GARDEN COURTE ALZHEIMER COMMUNITY.

—: Facility failed to identify and document preventative fall interventions on Temporary Service Plans (TSPs) and notify floor staff for implementation. Despite 45 previous fall interventions documented for R1, no new preventative interventions were added to the TSP following a fall on 01/13/2025. —: Facility failed to identify and document preventative fall interventions on Temporary Service Plans (TSPs) and notify floor staff for implementation. Despite 10 previous fall interventions documented for R2, no new preventative interventions were added to the TSP following a fall on 01/16/2025. —: Facility failed to identify and document preventative interventions on Temporary Service Plans and notify floor staff so they may be implemented following resident falls with injury. —: Facility failed to conduct a complete and thorough investigation as to how an injury of unknown origin may have been sustained, failed to determine if potential abuse was suspected or ruled out, and failed to document investigative findings.

—: Facility failed to report allegations of sexual abuse by staff to the Department as required. The facility conducted its own investigation but did not make the mandatory report to the regulatory agency.

WAC 388-78A-2600: The facility failed to develop and implement policies and procedures to maintain or enhance quality of life for residents including resident decision-making rights, and failed to train staff on policies and procedures related to suspected abandonment, abuse, neglect, exploitation, or financial exploitation of residents. WAC 388-78A-2450: The facility failed to verify staff work references prior to hiring and failed to maintain required documentation of contacting work references and professional licensing boards. WAC 388-78A-2660: The facility failed to ensure residents had the right to be free from abuse and neglect by staff persons. WAC 388-78A-2660: The facility used restraints on residents in violation of resident rights protections. WAC 388-78A-2510: The facility failed to ensure completion of specialized training consistent with chapter 388-112A WAC for staff serving residents with dementia as their primary special need.

—: Facility failed to follow policies and store medication properly, which resulted in a resident entering a staff office and ingesting another resident's medications.

WAC 388-78A-2703: The facility failed to ensure staff members locked the wheels on residents' wheelchairs during transfers to prevent avoidable injuries. This failure placed Resident 4 and Resident 5 at risk for sustaining avoidable injuries. WAC 388-78A-2703: The facility failed to ensure staff locked the wheels on a resident's wheelchair during a transfer to prevent avoidable injuries. Staff C was observed not locking the wheelchair wheels during a transfer and stated he routinely skips this safety measure for convenience.

WAC 388-78A-2040: Fire safety doors were observed propped open using rubber stoppers and wooden wedges in multiple locations including the medication technician offices, resident rooms, and administrative areas. Staff were found using door stoppers despite facility policies, training, and previous citations prohibiting this practice, creating fire and safety hazards for 88 residents.

WAC 388-78A-2600: The facility failed to implement facility policies and procedures when suspected abuse was reported for 2 residents, placing these residents at risk for ongoing harm and all 80 residents at risk of harm due to staff not following facility and state policies when suspected abuse had been reported. —: The facility failed to verify staff references prior to employment. —: The facility failed to ensure required training for staff working in a dementia care unit.