F0609

D

Failure to Submit Complete Abuse/Neglect Investigation Results to State Agency

Olympia, Washington Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that results of abuse and neglect investigations were fully developed and reported to the State Agency Hotline within 5 working days for three residents. For a resident with sepsis, pneumonia, severe cognitive impairment, and dependence in ADLs, an investigation dated 09/23/2025 addressed an allegation that staff did not change the resident's tube feeding and the resident was without food for an extended period. The 5‑day follow‑up investigation submitted to the State Agency lacked interviews of sample residents, and when surveyors requested staff interviews on 12/11/2025 and 12/18/2025, none were provided.

For a resident with a stroke, left‑side weakness, no cognitive impairment, and dependence in ADLs, an investigation dated 10/02/2025 documented that the resident reported staff were rude and unprofessional. The 5‑day follow‑up investigation submitted to the State Agency was missing staff interviews, and requested interviews on 12/11/2025 and 12/18/2025 were not provided. For another resident with a urinary tract infection, morbid obesity, no cognitive impairment, and dependence in ADLs, an investigation dated 11/04/2025 documented that the resident received care from a male staff member after requesting only female caregivers. The 5‑day follow‑up investigation submitted to the State Agency lacked interviews of sample residents, and requested resident interviews on 12/11/2025 and 12/18/2025 were not provided. The DON and the Administrator both stated that staff and resident interviews should be included in facility investigations.