Woodard Creek Health & Rehabilitation

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

impairment and required set-up assistance from staff with many ADLs.Review of progress notes, dated 06/06/2025, documented Resident 5 was not in their room at the beginning of the shift and their lunch tray was untouched.Review of progress notes, dated 06/07/2025, documented Resident 5 was not seen at the beginning of the shift. Staff called family and awaited a response. One family member responded and had not seen the resident. The last witnessed sighting of Resident 5 was during the am medication pass on 06/06/2025.Review of progress notes, dated 06/07/2025, documented Resident 5 did not return on 06/06/2025 after the resident signed out stating they were going to get a wheelchair for their pending discharge. Family initially did not know where Resident 5 was but soon located the resident. Resident 5's departure was considered an AMA discharge as the resident did not return to the facility on [DATE REDACTED].On 09/04/2025 at 3:23 pm, Staff B said she was off when this incident occurred. Staff B said she would have called this into the State Agency as an elopement. Staff B said this discharge should have been called to APS.On 09/04/2025 at 4:14 pm, Staff A said he was not sure this discharge should have been considered

an elopement because the resident signed out of the facility. Staff A said the resident did not return to the facility as expected and the staff did not know where the resident was. Staff A said this discharge should have been called to APS.Resident 6Resident 6 was admitted to the facility on [DATE REDACTED] with diagnoses of chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs) and oxygen dependence. No MDS was completed.Review of progress notes, dated 07/29/2025, documented Resident 6 was requesting to leave AMA. Staff notified the Administrator and family following facility protocol for AMA discharges.On 09/04/2025 at 3:23 pm, Staff B said this discharge should have been called to APS.On 09/04/2025 at 4:14 pm, Staff A said Resident 6's discharge should have been called to APS.REFERENCE: WAC 399-97-0640(5)(a)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodard Creek Health & Rehabilitation

3333 Ensign Road Northeast Olympia, WA 98506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure signs of psychosocial outcome related to allegations of abuse were monitored for 1 of 4 sampled residents (4) reviewed for abuse. This failure placed residents at risk of abuse, neglect and a decreased quality of life.Findings included .Resident 4 was admitted to the facility on [DATE REDACTED] with diagnoses of Parkinsonism syndrome (tremors, stiffness, slowness of movement, and difficulty maintaining balance) and chronic pain. The 5-day Medicare MDS, dated [DATE REDACTED], documented Resident 4 had moderate cognitive impairment and was dependent on staff for many ADLs.Review of Resident 4's care plan, dated 08/01/2025, documented Resident 4 suffered from Post Traumatic Stress Syndrome (mental health problem that can occur after a traumatic event) due to a history of physical and emotional abuse (a sexual assault) while in a nursing facility as a child.Review of facility incident report, dated 08/01/2025, documented Resident 4 made an allegation of sexual abuse by a staff. The investigation did not address the monitoring of potential psychosocial wellbeing.Review of physician orders, dated 08/01/2025, documented staff will monitor the resident for psychosocial wellbeing, observe and chart a progress note for behavior, refusal of care, social isolation, and pain management, and notify the provider of any of the above concerns, and monitor every shift for five days.A review of the progress notes did not show monitoring for psychosocial wellbeing related to the allegation of sexual abuse.On 09/04/2025 at 3:23 pm, Staff B said there was no monitoring of Resident 4's potential psychosocial being related to the abuse allegation. Staff B said staff should have documented monitoring.Reference WAC 388-97-0640(5)(a)

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodard Creek Health & Rehabilitation

3333 Ensign Road Northeast Olympia, WA 98506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

1:12 pm, Staff E, social services, said she was working with someone in the community to set up community housing for Resident 3. It was anticipated this would be a distance future, but it was in process.

Staff E thought this was documented in the medical record but was unable to find the documentation or and was not reflected in the care plan. The resident ended up leaving AMA, but Staff E felt this should have been handled as a safe discharge. The resident could take care of themselves and could essentially have everything prepared right away. Staff E acknowledged the resident did not have evidence of a discharge plan or reassessment of a plan in the medical record.On 09/04/2025 at 3:23 pm, Staff B said she could not find discharge planning in the resident's record.REFERENCE WAC 388-97-0120(2)(a-d)(3)(a)(4), -0140(1)(a)(b)(c)(i-iii).

