South Creek Post Acute

Respond appropriately to all alleged violations.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate a fall for 1 of 3 sampled residents (Resident 1) reviewed for facility investigations.

This failure placed residents at risk of unmet care needs and a diminished quality of life.

Findings included.Resident 1 admitted to the facility on [DATE].

The Medicare 5-day Minimum Data Set, an assessment tool, dated 06/25/2025, documented the resident was cognitively intact.

Record review of Resident 1's smoking care plan, dated 07/10/2025, documented the intervention, Supervision provided while resident is smoking.

Record review of Resident 1's smoking assessment, dated 07/10/2025, documented, Patient is unable to safely get to smoking area independently and has cognitive impairment.

Patient is unable to safely smoke independently.

Record review of Resident 1's fall investigation, dated 07/12/2025, documented, NAC [Nursing Assistant Certified] assisted resident outside to watch patient smoke. NAC witnessed resident slide out of wheelchair, and fall hitting her head on the concrete, knocking off her glasses. Resident 1's witness statement was, I fell down. I only hurt my pride.

In an interview on 08/25/2025 at 10:19 AM, Collateral Contact 1 said Resident 1 had a fall near the smoking area.

Collateral Contact 1 said Resident 1 had been left by a staff member when the fall occurred.

In an interview on 09/04/2025 at 11:11 AM, Resident 1 said during the fall incident, the NAC said she needed to use the restroom and left the resident outside. Resident 1 said her lit cigarette fell, and when she leaned forward from her wheelchair to pick it up, she fell from the chair and hit face first. In an interview on 09/04/2025 at 11:36 AM, Staff C, Residential Care Manager/Registered Nurse, said Resident 1 was an assisted smoker, meaning staff needed to stay with the resident when they smoke.

Staff C said during the fall near the smoking area, Resident 1 was being assisted to the smoking area.

Staff C said the NAC told Resident 1 she needed to use the restroom.

Staff C said the NAC came back two minutes later and found Resident 1 on the ground.

Staff C said she educated the NAC on the smoking times and to not leave residents alone when assisting with smoking.

When asked why the facility fall investigation documented the fall as a witnessed fall, Staff C said Resident 1 had told her the NAC had left at the time of the fall.

Staff C said she was mistaken documenting the fall as a witnessed fall and must have been thinking about another fall at the time the report was made. In an interview on 09/09/2025 at 11:11 AM, Staff B, Director of Nursing/Registered Nurse, said Residential Care Managers were responsible for gathering evidence and compiling information for fall investigations.

Staff B said the facility investigation concluded the resident fall was witnessed based on the statements obtained from Resident 1 and the staff on shift.

When informed of the discrepancies between the facility investigation and the interviews with Resident 1 and Staff C, Staff B said she would agree the witness statement in the facility fall investigation could have been more detailed.

Reference WAC 388-97 -0640 (6)(a)(b).

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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