Auburn Post Acute

speech, was able to make themselves understood, and could understand others.

The MDS showed

jeopardy to resident health or directed at others that put Resident 4 as significant risk for injury, interfering with the resident's care safety and participation in activities and social interactions.

The MDS showed the behaviors significantly disrupted the living environment and Resident 4 had medically complex conditions including anxiety,

Resident 4 was aggressive, engaged in loud arguments with staff and surrounding roommates, used foul language, and was name calling neighbors.

The progress note did not indicate what staff did to protect the residents, determine which residents were involved, who was notified of the incident, and if an investigation was initiated.<Resident 5>Review of a 12/19/2025 Quarterly MDS showed Resident 5 had had clear speech, was able to make themselves understood, and could understand others.

The MDS showed Resident 5 was cognitively intact, was able to make own decisions, and had no behaviors.

The MDS showed Resident 5 had medically complex conditions including fractures and adult failure to thrive.Review of Resident 5's progress notes dated 12/09/2025-12/17/2025 showed no indication staff put Resident 5 (Resident 4's roommate) on alert charting, made a progress note about the verbal incident, documented who was informed of the incident, what actions staff took to protect the residents and if an investigation was initiated.During an observation and interview on 02/03/2026 at 4:45 PM, Resident 5 was observed in bed. Resident 5 stated their roommate (Resident 4) would cuss at them for anything, would go off on the staff, cuss at everybody, throw things, and staff were aware but didn't do anything. Resident 5 stated they didn't like being yelled at or called names and was happy the roommate is no longer at the facility.

Review of the December 2025 facility abuse log showed no entries logged, reported or investigated for Resident 4 and Resident 5's verbal altercation.

During an interview on 02/13/2026 at 12:20 PM Staff D stated they would expect the resident-to-resident verbal altercation to be logged, reported, and investigated timely.

Staff D stated they reported the resident-to-resident altercation on 02/13/2026 and agreed it was not reported timely as they would expect.In a phone interview on 02/17/2026, Staff R (Interim Administrator) stated the facility made change in their administration and Staff R would be the new administrator and abuse coordinator at the facility.

Staff R stated changes were made to ensure all allegations of abuse were properly reported, logged, and investigated as required. REFERENCE: WAC 388-97-0860(1)(2)(a)(4)(5)(a)(6)(a-c)

505355 02/26/2026

Auburn Post Acute 414 - 17th Southeast Auburn, WA 98002

10/15/2024.Review of a 09/18/2025 revised skin care plan showed Resident 3 had a sacral PU that

reposition the resident every 2-3 hours while in bed and follow facility policies and protocols for the

staff did not complete and/or document the results of the skin evaluations on 10/14/2025, 10/21/2025, 10/28/2025, 11/11/2025, 11/25/2025, 12/01/2025, 12/08/2025, 12/22/2025, 12/30/2025, 01/05/2026, and 01/12/2026.Review of a 01/14/2026 wound provider note showed Resident 3 was seen for a new Stage 4 (severe full thickness wound extending to the muscle and the bone) sacral (tailbone) PU and a new Stage 3 PU to their right buttocks.Review of Resident 3's medical record from 10/30/2025-01/13/2026 showed no progress notes on the date the two PU's were discovered, who was notified, and what staff did in response to the two new PU's.

Review of Resident 3's medical record showed no skin/wound evaluations completed by staff to determine when the wound developed and was identified by facility staff.Observations on 01/21/2026 at 2:32 PM showed Resident 3 could not answer questions and was in bed on their back on an air mattress.

Staff J (Registered Nurse, RN) was present in the room and at 2:33 PM stated Resident 3 had a stage 1 PU to their sacrum (tailbone area) , the resident was repositioned every few hours but it made it hard because Resident 3 received tube-feeding (nutritional formula given directly into the stomach) and the head of the bed had to be elevated to prevent choking.In an interview on 02/26/2026 at 11:22 AM Staff B stated they would expect staff to complete a Braden skin assessment quarterly, update the skin care plan with current PU, complete and document skin and wound assessments.

Staff B stated Resident 3 had physician orders for barrier cream after each incontinent episode, did not know how staff did not identify the PU's to Resident 3's bottom until it was a stage 3 & stage 4 PU, and would expect the staff to be able to identify skin breakdown.

