Yakima Valley School

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteThe 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of potential abuse were reported to the administration and the state survey agency (SA) abuse hotline as required for 1 of 1 resident (Resident 1) reviewed for reporting allegations of abuse. Failure to report an incident of potential abuse placed residents at risk for additional abuse.

Inspectors wroteBased 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). [...]

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to have written policies and procedures to include the time frames for the immediate reporting of abuse according to CFR §483.12(c)(1) and a written policy to define how staff will communicate and coordinate situations of abuse with the quality assurance performance improvement (QAPI) program according to CFR §483.12(b)(4), and failed to ensure implementation of the facility procedure to immediately notify the Nursing Home Administrator (NHA), and State Survey Agency of abuse violations was followed by staff. This failure caused a delay of protection for 2 of 2 residents (Resident 1, 3) reviewed for allegations of abuse, and placed the residents at risk for unrecognized abuse and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personal privacy was protected for 4 of 4 residents (Resident 1, 2, 3, 4), reviewed for the right to privacy. Resident 1, 2, 3 and 4's images were recorded on a staff member's (Staff C, Nursing Assistant (NA)) personal cell phone without the resident's and/or designated representative's consent and sent in text messages to an individual outside the facility. This failure placed the residents at risk for embarrassment, a violation of their privacy, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly stored and labeled, found in a single locked drawer during one medication pass for 5 of 11 residents (Residents 4, 7, 26, 31, and 35) reviewed for medication administration. This failure placed residents at risk of receiving incorrect medication, adverse side effects and increased the facility's risk for medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Cottage refrigerators and cupboards were free of expired foods and refrigerator temperatures were logged appropriately for 3 of 8 Cottages (Cottages 401, 402, and 403) reviewed for food storage. This failure placed the residents at risk of receiving food or drink that decreased their quality of life and had the potential to cause harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that maintained a resident's dignity for 1 of 2 sampled residents (Resident 12) reviewed for gastrostomy tube ([GT], a surgically placed tube in the stomach to allow liquid food and water to be given). This failure placed the resident at risk for psychosocial harm and lack of privacy.

Inspectors wroteBased on interview and record review, the facility failed to ensure quarterly personal fund statements were provided to residents and/or resident representative (RR) for 2 of 9 sampled residents (Resident 43 and 47) reviewed for personal fund accounts. This failure placed residents at risk of not having an accurate accounting of their personal funds held in trust by the facility.

Inspectors wroteBased on interview and record review the facility failed to review and validate the 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) were correct on admission and corrected/updated as needed for 2 of 5 residents (Resident 47 and 50 ) reviewed for unnecessary medications. This failure placed the residents at risk for not receiving the care and services appropriate for their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) for 1 of 5 residents (Resident 39) reviewed for unnecessary medications. The facility failed to ensure individualized targeted behaviors were being monitored while they received psychotropic medications. These failures placed residents at an increased risk for experiencing medication-related adverse side effects, and unnecessary medications. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain infection control practices for 1 of 1 resident (Resident 39 ), by not wearing the proper Personal Protection Equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) during 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) isolation, perform hand hygiene and glove changes between dirty and clean tasks (after touching the resident and/or the resident's environment). These failures placed residents at risk for development of communicable diseases and the spread of infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed staff responsible for providing basic life support in an emergency, had current training and certification in Cardiopulmonary Resuscitation [(CPR) a lifesaving technique that's useful in many emergencies when someone's breathing or heartbeat has stopped, that is used prior to the arrival of emergency medical personnel] for 3 of 4 staff (Staff E, F, and G) reviewed for CPR certification. This failed practice put residents at risk for a delay in life saving treatment and/or receiving lifesaving treatment incorrectly that could result in injury and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents were served the appropriate diet texture to prevent choking hazards for 2 of 3 Residents (Residents 1 and 3) reviewed for food and nutrition services. This failed practice put residents at risk for a decreased nutritional intake, serious injury, and/or death.