cm by 1 cm red/pink area (approximately 3/4 inch by 3/8 inch). On 5/09/17 three abrasions were observed on the left bicep. Review of the 5/08/17 facility investigation noted that at approximately 4:05 p.m., Staff Member F, the Plant Manager, and Staff Member G, a Stationary Engineer, went to the cottage where Resident #2 resided to conduct an announced fire drill and evacuation. According to the 5/08/17 investigative statement from Staff Member F, when he and Staff Member G arrived at the cottage they announced the fire drill to Staff Member H, a Nursing Assistant. Staff Member H stated she did not want to participate and asked to speak with Staff Member G's boss on the phone. Staff Member H spoke to the boss but there were no changes in the planned fire drill. Staff Member H was not happy and threatened to send nasty work orders to the plant department. Staff Member H then jerked/got rough with a female client (Resident #2) while putting her in a wheelchair. Staff Member H then threatened to quit. The 5/08/17 facility investigation also contained a 5/08/17 statement from Staff Member G who recalled that Staff Member H was upset about having to conduct a fire drill when her helper was on break. Staff Member G advised Staff Member H that she could call for assistance. As Staff Member H was moving a resident (Resident #2) from a couch to a wheelchair, she was overly rough with her. A 5/10/17 written investigative statement from Staff Member H documented she had taken Resident #2's hands and pulled her to a sitting position prior to lifting her by her sides into her wheelchair. On 5/10/17 at approximately 2:15 p.m., an interview was conducted with Staff Member H with another investigator. Staff Member H recalled that two men had come to inform her that a fire drill was being conducted with an evacuation. Staff Member H stated she was frustrated. She had transferred Resident #2 without the use of the gait belt and recalled taking the resident's hands and waist to sit her up prior to transferring her to the wheelchair. Staff Member F was interviewed on 5/10/17 at approximately 4:20 p.m. and recalled that Staff Member H had stated she did not want to participate in the fire drill. Even after the phone call to Staff Member G's boss, that didn't stop the attitude. She threatened to send nasty work orders and to quit. Staff Member H approached Resident #2 and complained she had crapped her pants. Staff Member F observed feces in the resident's hand. Resident #2 was slouched over on the couch. Staff Member H then grabbed Resident #2's upper arms roughly, pulling/pushing her back and forth a couple times roughly. No gait belt was used during the transfer. When interviewed by telephone on 5/10/17 at approximately 4:45 p.m., Staff Member G recalled that Staff Member H was by herself when the fire drill was announced. She was not happy. Resident #2 was seated on the couch sideways. Staff Member H grabbed the resident from the front by her clothes and arms. Staff Member H stopped and shook the resident by the arms, moving her back and forth. It looked like Staff Member H was taking her aggression out on the resident. Staff Member H also mentioned the resident had feces on her. Staff Member F and G reported the staff member's actions and protective steps were taken. On 5/11/17 at approximately 12:15 p.m., observations were conducted of Resident #2's arm with Staff Member I, a LN. There was of a lateral scratch mark on the resident's left upper arm about 3/4 inches in length that appeared to be healing without complication. There were a couple smaller faint horizontal marks above the other area. A faint bruise appeared to be present on the back of the left upper arm.