Staff B stated when a new PU was identified staff should complete a progress note, an incident report, inform the provider, resident representative, obtain and implement treatment orders, and update the care plan. REFERENCE: WAC 388-97-1060(1)(b)(3)(b).

505355 02/26/2026

Auburn Post Acute 414 - 17th Southeast Auburn, WA 98002

Review of progress notes 01/01/2026 through 01/21/2026 showed no documentation of elopement.

Review of the January 2026 facility accident and incident log showed Resident 8 was a

Review of the 01/20/2026 facility investigation documents showed Resident 8 could not be located and the facility missing person policy was implemented.

The investigation showed Resident 8 wanted a cigarette and was let out of the facility by another resident at 7:13 PM. Resident 8 was located at the store two blocks away unsupervised and returned to the facility at 7:49 PM.

The investigation did not identify why the wander guard system did not alarm when Resident 8 left the facility.

The intervention implemented by the investigation was to initiate 1:1 supervision of Resident 8.

During observation and interview on 02/03/2026 at 3:02 PM, Resident 8 was self-propelling in their wheelchair on the second floor, there was no 1:1 staff supervising. Resident 8 was near the elevator, a wander guard device was observed on the wheelchair, and the wander guard system did not alarm.

At 3:06 PM, Resident 8 moved closer and pushed the elevator button, then the alarm sounded. Resident 8 stated they wanted their money, had $5000 and needed to get to the bank. At 3:07 PM the alarm was still sounding; Resident 8 stated, I'm going to [the store] by myself. At 3:09 PM Staff P (Housekeeping Manager) arrived and turned off the alarm when Resident 8 self-propelled away from the elevators. No 1:1 supervision by staff was observed.

Review of a binder at the nurses station contained an undated document named 1:1 supervision guideline elopement prevention plan for Resident 8.

The plan directed staff to always maintain a continuous line of sight of Resident 8, stay within arm's length when near exits or high-risk areas, accompany Resident 8 during all movement throughout the facility, do not leave unattended for any reason, if relief was needed ensure proper hand off before stepping away.

Staff logs in the book showed staff signing in from 6:00 AM to 2:00 PM and 2:00 PM to 10:00 PM starting on 01/23/2026. A staff member signed in on 02/03/2026 at 2:00 PM to supervise Resident 8. In an interview on 02/03/2026 at 5:25 PM, Staff B stated Resident 8 was able to get on the elevator from the second floor without staff knowledge.

Staff B stated Resident 8 often expressed desire to smoke which increased their risk of elopement.

Staff B stated Resident 8 eloped from the facility on 01/20/2026. In an interview on 02/13/2026 at 11: 45 AM Staff A stated an elopement, or missing resident would be a resident who was not cognitively able to manage themselves outside of the facility.

Staff A stated staff were expected to follow the policy for a missing resident.

Staff A stated the incident should be reported to the administrator, written on the incident log, investigated, and interventions implemented to prevent re-occurrence.

Staff A stated Resident 8's incidents of elopement were not on the incident log or investigated. In an interview on 02/26/2026 at 3:00 PM, Staff R (Interim Administrator) stated an administrator is responsible for the safety of residents and staff are required to report resident incidents so interventions can occur timely.

Staff R stated the facility should have, and did not, implement a smoking policy that supports resident rights and safety.

Staff R stated the facility had a policy for elopement and the policy was not followed by administration or staff for Resident 8.

Reference: WAC 388-97-1060 (1)(3)(g); -1620(7)(b)-3220(1).

505355 02/26/2026

Auburn Post Acute 414 - 17th Southeast Auburn, WA 98002

Accident Hazards/ Supervision/ Devices related to the facility's failure to ensure safety when

01/13/2026, 01/16/2026, and 01/31/2026. Resident 13 was smoking inside the facility on

independently.In an interview on 02/26/2026 at 3:00 PM, Staff R (Interim Administrator) stated an administrator is responsible for the safety of residents and staff are required to report resident incidents so interventions can occur timely.

Staff R stated the facility should have, and did not, implement a smoking policy that supports resident rights and safety.

Staff R stated the facility had a policy for elopement and the policy was not followed by staff for Resident 8.<Nurse Aide Training>In an interview on 02/26/2026 at 1:35 PM, Staff U (Staff Development Coordinator) described orientation, ongoing education, and competency evaluation for staff.

