**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure supervision for 1 of 4 residents (Resident 1) reviewed for dental sedation. The failure to follow post sedation safety protocol resulted in Resident 1 to have an unwitnessed fall that caused a 10-centimeter (cm) laceration mid forehead that required 11 staples at the hospital. Findings included.Record review of facility's policy titled, Level of Supervision (LOS) 1.08, dated 10/2024, showed that a LOS would be assigned to provide an appropriate degree of supervision for each resident. Direct care staff would check the LOS assigned in the resident's record daily. Definition for LOS 3 was supervision must be positioned in a manner to protect the resident from or deter danger. Enhanced staffing [was] required.Record review of facility's policy titled, Nursing Standard Operating Procedure IV.A.17 Sedation, dated 02/2024, showed that after receiving sedation, the Attendant Counselor (AC, a nursing assistant) would maintain close observation of the resident (LOS 3), maintain safety precautions as directed by the nurse and the resident would not be allowed to lay down in bed until released by the nurse.Resident 1Resident 1 was admitted to the facility on [DATE] for a short-term respite stay and discharged back home on [DATE].Review of the resident's 07/31/2025 comprehensive assessment showed Resident 1 had severe intellectual disabilities (a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently), anxiety disorder (the mind and body's reaction to stressful, dangerous, or unfamiliar situations) and was blind. The resident was dependent on staff for their activities of daily living (dressing, toileting and bathing); however, they were independent with walking around in the cottage.Review of the 07/24/2025 care plan showed the resident would receive sedation prior to going to dental and upon return to the cottage the resident would be monitored by staff for drowsiness, eating problems and discomfort.Review of the 07/31/2025 facility investigation showed Resident 1 received Lorazepam (a medication that has sedative and antianxiety effects) three milligrams (mg) on 07/29/2025 at 8:30 AM for a dental appointment. Later that day, Resident 1 had an unwitnessed fall in the cottage at 1:15 PM that caused a laceration to their forehead and required medical care at the hospital.Record review of the 07/29/2025 Sedation Protocol Checklist showed Resident 1 was to remain in the wheelchair with a positioning belt and stay in the line of sight of staff until released by the nurse. The resident's vital signs were attempted prior to the sedation and every 30 minutes after until the resident returned to their baseline. Resident 1 would not allow their pulse or blood pressure to be measured; however, their level of consciousness and respiratory rate was monitored by the unit nurse and were within stable parameters. Resident 1 was drowsy and had not been released by the nurse prior to their injury.Review of statements included in the 07/31/2025 facility investigation showed that Staff D, AC, was working with Resident 1 just prior to the incident on 07/29/2025. Staff D transferred Resident 1 to their bed due to falling asleep in their wheelchair around 1:00 PM. Staff D watched Resident 1 from the bedroom door for about 10 minutes until Resident 1 appeared asleep. Staff D then went to the front of the cottage to wash their hands and chart. When done washing their hands, they heard a noise in the back of the cottage and found Resident 1 bleeding from their forehead, while standing in the hallway.Review of statements included in the 07/31/2025 facility investigation showed that Staff C, Licensed Practical Nurse, was the nurse on duty when Resident 1 was found with a laceration on their forehead. They reported they had not released Resident 1 from sedation observation and were not notified prior to the resident's transfer to bed.Review of the 07/31/2025 facility investigation conclusion showed Staff D failed to follow the sedation protocols to maintain line of sight of the resident.Review of a 07/29/2025 at 2:49 PM progress note showed Staff C was called to attend Resident 1 at 1:14 PM after staff heard a loud thud in the back hall. Resident 1 was standing near their bedroom door with a bleeding laceration to their forehead. The laceration was measured 10 cm long by 2 cm wide and 0.5 cm deep. Pressure was applied and the resident was transported by ambulance to the hospital.During a telephone interview on 08/18/2025 at 12:45 PM, Resident 1's Representative (RR) stated the facility reached them by phone by the time Resident 1 was in transport to the hospital. The staff stated they thought Resident 1 fell in the back hall and hit their head on a hard surface. The RR stated, the wound was horrific and was very upset this happened. The RR stated after returning home, they took Resident 1 to the hospital on [DATE] to have the staples removed. The RR stated the hospital staff instructed them to clean the wound two to three times a day and it would take a while to heal. The RR stated Resident 1 was very resistant to having the wound cleaned and it had become a fight.During an interview on 08/18/2025 at 1:20 PM, Staff D stated they knew Resident 1 was LOS 3 and thought they could leave the resident's bedside after they fell asleep. Staff D stated they did not know that LOS 3 with sedation required continuous line of sight until the nurse released the resident from monitoring. Staff D stated they should not have left Resident 1 alone in their room.During an interview on 08/20/2025 at 10:15 AM, Staff A, Superintendent/NH Administrator, stated their investigation showed Staff C was new to day shift and had not been trained on the sedation protocol. We should have done a better job to protect [Resident 1].Reference: WAC 388-97-1060 (3)(g)This is a repeat citation from the Statement of Deficiencies dated 05/28/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect a resident's right to be free from physical abuse for 2 of 2 cognitively impaired residents (Resident 1 and Resident 3) reviewed for allegations of abuse. This failure resulted in physical harm when Resident 1 who had severe cognitive impairment, dependence on staff, and was unable to express discomfort, was kicked in the face. Resident 1 experienced psychosocial harm, applying the reasonable person concept when Resident 1 had a change in sleep behaviors and eating patterns and seemed more withdrawn. This failure placed the residents at risk for further abuse, injury, and diminished quality of life. Findings included . Review of the State Operations Manual (SOM), Psychosocial Outcome Severity Guide dated 10/24/2022, showed when a resident's reaction to a deficient practice (such as physical abuse) were markedly incongruent (or different) with the level of reaction a reasonable person in the resident's position would have to the physical abuse (such as the facility being their home with the expectation of safety and trust in the facility staff to protect them from harm). Record review of the facility's policy titled, Resident Rights 1.02, dated 06/30/2023, showed that residents have the right to legal protections from mental, physical, and sexual abuse. Record review of Developmental Disabilities Administration (DDA) policy titled, Protection from Abuse: Mandatory Reporting 5.13, dated 07/2024, showed abuse and neglect of vulnerable adults is prohibited by law and will not be tolerated. <Resident 1> A record review showed Resident 1 was admitted on [DATE] with multiple diagnoses including profound intellectual disabilities (a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently), autism (a condition related to brain development that impacts how a person perceives and socializes with others), insomnia (a sleep disorder characterized by difficulty falling asleep or staying asleep) and anxiety disorder (the mind and body's reaction to stressful, dangerous, or unfamiliar situations). Review of the 06/01/2024 comprehensive assessment showed Resident 1 had no speech, highly impaired vision and moderate cognitive impairment. The resident had self-injurious behaviors (SIB) that put them at risk for injury to themselves. Review of Resident 1's care plan dated 06/14/2024 showed that they exhibited severe self-injurious behaviors, such as slapping self, punching their head or pulling their hair. Staff had interventions to redirect the behavior by identifying what the resident needed and if not redirectable, the staff had a protective helmet and mitts they could apply with a physician order to protect the resident from injury. Further review of Resident 1's care plan showed that when awake, they were on a Level of Supervision (LOS) 4: One-to-one supervision, allowing as much social space as possible. Supervision must be positioned in a manner to prevent danger or harm to self or others. If the resident were in their room, staff were to be positioned outside the door, with the curtain pulled, staff were to be positioned outside their door and perform visual checks (eyes on Resident 