Based on record review and interview, the facility failed to ensure 1 of 3 sampled residents (#2) was treated with appropriate dignity/respect. Deficient practice was identified for Resident #2 when facility staff utilized chemical restraints, in the form of injections of psychoactive medications and a sedating anti-histimine medication, for behavioral management. There was not a clinical evaluationt that necessitated the use of the chemical restraint. Resident #2 experienced psychosocial harm and resultant sedation as a result of the imposed medications. Findings include but were not limited to: Review of the facility's Protection From Abuse: Mandatory Reporting Policy 5.13 revealed that in Chapter 5, page 11 of 15, there was a definition of a chemical restraint. The policy documented: Chemical restraint means the administration of any drug to manage a vulnerable adult's behavior in a way that reduces the safety risk to the vulnerable adult or others, has the temporary effect of restricting the vulnerable adult's freedom of movement, and is not standard treatment for [REDACTED]. Resident #2: Review of a 2/09/17 Rule Exception Request revealed an emergent request for short term placement of an individual who was less than [AGE] years old but who would have her 18th birthday on 4/16/17. The individual had been residing in a hospital emergency room since 1/27/17 as a result of an incident when she had assaulted two staff members, a fell ow client, and two responding police officers. The resident's previous placement refused to re-admit her because they do not feel she is stable and predictable. The resident was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. The resident's admitting medications included a daily anti-depressant and an anti-psychotic medication administered twice daily. On 2/13/17 an ARNP ordered oral or injectable [MEDICATION NAME] (a sedating anti-[MEDICATION NAME] medication, usually given for allergy management) and oral or injectable [MEDICATION NAME] (an anti-psychotic medication) for management of agitation, only if authorized by the physician or ARNP (Nurse Practitioner). The facility created a 2/10/17 care plan for the resident that included a reference to the Positive Behavioral Support Plan to help manage the resident's maladaptive behaviors. Review of the resident's Positive Behavior Support Plan, dated 9/02/16, revealed the resident had multiple behaviors including Non-Compliance/Emotional Regulation (primary function: attention seeking): (Resident's name) will yell throw items, break things, or threaten to hurt herself when she become agitated. Staff were to avoid the antecedents that occur prior to the challenging behaviors that are the focus of the plan. The resident will yell, throw items, break things, or threaten to hurt herself when she becomes agitated. Environmental Strategies included responding to the resident quickly and listening to her and acknowledging her concerns. She also had a tool kit with coloring, silly putty, and puzzles). Staff were to guide her use STOP Skill. If she became further agitated staff were to give her space to take a break from the situation. Further review of the 2/10/17 care plan approaches included directing staff to position themselves between the resident and her peers and/or removing peers to a safe area to prevent a peer-to-peer assault. An Action-Stat could be called to secure additional staff. Increases in behavior were to be reported to the physician, ARNP (Nurse Practitioner), and Psychology. Additionally, there was documentation of the resident's history of self-injurious behaviors, property destruction, and elopement with running into traffic. It was an option to call 911 if the resident placed herself at risk for significant harm. According to the 2/15/17 order, another ARNP provided orders for an as needed oral anti-psychotic medication, [MEDICATION NAME] 25 milligrams (mg) twice daily as needed for agitation and injectable [MEDICATION NAME], an anti-psychotic medication, 5 mg twice daily if needed for agitation. The oral anti-psychotic was to be offered first and only after obtaining permission from the physician or ARNP. Target behaviors identified for April 2017 included: physical aggression, verbal aggression, obsessive behavior, suicidal ideation, refusal of hygiene tasks, elopement, property destruction, delusions, false accusations, and stealing. On 4/14/17 the ARNP evaluated the resident and documented that on 3/08/17 the resident's routine anti-psychotic medication was increased. On 4/11/17 the resident was sent to the hospital emergency room after ingesting a part of an electrical cord and received an x-ray. The resident had lost 12 pounds since admission and was 255 pounds on 4/01/17. No skin issues were noted. Review of nursing entries on 4/16/17 by Staff Member D, a Licensed Nurse (LN), revealed that at 3:35 p.m., a new resident arrived to the cottage with her parents. Resident #2 began yelling and screaming profanity. I hate people. I'm going to kill that little f___ing [***] . Resident #2 ran down to her bedroom and continued to scream and cuss. She grabbed her belongings and threw all over her room and out into the hallway. Two to three staff members were present. Attempts were made to provide food, fluids, and verbal redirection. Staff used mats to protect Resident #2 and the other residents. The other residents were redirected to the living room. An Action Stat was called to obtain additional staff. The resident continued to yell and made threats of harm to others and herself. Staff Member D called the ARNP at 3:55 p.m. and received an order for [REDACTED]. At 4:20 p.m. Staff Member D contacted Staff Member E, the Director of Nursing, to notify her of the use of 2-3 staff members and the injection administered to Resident #2. According to the 4/16/17 