When asked to provide documentation for training at hire, orientation, annual mandatory training, annual performance evaluations for competency, and training provided as stated in the facility assessment.

Staff U stated they could not provide documentation for the sampled staff.

Staff U stated there was not a system in place for scheduling, documenting, tracking, or monitoring staff completion of required training.In an interview on 02/26/2026 at 3:00 PM, Staff R stated an administrator is responsible for the training and competency of all staff.

Staff R stated the facility should have, and did not implement a policy for training, did not document or track required training or competency of staff.

Refer to F-F600 Free from Abuse and NeglectRefer to F-F610 Investigate/Prevent/Correct Alleged ViolationRefer to F-F689 Free of Accident Hazards/Supervision/DevicesRefer to F-F947 Required In-Service Training for Nurse Aides Reference: WAC 388-97-1620(1)(2)(b)(i-ii)(c)(3)(b)(d).

505355 02/26/2026

Auburn Post Acute 414 - 17th Southeast Auburn, WA 98002

Findings included .<CMS-Electronic Staffing Data Submission PBJ>

Review of the June 2022, CMS Long-Term Care Facility PBJ Policy Manual, showed long term care facilities were required to electronically submit direct care staffing information based on payroll and auditable data.

The data, when combined with the census information can be used to not only report on the level of staff in each nursing home, but reports staff turnover and tenure, that can impact the quality of care delivered at the facility.

The policy manual showed the facility must electronically submit complete and accurate information by the required deadline to include; direct care staff, the category of work for each direct care staff member, resident census data, and direct care staff turnover and tenure.

Review of the PBJ data submitted by the facility for Q2, dated April 01, 2025 through June 20, 2025 showed a reported census total of 6988.

Review of the facility monthly census for April 2025 showed 2266, May 2025 showed 2242, and June 2025 showed 2238 for a census total of 6746. A difference of 242 days.

During an interview on 01/07/2026 at 3:10 PM Staff A (Administrator) stated PBJ submission and census reporting was completed on a corporate level.

Staff A stated issues were identified with prior Minimum Data Set (MDS, an assessment tool) submission being timely and accurate. In an electronic communication (e-mail) on 01/12/2026 at 8:45 PM, Staff C (Corporate Staff) wrote the accurate census for Q2 was 6789 after reviewing all PBJ submission documents.

During an interview on 01/21/2026 at 3:35 PM, Staff A stated they would expect complete and accurate PBJ information to be submitted as required. REFERENCE: WAC 388-97-1090(1)(2)(3)

505355 02/26/2026

Auburn Post Acute 414 - 17th Southeast Auburn, WA 98002

Findings included.

Review of the undated Facility Smoking policy showed Smoking cigarettes, marijuana, and the use of any/all tobacco products as well as electronic cigarettes and vaping devices anywhere on the premises by residents is strictly prohibited.

Residents admitted after 04/18/2024 must smoke off the facility premises under direct supervision by a non-staff responsible party.

The policy directed the non-staff responsible party to store all smoking supplies off the facility premises.

The policy showed staff would assess smokers for smoking safety, handling smoking materials, and the use of a wheelchair or walker while outside.

Smokers were expected to sign out when going out to smoke and sign in upon return.

The policy showed an area for the residents to sign acknowledgement and compliance with the facility smoking policy.

The policy did not define where the facility premises ended, a designated smoking area, smoking safety, or any rules that applied to residents admitted prior to 04/18/2024.

Observation and interview on 02/13/2026 at 11:39 AM showed the designated smoking area was in the back of the parking garage, the ground was littered with hundreds of cigarette butts, a fire extinguisher was lying on the ground in the gravel, a fire blanket and second fire extinguisher was secured to the wall but blocked by two large trash cans, a chair, and a bed frame making them not accessible.

Staff W (Maintenance Assistant) observed the designated smoking area, stated certain residents were allowed to smoke there, identified the hundreds of cigarette butts on the ground and stated people should use the ash tray, lifted the fire extinguisher, stood it up on the pavement, and stated the fire extinguisher laying on the ground was unsafe. In an interview and record review on 02/13/2026 at 4:08 PM with Staff A (Administrator) and Staff B (Director of Nursing), the facility smoking policy and a list of residents who smoked were provided, 17 residents were identified by the facility as known smokers.

Staff A stated residents were identified as smokers on admission; residents signed the non-smoking facility policy, and alternate treatments for smoking were offered.