1) every five minutes. When sleeping, the resident was on a LOS 3: supervision must be positioned in a manner to protect from or deter danger. Staff were to provide 15-minute checks when they were asleep, and the curtain was pulled. <Allegation 1> Record review of a 07/25/2024 witness statement written by Staff M, Attendant Counselor Nursing Assistant (NA) showed that on a day they worked evening shift in cottage 405/406 (shift log showed the date was 06/29/2024) while they were one-to-one supervision with Resident 1, they observed Staff N, NA, hit Resident 1 in the head around 5:30 PM. They stated that they took Resident 1 to the toilet and noticed they had a soiled incontinent brief. They asked Staff N to keep an eye on the resident while they got a new brief and disposed the soiled one. Staff M stated that when they returned to the bathroom, Staff N was telling Resident 1 that they needed to sit down (on the toilet) and push. Resident 1 began hitting themselves in the head and Staff N proceeded to also hit the resident in the head stating that was how to get Resident 1 to stop their SIB. Resident 1's SIB did not stop, and the nurse was notified and helped take Resident 1 to their room to apply their safety gear. Review of a 07/16/2024 DDA Statewide Investigation Unit ([NAME]- performs impartial abuse and neglect investigations in state residential facilities) report showed the facility was informed of an allegation that Staff N had hit Resident 1 in the head to stop their behaviors, no date, time or name of witness of the alleged abuse was provided. The facility removed Staff N from resident care. Based on the information available at the time, there was insufficient evidence to conclude the allegation occurred. The investigation had been turned over to law enforcement on 07/10/2024. Review of nursing progress notes from 06/29/2024 showed that Resident 1 had three episodes of SIB between 6:00 PM and 9:20 PM. The resident required application of their helmet and mitts due to Resident 1 pulling their hair, hitting their face/head with fists and biting their wrists. The nurse documented at 9:30 PM that there was no open skin on the resident's wrists nor other skin injuries observed from Resident 1's attempts at SIB. Review of Resident 1's sleep and meal consumption logs from 06/29/2024, 06/30/2024 and 07/01/2024 showed no changes to their usual sleeping and eating habits. <Allegation 2> Review of a 07/10/2024 DDA [NAME] report showed that through several witness reports and the change in Resident 1's sleep behavior, it was more likely than not that on 07/06/2024 Staff C, NA, kicked Resident 1 (in the face). Staff C was removed from direct resident care after the incident. Review of a witness statement written by Staff D, NA, on 07/08/2024, showed that on 07/06/2024 at 10:00 PM, Resident 1 was lying down in bed and could be heard tapping on their head. [I] redirected to not hit [them]self and told [them] it's bedtime. Staff C goes in and kicks [Resident 1] in the face. [I] told [Staff C] to leave, [Resident 1] had no response and went to bed. Review of a nursing progress note dated 07/07/2024 showed that on 07/06/2024 at 10:50 PM Resident 1 was examined from head to toe. The nurse observed the resident's right cheek was light red, no other injuries were found, and the resident went right back to sleep. Review of Staff E's, NA, statement from 07/11/2024 at 6:45 PM phone interview, documented in the 07/10/2024 DDA [NAME] report showed, Staff E was in the cottage 405 hall near Resident 1's bedroom, on 07/06/2024 at 10:00 PM. They could hear Resident 1 in the beginning stages of a behavior and asked Staff D if they needed help with Resident 1's safety gear (helmet/mitts). Staff E stated that Staff C started walking to Resident 1's room and stated 'oh, I want some of this' with Staff F, NA, behind them. Staff E stated within seconds, they (Staff C and Staff F) were walking out of the room giggling and there were no sounds coming from Resident 1's room. Staff E asked them 'what did you do to get [Resident 1] to stop the behavior' and they just ignored Staff E. Review of Staff G's, NA, statement from 07/15/2024 at 1:22 PM interview, documented in the 07/10/2024 DDA [NAME] report, showed that they were hanging around the hallway of cottage 405 by the bedrooms around 10:00 PM on 07/06/2024. Staff G stated they saw Staff C and Staff F enter Resident 1's bedroom. Staff G walked towards the room and stood by a short distance outside of the doorway. Staff G stated they saw Staff C pick up