nursing entry, at 5:10 p.m., the resident grabbed the drawers in the closet and started throwing the wooden drawers at staff with statements that she was trying to kill the staff. At 5:20 p.m., another call was made to the ARNP. The ARNP ordered [MEDICATION NAME] (anti-anxiety medication) and [MEDICATION NAME] 10 mg (another anti-psychotic medication) be injected. The medications were administered at 5:25 p.m. The resident continued to demonstrate aggressive behaviors including opening the window and attempting to exit the window. Two staff stopped her exit by using mats. The resident's agitated behaviors continued until 6:30 p.m. when the resident walked to her bed, sat down, and then laid on her bed (approximately three hours after the initiation of the behavioral escalation). At 6:45 p.m., Resident #2 was on her bed with her eyes closed and appeared to be sleeping on her side. At 7:00 p.m. the resident was sleeping in the same position. At 7:50 p.m. the resident was aroused and she refused her oral medications. The resident continued to sleeping at 8:30 p.m. and 9:15 p.m. still lying in the same position. The following night shift entry stated the resident slept throughout most of the shift. The 4/17/17 day shift entry documented the resident stayed in bed until 11:30 a.m., refusing breakfast but ate her lunch. The resident was discharged on [DATE] during the afternoon. The resident's discharge skin check revealed a 4 centimeter (approximately 1 1/2 inch) reddened area on her lower right breast area. The resident refused a skin check in her peri-area prior to discharge. Refer to F221 related to the use of the mats to restrain the resident in order to administer the injectable medications. Although the ARNP was contacted prior to the injections on 4/16/17, there was no evidence of a clinical evaluation in conjunction with the castostrophic behaviors to identify medical symptoms necessitating the use of the as needed medications. In addition, the resident's legal representative/family member was not included in a discussion about the potential risks and benefits and alternatives to restraint use. (See F154). Interviews were conducted with Staff Member D on 4/20/17 at approximately 4:40 p.m. and on 4/28/17 by telephone at approximately 9:00 a.m. Staff Member D described Resident #2's behaviors on 4/16/17 stating she had to call an Action Stat to request additional staff. When asked about whether the resident willingly received the ordered injections, Staff Member D stated, after she told the resident she had an injection(s) ordered by the doctor, the resident threw herself to the floor and was hitting and kicking. The LN stated the resident would have kicked her (the LN's) teeth out. Four staff members were present to facilitate the injection, including the LN. The resident was positioned on her side. One staff member held a mat on the resident's legs (but not applying all their weight against the mat) while the LN administered the injections. Another staff member placed a mat over the resident's upper body while the LN lowered the resident's sweat pants and gave the injection. The resident kicked and slugged the mat. The fourth staff member stood by for additional help as needed. On 4/24/17 at approximately 1:15 p.m., an interview was conducted with the ARNP who prescribed the medications for Resident #2 on 4/16/17. The ARNP stated Resident #2 was at risk of harming herself and was aggressive with others. It was a dangerous situation. Other interventions are to be tried first like snacks, pain assessment, redirection, and de-escalation techniques. The resident was in a crisis bed at the faciilty.

Based on record review and interview, the facility failed to ensure 1 of 3 sampled residents (#2) was treated with appropriate dignity/respect when facility staff administered injections of psychoactive medications using physical restraint. There were no clearly identified medical symptom(s) that necessitated the use of a physical restraint and the resident's care plan did not include the use of physical restraint. Resident #2 experienced psychosocial harm as a result of the imposed restraints. Findings include but were not limited to: Resident #2: Review of a 2/09/17 Rule Exception Request revealed an emergent request for short term placement of an individual who was less than [AGE] years old. The individual had been residing in a hospital emergency room since 1/27/17 as a result of an incident when she had assaulted two staff members, a fell ow client, and two responding police officers. The resident's previous placement setting refused to re-admit her because they do not feel she is stable and predictable. The resident was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. The resident's admitting medications included a daily anti-depressant and an anti-psychotic medication administered twice daily. On 2/13/17 an ARNP (Nurse Practitioner) ordered oral or injectable [MEDICATION NAME] (a sedating anti-[MEDICATION NAME] medication, usually given for allergy management) and oral or injectable [MEDICATION NAME] (an anti-psychotic medication) for management of agitation only after the dose was authorized by the physician or ARNP. The facility created a 2/10/17 care plan for the resident that included a reference to the Positive Behavioral Support Plan to help manage the resident's maladaptive behaviors. Review of the resident's Positive Behavior Support Plan, dated 9/02/16, revealed the resident had multiple behaviors including Non-Compliance/Emotional Regulation (primary function: attention seeking): (Resident's name) will yell, throw items, break things, or threaten to hurt herself when she become agitated. Staff were to avoid the antecedents that occur prior to the challenging behaviors that are the focus of the plan. The resident will yell, throw