Staff A stated three residents were grandfathered into the prior smoking policy which allowed the residents to smoke in a designated smoking area in the parking garage, but other residents must go off property to smoke.

Staff B stated residents that are active smokers were assessed to be independent with smoking, the assessment would be in their medical record, and they would have a smoking focused care plan.

Staff B stated smoking supplies were kept on the medication cart and the residents would check out their supplies from the nurse, then sign out to go smoke outside.

Staff A stated smoking inside the facility and the atrium was prohibited.

When Staff A and Staff B were asked if the smoking policy provided was being followed, Staff A stated the smoking policy was unclear and was not followed by residents or staff.

Staff B stated there was a breakdown in the system of residents smoking. In an interview on 02/26/2026 at 3:00 PM, Staff R (Interim Administrator) stated an administrator is responsible for the safety of residents.

Staff R stated the facility should have, and did not, implement or maintain a smoking policy that supported resident rights and resident safety.

Refer to F-F689 Accidents/Hazards/Supervision/Devices. REFERENCE: WAC 388-97-1780(1)(2)(a)(i)(d).

505355 02/26/2026

Auburn Post Acute 414 - 17th Southeast Auburn, WA 98002

Review of the revised 08/04/2025 Facility Assessment (FA) showed the facility had 96 licensed beds with an average daily census of 74 residents.

The FA showed the facility staff provided care to residents with common conditions including psychiatric, mood, and substance use disorders, cognitive impairment, memory deficits, dementia, traumatic brain injury, and behaviors related to these conditions.

The FA showed residents required care for skin and wound care, and activities of daily living such as bathing, dressing, oral care, eating, transfers, and ambulation.

The FA showed a staffing plan which included 41 nurse aides working eight-hour shifts with assignments of 1:10 ratio of staff to residents.

The FA showed staff required training in communication with residents, resident rights, abuse/neglect identification, reporting and prevention, infection control, resident-centered care, cultural competency in care delivery, activities of daily living, disaster planning, measurement of vital signs, care to residents with cognitive impairment, mental and psychosocial disorders, non-pharmacological management of resident behaviors, caring for residents with a trauma history, and care to residents with substance use disorders. An observation on 02/26/2026 at 11:28 AM showed Staff Y and Z answering call lights on the long-term side of the unit.

Review of the nurse aide assignment sheet for 02/26/2026 showed Staff Y (CNA- Certified Nursing Assistant) and Staff Z (CNA) were assigned to resident care on the day shift and Staff X was assigned to the evening shift.

Review of the current staff list provided by the facility on 02/26/2026 showed Staff X (CNA) was hired on 01/03/2026.

Staff Y was hired on 10/30/2024.

Staff Z was hired on 10/09/2024.In an interview on 02/26/2026 at 1:05 PM, Staff U (Staff Development Coordinator) stated staff received video training on a corporate portal prior to orientation which included abuse/neglect, resident rights, infection control, and dementia.

Staff U stated these topics were also discussed at all staff meetings.

Staff U stated there was not a tracking system to ensure staff participation on annual required training topics.

Staff U stated nurse aide inservice training could be obtained through reports from an online training portal, but there was no system in place to track the 12-hour nurse aide required inservice training.

Staff U stated there was no support from the Administrator to put systems in place to track staff training, assess staff competency through skills evaluation, and no communication to Staff U regarding nurse aide performance evaluation for additional training needs of nurse aide staff.

Staff U stated they were not involved in nurse aide performance reviews to provide training in identified areas of weakness.

Staff U was asked to provide documentation of annual mandatory training, performance evaluations, skills assessment for competency, and 12-hour in-service documentation for nurse aide Staff X, Y, and Z. No documentation was provided. In an interview on 02/26/2026 at 3:00 PM, Staff R (Interim Administrator) stated the facility should have a mandatory annual inservice schedule to provide in-service training for all staff; that the training provided should be tracked and participation should be documented.

Staff R stated the facility should provide, track and document 12-hour inservice training for nurse aide staff.

Staff R stated nurse aides should have performance and competency evaluated annually.

Staff R stated there were no systems in place and no documents could be provided for the training requirements identified in the FA.

Refer to F-F835 Administration.REFERENCE: WAC 388-97-1660(1)(a), -1680(1)(2)(a-b)(i-ii)(c),-1740(4)(b),-1040(1)(c).