Cascade Valley Senior Living.

Statement of Deficiencies License #: 2679 Compliance Determination # 61611 Plan of Correction Cascade Valley Seniar Living Completion Date Page1 of6 Licensee: VOP Cascade Valley, LLC 06/30/2025 You are required :to be in compliance at all tines with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for the unannounced on-site full inspection on 06/25/2025 and 06/27/2025 of: Cascade Valley Senior Living 8400 207TH PL NE ARLINGTON, WA 98223 The fallowing sample was selected for review during the unannounced on-site visit: 8 of 52 current residents and 0 former residents. The. department staff that inspected the Assisted Living Facility: Jodi Condyles, Nursing Consultant Institutional Allison Nunn, Long Term Care Surveyor From: DSHS, Aging .and Long-Term. Support Administration 3906-172nd St NE, Suite #100 Arlington, WA 98223 ‘@YSGOM JOJEIO7 OU} JO} SBDIAIOS Bled jelUepisey Aq peedeid sem jUSWNDOP sIy| 07.07.2025 11:49:87 State oF Hashington Statement of Deficiencies License #: 2679 Cornpliance Determination # 61611 Plan of Correction Cascade Valley Senior Living Completion Date Page2 of6 Licensee: VOP Cascade Valley, LLC 06/30/2025 As a result of the on-site visit(s), the department found that you are not in compliance with the licensing laws and regulations as stated in the cited deficiencies in the enclased report. Aan Kply 07/07/2025 | understand that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. Administrator (or Representative) WAC 388-78A-2474 Training and home care aide certification requirements. (2) The assisted living facility must ensure all assisted living facility administrators, or their ‘designees, and caregivers hired on of after January 7, 2012 meet the long-term care worker training requirements of chapter 388-112A WAC, including but not limited to: (c) Specialty for dementia, mental illness and/or developmental disabilitiés when serving residents with any of those primary special needs; (d) Cardiopulmonary resuscitation and first aid; and This requirement was not met as evidenced by: Baséd on record review and interview, thé Assisted Living Facility (ALF) failed to ensure 1 of 6 staff (Staff A) completed Dementia specialty training and 2 of 6 (Staff B and F) completed Cardiopulmonary Resuscitation (CPR) and First Aid training. These failures resulted in Staff A, B, and F not having the required training related to their job responsibilities and expectations and placed all 52 residents at risk of compromised care, services and safety. Findings included... Dementia specialty training: Review of WAC 388-112A-0495(4) showed if an ALF serves one or more residents with special neéds, long-term care workers must complete specialty training within 120 days of their date of hire, 9/13 ‘@YSGOM JOJEIO7 OU} JO} SBDIAIOS Bled jelUepisey Aq peedeid sem jUSWNDOP sIy| 07.07.2025 11:49:07 State of Washington ‘Statenrent of Deficiencies License #: 2679 Compliance Determination # 61611 Plan of Correction Cascade Valley Senior Living Completion Date Page3 of6 Licensee: VOP Cascade Valley, LLC 06/30/2025 Review of the ALF’s Resident Characteristic Roster dated 06/25/2025, showed nine residents living in the- ALF had a Dementia/Alzheimer’s impairment. Review of the ALF’s undated Disclosure of Services, Subsection 7, Care for Residents with Denientia, Developmental Disabilities or Mental Iliness, snowed if the ALF choose to serve residents with Dementia and/or Mental Health Ilinéss, the ALF must provide employees with specialty training in these areas. Review of the ALF's employee files showed the following: Staff A, Executive Director, was hired on 11/21/2021 and had no record of a cornpleted Dementia Specialty training. On 06/26/2025 at 9:27 AM Staff A stated that they had not completed Dementia specialty training and was not aware the training was required for the Executive Director, Cardiopulmonary Resuscitation and First Aid Training Review of WAC 388-112A-0720(2)(a) showed long-term care workers must have and maintain a valid CPR and first-aid card or certificate within thirty days of their date of hire. Review of the ALF’s employee files showed the following: Staff B, Care Partner, was hired on 01/17/2025 and had no documentation of a completed CPR/First Aid training. Staff F, Care Partner, was hired.an 02/18/2025 and had no documentation of a completed CPR/First Aid training. On 06/27/2025 at 2:25 PM, Staff B stated that they don't have a current CPR/First Aid card, Staff B stated that they would be in the next CPR/First Aid class held at the ALF. On 06/27/2025 at 