Based on observation, interview, and record review, the facility failed to ensure residents were permitted to exercise their rights when the facility obtained consent from family members for the placement of wander-guard devices without establishing that the family members had legal authority to make decisions on behalf of 2 of 3 residents (Residents 1 and 6) reviewed for resident rights. This failure caused actual psychosocial harm to Resident 1 by significantly compromising the resident's psychosocial well-being, as evidenced by persistent emotional distress, including crying; repeated statements of feeling imprisoned, trapped, and desperate; and expressions of suicidal ideation when the resident was prevented from attending church. …
F561 citations in Washington
Self-determination · Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Washington cites F561 more often than its own record predicts
1.55 times the share F561 takes of citations nationally.
Of every deficiency written in Washington in 2025, this is the portion that was F561.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Washington surveyors wrote
F561 findings written in Washington, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on interview and record review, the facility failed to honor bathing preferences for 2 of 3 residents (Residents 19 and 99) reviewed for bathing. The facility's failure to accommodate resident choices/preferences related to bathing and daily schedules placed residents at risk for poor hygiene, feelings of un-cleanliness, powerlessness, diminished self-worth, and a decreased quality of life. Findings included . Review of the undated facility policy titled, Shower/Tub Bath, showed the facility would offer residents at a minimum of at least two full baths or showers per week and to the extent possible resident preference for type and frequency of baths would be taken into consideration and honored. …
The short window
Recent years
| Year | Share of Washington citations | vs expected |
|---|---|---|
| 2023 | 0.59% | 1.13× |
| 2024 | 0.49% | 1.18× |
| 2025 | 0.59% | 1.55× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Washington surveyors cite →
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