items, break things, or threaten to hurt herself when she becomes agitated. Environmental Strategies included responding to the resident quickly and listening to her and acknowledging her concerns. She also had a tool kit with coloring (items), silly putty, and puzzles. Staff were to guide her use STOP Skill. If she became further agitated staff were to give her space to take a break from the situation. Further review of the 2/10/17 care plan approaches included directing staff to position themselves between the resident and her peers and/or removing peers to a safe area to prevent a peer-to-peer assault. An Action-Stat could be called to secure additional staff. Increases in behavior were to be reported to the physician, ARNP, and Psychology. Additionally, there was documentation of the resident's history of self-injurious behaviors, property destruction, and elopement with running into traffic. It was an option to call 911 if the resident placed herself at risk for significant harm. According to a 2/15/17 order, another ARNP had written orders for an as needed oral anti-psychotic medication, [MEDICATION NAME] 25 milligrams (mg) twice daily as needed for agitation and an injectable anti-psychotic medication, [MEDICATION NAME] 5 mg twice daily if needed for agitation. The oral anti-psychotic was to be offered first and only after obtaining permission from the physician or ARNP. Review of nursing entries on 4/16/17 by Staff Member D, a Licensed Nurse (LN), revealed that at 3:35 p.m., a new resident arrived to the cottage with her parents. Resident #2 began yelling and screaming profanity. I hate people. I'm going to kill that little f___ing [***] . Resident #2 ran down to her bedroom and continued to scream and cuss. She grabbed her belongings and threw all over her room and out into the hallway. Two to three staff members were present. Attempts were made to provide food, fluids, and verbal redirection. Staff used mats to protect Resident #2 and the other residents. The other residents were redirected to the living room. An Action Stat was called to obtain additional staff. The resident continued to yell and made threats of harm to others and herself. Staff Member D called the ARNP at 3:55 p.m. and received an order for [REDACTED]. At 4:20 p.m. Staff Member D contacted Staff Member E, the Director of Nursing, to notify her about the use of 2-3 staff members and the injection administered to Resident #2. According to the 4/16/17 nursing entry, at 5:10 p.m., the resident grabbed the drawers in the closet and started throwing the wooden drawers at staff with statements that she was trying to kill the staff. At 5:20 p.m., another call was made to the ARNP. The ARNP ordered [MEDICATION NAME] (anti-anxiety medication) and [MEDICATION NAME] 2 mg (another anti-psychotic medication) be injected. The medications were administered at 5:25 p.m. The resident continued to demonstrate aggressive behaviors including opening the window and attempting to exit the window. Two staff stopped her exit by using mats. The resident's agitated behaviors continued until 6:30 p.m. when the resident walked to her bed and sat down (approximately three hours after the initiation of the behavioral escalation). She then laid on the bed on her side. According to the 4/17/17 day shift entry, the resident stayed in bed until about 11:30 a.m., declining to get up for breakfast. Resident got up about 11:30 and ate lunch. Review of the facility December 2015 Mat Use Protocol documented permissible use of mats including protecting a person from themselves, protecting others from a potentially aggressive person, before the need for physical interventions, and to use the least restrictive de-escalation methods with residents. When and How Are Mats NOT used? 1) Mats are never used to punish or threaten. 2) Mats are never used to push, pin or hold a person unless there is a specific approved Positive Behavior Support Plan in place to do so .No one may be pinned to the floor, bed or wall, etc, by people with mats. 'Close proximity' does not mean controlling all body movement .But mats do not force a person's movement to stop. He/she stops. Interviews were conducted with Staff Member D on 4/20/17 at approximately 4:40 p.m. and on 4/28/17 by telephone at approximately 9:00 a.m. Staff Member D described Resident #2's behaviors on 4/16/17 stating she had to call an Action Stat to request additional staff. When asked about whether the resident willingly received the ordered injections, Staff Member D stated, after she told the resident she had an injection(s) ordered by the doctor, the resident threw herself to the floor and was hitting and kicking. The LN stated the resident would have kicked her (the LN's) teeth out. Four staff members were present to facilitate the injection, including the LN. The resident was positioned on her side. One staff member held a mat on the resident's legs while administering the injections. Another staff member placed a mat over the resident's upper body while the LN lowered the resident's sweat pants and gave the injection(s). The resident kicked and slugged the mat. The other staff member stood by for additional help as needed. On 4/20/17 at approximately 5:10 p.m., Staff Member F was interviewed about the events of 4/16/17 with Resident #2. Staff Member F recalled the resident was out and when she returned to the cottage she was very upset about the new resident arriving. Staff Member F had assisted the LN for the injection that afternoon. The resident was positioned on her side on the floor for the injection. They used a mat on the resident's legs to prevent injuries. When interviewed on 4/21/17 at approximately 10:00 a.m., Staff Member E, the Director of Nursing Services, stated that the use of mat(s) was acceptable but residents were not to be held down with mats.