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodard Creek Health & Rehabilitation

3333 Ensign Road Northeast Olympia, WA 98506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to complete a discharge summary for 1 of 3 residents (2) reviewed for discharge planning. The facility failed to provide written bed hold notices at the time of a therapeutic leave for 1 of 1 sampled resident (3) reviewed for therapeutic leaves. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed, protection of resident rights

during transfers, and a diminished quality of life.Findings included .Discharge SummaryThe facility policy, Transfer or Discharge, Preparing a Resident For, dated 10/01/2021, documented a post-discharge plan is developed for each resident prior to his or her transfer or discharge. Nursing services and/or social services is responsible for preparing a discharge summary and post-discharge plan and completing a discharge note in the medical record.Resident 2Resident 2 was admitted to the facility on [DATE REDACTED] with diagnoses including dementia and dysphasia. No minimum data set (MDS), an assessment tool, was completed.Review of care plan, dated 06/25/2025, documented Resident 2 was to reside at the facility on a short-term basis. Staff would review and update discharge plans with the resident when needed.Review of Social Service Initial Assessment, dated 06/24/2025, documented Resident 2 would return home after their stay at the facility.Review of progress notes, dated 07/01/2025, documented Resident 2 was transferring to another long-term care facility. Medications reviewed with the resident and family. Belongings were sent with

the resident.Review of discharge POC - Resident discharge instructions, dated [DATE REDACTED], were blank.Review of the medical record showed no Discharge Summary was completed or sent to the receiving facility.On 09/04/2025 at 3:03 pm, Staff B Registered Nurse (RN) and Director of Nursing (DNS), said for Resident 2

they sent the receiving facilities orders, progress note, medication/treatment administration and provider notes. Staff B said they didn't always complete the discharge summary or instructions. Staff B said they should have been doing it.Resident 3Resident 3 was admitted to the facility on [DATE REDACTED] with diagnoses of congestive heart failure (the heart cannot pump blood effectively enough to meet the body's needs) and cirrhosis (advanced scarring of the liver). The Annual MDS, dated [DATE REDACTED], documented Resident 3 had no cognitive impairment and was independent with activities of daily living.Review of care plan, dated 04/09/2025, documented Resident 3 was staying at the facility long-term, and the discharge plan would be reviewed with the resident.Review of progress notes, dated 05/02/2025, documented Resident 3 left on a leave of absence (LOA). The medical record did not indicate when the resident returned from the LOA.

There was no documentation showing a bed hold was offered.Review of progress notes, dated 05/23/2025, documented Resident 3 left on a LOA until 05/27/2025. There was no documentation showing a bed hold was offered.On 09/04/2025 at 1:12 pm, Staff E, social services, said Resident 3 would leave often on therapeutic leaves (LOA). Staff E said they did not provide bed holds to residents leaving on therapeutic leaves and were not aware of the requirement.Reference WAC 388-97-0080 (1)(b)(2)(a)(d)(6)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodard Creek Health & Rehabilitation

3333 Ensign Road Northeast Olympia, WA 98506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review, the facility failed to ensure resident care plans were reviewed, revised, and accurately reflected resident care needs for 2 of 13 sampled residents (2 & 4) reviewed for care plan revisions. This failure placed residents at risk for unidentified and unmet care needs and a diminished quality of life.Findings included .Resident 2Resident 2 was admitted to the facility on [DATE REDACTED] with diagnoses including dementia and dysphasia. No minimum data set (MDS), an assessment tool, was completed.Review of the care plan, dated 06/25/2025, documented Resident 2 was at risk for dehydration, weight loss, or malnutrition related to advanced age. Interventions included checking weights as ordered.Review of physician orders, dated 06/24/2025, documented Resident 2 required moderately thick liquids with thin water between meals, small bites of food and sips of water, and use of a chin tuck, swallowing twice with every bite and/or sip.The Diet Nutritional Assessment, dated 06/278/2025, documented Resident 2 required moderately thick liquids with thin water between meals, small bites of food and sips of water, and use a chin tuck, swallowing twice with every bite and/or sip. The resident was identified at risk for malnutrition related to CHF, Parkinson's disease and diabetes mellitus.On 09/04/2025 at 3:03 pm, Staff B Registered Nurse (RN) and Director of Nursing (DNS), said the care plan should have been updated to include Resident 2's specific dietary needs.Resident 4Resident 4 was admitted to the facility on [DATE REDACTED] with diagnoses of Parkinsonism syndrome (tremors, stiffness, slowness of movement, and difficulty maintaining balance) and chronic pain. The 5-day Medicare MDS, dated [DATE REDACTED], documented Resident 4 had moderate cognitive impairment and was dependent on staff for many activities of daily living.The care plan, dated 08/01/2025, documented Resident 4 suffered from Post Traumatic Stress Syndrome (mental health problem that can occur after a traumatic event) due to a history of physical and emotional abuse (a sexual assault) while in a nursing facility as a child.The incident report, dated 08/01/2025, documented Resident 4 made an allegation of sexual abuse by a staff.On 09/04/2025 at 3:23 pm, Staff B said Resident 4's care plan was not revised to include the allegation of sexual abuse on 08/01/2025.Reference WAC: 388-97-1020 (2)(e)(f)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodard Creek Health & Rehabilitation