their right leg, like they were going to kick Resident 1, at the same time Staff F was closing the curtain. Staff G stated that they 'found it strange' that they were handling a behavior with the lights off and closing the curtain. Staff G stated they didn't hear Resident 1 after they closed the curtain only heard Staff C state you need to stop and go to sleep. Review of Staff F's statement from 07/15/2024 at 1:57 PM, documented in the 07/10/2024 DDA [NAME] report showed that they walked in directly behind Staff C and saw them lift their leg towards Resident 1. Staff F stated they then saw Staff C raise their arms over their head and bringing them down on Resident 1. Staff F stated they didn't directly see where Staff C hit or kicked Resident 1 but heard (the sounds of) making impact. During an interview on 08/07/2024 at 2:54 PM, Staff D refused to talk about what they witnessed on 07/06/2024 and stated, I don't want to talk, you can read my statement and ended the interview. During an interview on 08/07/2024 at 3:15 PM, Staff E, stated they were assigned one-to-one for a resident in the bedroom next to Resident 1 on 07/06/2024. Staff E stated they could hear Resident 1 start hitting themselves, I stated, is [Resident 1] going to SIB? Staff D, who was the assigned one-to-one, stood up, but Staff C headed for Resident 1's room and stated 'oh, I want some of this'. Staff F was behind Staff C, and they went into Resident 1's room with Staff D following. I heard the privacy curtain close. Staff D came out quick. I said, wow you got [Resident 1] to calm down fast. Staff D had a look of shock on their face and said, a yeah. Staff C and Staff F both came out of the room. I did not know what happened until the next day. I started my shift at 2:00 PM with Resident 1, they were sleeping and according to their sleep log had slept the whole day. Resident 1 woke up for dinner and then returned to bed and this was not normal for them. During an interview on 08/08/2024 at 4:35 PM, Staff L, NA, stated they worked evening shift in cottage 405 on 07/06/2024. Staff L stated they were in the back hallway around the time of the incident talking with Staff E and had their back to Resident 1's room. Staff L stated they heard a bit of a commotion from the room, then Resident 1 got quiet, the room got quiet. After Staff C and Staff F went to the front of the cottage, Staff D looked worried, anxious and was pacing. Staff L stated they followed Staff D into Resident 1's room and saw Staff D use their cell phone flashlight to check the right side of Resident 1's face. Staff D did not say what they were looking for. Staff L stated that the next day Resident 1 was really out of it, they slept a lot, skipped dinner and a snack, that was real unusual behavior. During an interview on 08/09/2024 at 3:05 PM, Staff K, NA, stated that they worked evening shift in cottage 405 on 07/07/2024. Staff K stated that Resident 1 was not their normal self, they seemed withdrawn and was sleeping more than usual. Staff K stated they looked at Resident 1's sleep log and they had slept all on day shift and on evening shift until 8:00 PM. <Resident 3> A record review showed Resident 3 was admitted on [DATE] with multiple diagnoses including cerebral palsy (a group of conditions that affect movement and posture. It's caused by damage that occurs to the developing brain, most often before birth), unspecified intellectual disabilities (a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently), and adjustment disorder (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior). Review of the 07/14/2024 comprehensive assessment showed Resident 3 had no speech, highly impaired vision and moderate cognitive impairment. Review of Resident 3's care plan dated 04/14/2024 showed they could be unsteady with ambulation, did not understand personal space, would get too close to others trying to touch or pinch and was obsessive about taking their clothes off. Further review of the care plan showed Resident 3 was a LOS 3 (supervision must be positioned in a manner to protect from or deter danger. Enhanced staffing was required) when the resident was awake. They were a LOS 2 (knowledge of where resident was at all times, whom they were with and what they were doing) when asleep. Review of an 08/03/2024 DDA [NAME] report showed that based on two staff witness statements, it was more likely than not that on 08/02/2024 Staff I, NA, drug Resident 3 across the floor from the living area to the resident's bedroom by dragging Resident 3's lower body