Based on observation, record review, and interview, the facility failed to ensue the residents' environment was as free of accident hazards as possible and failed to provide sufficient supervision to prevent avoidable resident occurrences for 2 of 3 sampled residents (#3 & #4). Resident #4 was harmed when he accessed a caregiver's hot coffee and sustained first and second degree burns on his inner thighs. Resident #3 was restrained on the floor by caregivers contrary to his care directives. Findings include: Resident #4: Review of the medical record revealed the resident had multiple [DIAGNOSES REDACTED]. The resident's plan of care noted he was not to have anything by mouth and received nutrition through a feeding tube. Resident #4's care directives further documented he required close monitoring at meal time due to his history of food seeking. The resident utilized a wheelchair for mobility and was able to transfer and walk with staff assistance. Resident #4's care directives also included a caution that the resident had poor safety awareness. Staff were to have knowledge of where the resident was at all times, whom he was with, and what he was doing. Facility investigative documents, dated 11/27/10 at 11:00 p.m., revealed the resident was sitting on the couch next to a staff member and her cup of hot coffee. The staff member looked away and Resident #4 "reached for coffee, spilling on legs causing scald/burn areas R (right) & L (left) inner thigh/leg right greater than left". The resident was wearing shorts at the time. The facility investigation documented the resident sustained [REDACTED]. Licensed Nurse (LN) #4 documented the resident had multiple burned areas, one on the right inner thigh/leg approximately two by four inches and one lower on the right inner leg approximately 1/4 inch by 3/4 inch. Additionally, there was a burn on his left inner thigh nearly one inch by less than 1/8 inch. Review of the November 2010 medication administration record (MAR) revealed the resident received Tylenol for leg pain on 11/27/10 at 11:15 p.m. The 11/27/10 11:20 p.m. nursing entry documented the skin on the resident's right inner thigh was peeling. A treatment order was obtained from an on-call physician for the burn and was initiated. The resident tolerated the treatment well with "some vocalizing" (making voices). On 11/29/10 the Nurse Practitioner examined the resident's burns and also identified the burns as 2nd degree burns. Monitoring and treatments continued through 12/10/10. A 12/15/10 nursing entry documented the burns were resolved/healed. Observations on 12/15/10 at approximately 3:25 p.m. with LN #1, a day shift employee, revealed the resident's right inner thigh had patches of pink intact skin. LN #1 recalled the resident had an increased interest in seeking/grabbing at beverages for approximately a month before the coffee burn incident. Interviewed on 12/15/10 at approximately 3:55 p.m., Nursing Assistant (NA) #1, an evening shift employee, stated for the past several months Resident #4 had demonstrated an increase in seeking out food/beverages. On 12/16/10 at approximately 3:45 p.m., the Director of Nursing (DNS) stated there was no specific facility policy related to staff members' food and fluids on the unit, but the facility expectation was that staff members' personal foods/beverages were to be stored away from the residents. Staff had a dedicated place in the refrigerator. It was "the residents' home". When interviewed on 12/16/10 at approximately 10:40 p.m., NA #3, the assigned caregiver in cottage #201 on 11/27/10 recalled another NA, NA #2, had come over from the adjacent cottage to assist her with a clothing related task. NA #3 stated it was not unusual for staff to drink coffee and to set their cups down in the unit. On 12/17/10 at approximately 4:45 p.m., NA #2, the other NA on-duty on 11/27/10 at the time of the coffee incident, recalled she had just poured a cup of hot coffee into a travel-type mug without a lid and brought it with her from the cottage next door, cottage #202. The resident was seated on the couch next to a table and NA #2 sat in a recliner next to the table. NA #2 set her cup of coffee down on the table between the couch and recliner, next to the resident. NA #2 turned her head while talking to another caregiver, NA #3. NA #2 recalled