F0835

F

Systemic Administrative Failures in Abuse Oversight, Smoking Safety, Elopement, and Staff Training

Auburn, Washington Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

Facility administration failed to manage the facility in compliance with state and federal requirements by not ensuring effective oversight, monitoring, investigation, reporting, and prevention related to abuse, smoking, elopement, and staff training. The administrator’s job description, signed in October 2025, assigned responsibility for daily operations, effective use of resources, ensuring residents are free from abuse, ensuring adequate and competent staffing, and monitoring outcomes of all facility programs, policies, and procedures. The administrator also served as the abuse coordinator and stated that staff were educated on abuse policies upon hire, annually, and as needed. However, a regional market leader reported that management did not consistently review resident progress notes every 24–72 hours as expected to identify care concerns and incidents, and that not all incidents of abuse, smoking, or elopement were identified or reported to management, resulting in missed investigations and missed opportunities for prevention.

Surveyors identified repeat issues related to accident hazards and supervision, particularly around resident smoking. A prior complaint survey in May 2024 had already cited the facility at F689 for failing to timely and accurately assess a resident’s ability to smoke safely, secure smoking supplies, and enforce the smoking policy when a resident repeatedly smoked inside the facility, which had risen to Immediate Jeopardy at that time. During the current survey, the administrator provided a list of 17 known resident smokers and stated that residents who smoke were identified on admission, signed a non‑smoking policy, and were required to go off property to smoke. The DON stated that smokers should be assessed, have a smoking‑focused care plan, and have smoking supplies checked in and out from the med cart. Despite this, the administrator acknowledged knowing that two residents had recently smoked multiple times inside the facility, including one resident who smoked indoors three days before the interview, and the DON confirmed that seven identified smokers had no smoking assessments in their medical records.

The survey determined an Immediate Jeopardy at F689 beginning in late December 2025 due to repeated indoor smoking by two residents who were assessed as not safe to smoke independently. One resident was identified smoking inside the facility on multiple dates in December 2025 and January 2026, and another resident smoked inside on several dates in December 2025 and again in February 2026. Additionally, the interim administrator later stated that the administrator is responsible for resident safety and that staff are required to report incidents so interventions can occur, but acknowledged that the facility did not implement a smoking policy that supported resident rights and safety and that the elopement policy was not followed for one of the residents. Separately, the staff development coordinator reported that there was no system in place to schedule, document, track, or monitor required staff training and competency, and could not provide documentation of orientation, mandatory training, annual evaluations, or training described in the facility assessment. The interim administrator confirmed that the facility lacked and did not implement a policy for training, documentation, or tracking of required training and competency, contributing to deficiencies cited under F600, F610, F689, and F947.