as they held the top of the torso with their arm hooked under Resident 3's shoulder. Review of an 08/03/2024 at 11:01 AM nursing progress note showed that Resident 3 had a full body check with no injuries found. Review of an 08/03/2024 witness statement written by Staff H, NA, showed that on 08/02/2024 at 2:15 PM, they observed Resident 3 begin taking off their shoes while sitting in a recliner in the cottage 203 living area. They stated Staff I walked up to Resident 3, grabbed their shirt pulling them aggressively to the floor. Resident 3 then grabbed another resident's shirt who was also sitting on the floor. Staff H stated they got between the two residents, and Staff I then drug Resident 3 back to their bedroom. After Resident 3 got to their room, they started taking off their clothes and the privacy curtain was closed let Resident 3 cool down. Record review of an 08/03/2024 witness statement written by Staff J, NA, showed that on 08/02/2024 at 2:25 PM they observed Resident 3 throwing their shoes on the floor. Staff I told Resident 3 to take their shoes to their room three times. The third time, Staff I suddenly grabbed Resident 3's shirt and pulled them out of the recliner and when on the floor, Resident 3 grabbed another resident's shirt. During an interview on 08/14/2024 at 2:03 pm, Staff I stated they worked in cottage 203 on 08/02/2024. They stated that Resident 3 was sitting in a recliner in the living area and started to remove and toss their shoes. Staff I asked Resident 3 to grab their shoes and let's go to your room, the resident had no response. Staff I stated they gave the verbal que again, but the resident scooted forward in the chair, sat on the floor and grabbed another resident's shirt. Staff I stated that after a couple minutes, Resident 3 stood up on their own and were directed to their room by walking next to the resident. Staff I denied pulling the resident out of the recliner and denied dragging the resident across the floor back to their bedroom. During an interview on 08/14/2024 at 2:40 PM, Staff H stated they witnessed the incident in cottage 203 on 08/02/2024. Staff H stated Resident 3 was upset because they wanted to go on a walk and could not at that time. Resident 3 was sitting in a recliner and started to take off their shoe and tossed it. Staff I told Resident 3 to pick up your shoe and let's go to your room. Staff H stated, Resident 3 shook their head no and took off the other shoe. Then Staff I walked over to Resident 3 and grabbed the front of the resident's shirt and pulled them off the chair. Resident 3 was then laying on the floor and reached out to grab another resident's shirt. I got in the middle and pried Resident 3's fingers off the shirt. Staff H stated, [Staff I] was now grabbing Resident 3 by the wrists to get them up, but they would not stand, and while the resident was on their back, Staff I drug Resident 3 to the back hall with Staff J walking behind Staff I. Staff H stated they heard Resident 3 screaming after they were all out of sight around the corner. During an interview on 08/15/2024 at 1:45 PM, Staff J stated that on 08/02/2024 at shift overlap Resident 3 was seated in a recliner in the cottage 203 living area and had just returned from a recreation outing. They observed Resident 3 take off their shoe and toss it on the floor. Staff I told Resident 3 to put your shoe back in your room. Resident 3 then removed their other shoe and tossed it to the floor. Staff I said again put your shoes back in your room. The third time Staff I told Resident 3 to pick up their shoes, Staff I approached Resident 3 and hooked their arm under the resident's left arm making an upward motion. Resident 3 slid onto the floor and grabbed another resident's shirt. Resident 3, now laying on the floor, was grabbed by Staff I on to the left upper arm and front of the resident's shirt, and was drug across the floor by Staff I, who was walking backwards. Staff J stated they helped Staff I by lifting both of Resident 3's legs by holding their feet. Staff J stated Resident 3 was screaming and yelling when they got back to their bedroom. Resident 3 got up on their bed and removed all their clothing. Staff J stated they felt it was wrong and was in shock that Staff I did that. During an interview on 08/15/2024 at 2:45 PM, Staff B, Assistant Superintendent, stated that they were shocked at the abuse that had occurred and did not understand why this was happening. These residents do not deserve to be treated this way. Reference: WAC- 388-97-0640 (1), (3)(a)