Resident #4 made a noise. NA #2 responded quickly after she recognized the coffee spill and stripped the resident's clothing off. At that time she observed the resident's skin was peeling off his right inner thigh. "I believe he was hurting." Further observations were conducted on 12/21/10 at approximately 11:00 a.m. in cottage #202, the cottage next to Resident #4's cottage. A coffee maker containing coffee was observed in a room adjacent to the residents' living room area. The door was open and the coffee maker was in a direct line of access, approximately 7 feet from the door. The coffee was at 122 degrees Fahrenheit at that time but the unit was no longer on. Staff interviews with LN #2, NA #4, and NA #5 on the unit revealed the mobility status of the current cognitively impaired residents. Two residents (#5 & #8) had the physical capability to move about without staff assistance but they did not typically wander. However, the cottage housed respite residents who were placed on a temporary basis and who potentially would be at greater risk for accessing an unsecured coffee maker and at times very hot coffee. Resident #3: Review of the medical record revealed the resident had multiple [DIAGNOSES REDACTED]. The resident's care plan documented he had a history of [REDACTED]. The resident was noted to be frequently combative during personal care. Personal care was not to be attempted without a second person present. Staff were to use mats to protect themselves and the resident from injury. Additionally, the facility Psychologist provided a written guideline for staff entitled, "Things To Remember" when caring for Resident #4. Staff members were not to trap the resident, were to leave him a way to move, and were to "use minimum physical contact and avoid restraint"during periods of behavioral escalations. Staff were to step-back, not step in when the resident was upset. A nursing entry, dated 11/08/10, documented LN #3 had responded to the resident's cottage at 11:50 p.m. on 11/07/10 following a staff report of behavioral escalation. According to investigative documents, NAs #6 and #7 were caring for the resident on the 11/07/10 night shift. LN #3 responded to the cottage and witnessed the assigned NAs holding the resident down on the floor. Protective mats had not been used and were not present or in close proximity. LN #3 retrieved the mats for the staff and directed them to release the resident and take him to his room. Interviewed on 12/15/10 at approximately 11:20 p.m., NA #6 stated she had cared for the resident only twice in the past and he had slept both nights. She had read some of his care directives in the past but hadn't recalled all the details. On 11/07/10, after a bath, the resident lunged at NA #6 and they both were on the floor. The resident was attempting to scratch NA #6. NA #6 was not familiar with the use of mats and did not have one available. Instead, NA #6 and NA #7 held the resident's hands down in an attempt to prevent injury to themselves and the resident. However, the resident scratched NA #6 on her hands. LN #3 was interviewed on 12/16/10 at approximately 11:00 p.m. The LN stated she had been summoned to the cottage based on a call from NA #6. Whe LN #3 entered the cottage she noted the NAs did not have the mats; they were in another room. One NA was on each side of the resident and they were exerting enough force to keep him down on the floor. They had not followed the resident's care plan. When LN #3 provided the mats and gave direction for the NAs to use them, the resident calmed quickly. No physical injuries were noted. On 12/17/10 at approximately 4:38 p.m. NA #7 was interviewed. NA #7 stated she was never trained on the use of mats and had not fully reviewed the resident's care directives. The caregiver recalled that she and NA #6 were kneeling on the floor next to the resident and each held one of the resident's hands. On 11/07/10 two caregivers were assigned to care for the resident with signficant behavioral issues. The NAs had little experience with the resident, were relatively unfamiliar with his care plan, and had not previously been trained on the use of mats, a component of his behavioral management plan. There was insufficient supervision to ensure the resident's plan of care was followed and the resident was managed appropriately.