F0610

D

Failure to Timely Initiate and Document Abuse/Neglect Investigation

Centralia, Washington Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The facility failed to initiate and complete a thorough investigation of an allegation of abuse and/or neglect within required timeframes, as required by its policy and WAC 388-97-0640(6). The facility’s abuse, neglect, exploitation, or misappropriation policy dated September 2022 stated that all allegations are to be thoroughly investigated, and that the administrator is responsible for initiating investigations upon receipt of an allegation and ensuring they are documented. Resident 1, admitted with diagnoses including COPD and opioid dependence, was the subject of an allegation reported to the Administrator (Staff A) on 01/27/2026 at 2:10 PM. The allegation involved reported marks on the resident’s wrists related to restraints and that the resident had been found unresponsive due to being overmedicated.

Despite receiving this allegation on 01/27/2026, Staff A did not initiate a new investigation at that time, stating she believed a prior investigation had addressed similar concerns. The DON (Staff B) reported on 02/13/2026 at 2:00 PM that she had not been informed of the allegation between 01/27/2026 and 02/13/2026, had not initiated an investigation, and could not locate any documentation of an investigation specific to the reported restraint-related marks and unresponsiveness. Facility documentation showed the investigation was not initiated and documented until 02/13/2026. On 02/20/2026 at 1:10 PM, Staff B confirmed the facility did not initiate or complete the investigation within five working days of the allegation being received on 01/27/2026 because she was not aware of it.