3333 Ensign Road Northeast Olympia, WA 98506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident 5's departure is considered an AMA discharge as the resident did not return to the facility on [DATE REDACTED].On 09/04/2025 at 3:23 pm, Staff B said she was off when the incident occurred. Staff B said she would consider this an elopement and feels elopement protocol should have been followed.On 09/04/2025 at 4:14 pm, Staff A said he was not sure Resident 5's absence should have been considered an elopement because the resident signed out of the facility. Staff A admitted the resident did not return to the facility as expected and the staff did not know where the resident was for a period.AMAThe facility policy, Discharging

a Resident Without a Physician's Approval, dated 10/01/2021, documented the facility would make all reasonable efforts to ensure that the resident was educated on risks associated with leaving the facility without a physician's approval. Efforts would be made to ensure the resident had safest discharge possible.

Staff would promptly notify the attending physician of the resident's wishes to be discharged . The nurse would document in the resident's record the provider's response to the resident's request to leave the facility. Staff would document education and discharge instructions made to the resident in the medical record. The documentation included a review of medications and treatments, information on community resources, appointments, and safety precautions. If the resident insisted upon being discharged without the approval of the attending physician, the resident must sign a Release of Responsibility form. Should the resident refuse to sign the release, such refusal must be documented in the resident's medical record and witnessed by two staff members.Resident 3Resident 3 was admitted to the facility on [DATE REDACTED] with diagnoses of congestive heart failure (the heart cannot pump blood effectively enough to meet the body's needs) and cirrhosis (advanced scarring of the liver). The Annual MDS, dated [DATE REDACTED], documented Resident 3 had no cognitive impairment and was independent with ADLs.Progress notes, dated 06/08/2025, documented Resident 3 left the building AMA. The resident would not wait to take the facility stored medications. The resident would be back to retrieve their belongings.On 07/28/2025 at 4:34 pm, Resident 3 said the facility did not have medications sent to a pharmacy after they left the facility. Resident 3 said they were forced out of the facility and did not want to leave.On 09/04/2025 at 3:23 pm, Staff B said

the medical record did not reflect all that was done to try and get Resident 3 to stay at the facility. Staff B said she tried to get the resident to stay at the facility but did not write a note. The facility should have faxed

the resident's medications to a pharmacy, but she could not tell by reviewing the record if that was done.

Staff B said there should have been a Release of Responsibility form completed but this was not in the medical record. Staff B said the record should explain everything that was done to make the discharge as safe as possible, but this was not reflected in Resident 3's record.Resident 6Resident 6 was admitted to the facility on [DATE REDACTED] with diagnoses of chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs) and oxygen dependence. The record did not include an MDS.Progress notes, dated 07/29/2025, documented Resident 6 is requesting to leave AMA. Notified Administrator and Family following facility protocol for AMA discharges.On 09/04/2025 at 3:23 pm, Staff B said there should have been a Release of Responsibility form completed but this was not in the medical record. Staff B said

the record should explain everything that was done to make the discharge as safe as possible.Reference WAC 388-97-1060(3)(g)

Event ID:

Facility ID:

If continuation sheet