2:17 PM, Staff F stated that they don't have a current CPR/First Aid card. Staff F stated that they knew they needed to renew their CPR/First Aid card and that they would be in the next class held at the ALF. On 06/27/2025 at 11:55 AM, Staff. G, Business Cffice Manager, stated that they were waiting for the CPR/First Aid instructor to confirm a date in July and that the class would 10/13 ‘@YSGOM JOJEIO7 OU} JO} SBDIAIOS Bled jelUepisey Aq peedeid sem jUSWNDOP sIy| 07.07.2025 11:49:07 State oF Washington ‘Statenrent of Deficiencies License #: 2679 Compliance Determination # 61611 Plan of Correction Cascade Valley Senior Living Completion Date Page4 of6 Licensee: VOP Cascade Valley, LLC 06/30/2025 be held at the ALF. Plan/Attestation Statement | hereby certify that | have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Cascade Valley Senior Living is or will be in compliance with this law and / or regulation on. (Date), g ~ PE PD) ZS In addition, | will implement a system to monitor and ensure continued compliance with this requirement. Sanolk Le et 07-02 ~ ats Administrator (or Representative) Date WAC 388-784-2484 Tuberculosis Two step skin testing. Unless the staff person meets the requirement for having no skin testing or only one test, the assisted living facility choosing to do skin testing, must ensure that each staff person has the following two-step skin testing: (1) An initial skin test within three days of employment; and This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure 3 of 6 staff (Staff A, C, and D) completed the initial step of two-step. Tuberculosis (TB) testing within three days of hire. This failure resulted in Staff A, C, and D not having been tested for TB and placed all.52 residents at risk of exposure to a communicable disease. Findings included... Review of the ALF’s employee files showed the following: Staff A, Executive Director, was hired 11/21/2021. Staff A’s file showed they completed the initial step of the TB testing on 06/05/2024, 927 days after theirhire date. Staff C, Care Partner, was hired 12/12/2024. There was no TB test documentation available for review. Staff D, Caregiver, was hired 04/29/2025. There was no TB test completed within three days of hire. W/13 ‘@YSGOM JOJEIO7 OU} JO} SBDIAIOS Bled jelUepisey Aq peedeid sem jUSWNDOP sIy| 07.07.2025 11:49:07 State oF Washington Statement of Deficiencies License #: 2679 Cormpliance Determination # 61611 Plan of Correction Cascade Valley Senior Living Completion Date Page 5 of6 Licensee: VOP Cascade Valley, LLC 06/30/2025 On 06/26/2025 at 9:31 AM., Staff.A stated that they started in a difference position at the ALF and didn't have a TB test at time of hire. Plan/Attestation Statement | hereby certify that | have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Cascade Valley Senior Living j or will be in compliance with this law and / or regulation on (Date) aa og _ In addition, | willimplement a system to monitor and ensure continued compliance with this requirement. , nol Le trf Q2- Gt- 2052S © nistrator (or Representative) Date WAC 388-78A-2468 Background checks Employment Conditional hire Pending results of Washington state name and date of birth background check. The assisted living facility may conditionally hire an administrator, caregiver, or staff person directly or by contract, pending the result of the Washington state name and date of birth background check, provided that. the assisted living facility: (1) Submits the background authorization form for the person to the department no later than one business day after he or she starts working; This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure 1 of 6 staff (Staff A) had a Washington State name and date of birth background check that was submitted within one business day after Staff A's date of hire.

deficiency or deficiencies immediately; and * Complete correction as soon as possible. You Are Not: * Required to submit a plan-of-correction for the deficiency or deficiencies found. The Department May: * Inspect the facility to determine if you have corrected all deficiencies. You May: ¢ Contact me for clarification of the deficiency or deficiencies found. In Addition, You May: « Request an Informal Dispute Resolution (IDR) review within 10 working days after you receive this letter. Your IDR request must include: o What specific deficiency or deficiencies you disagree with; o Why you disagree with each deficiency; and o Whether you want an IDR to occur in-person, by telephone or as a paper review. o Send your request to: Email: RCSIDR@dshs.wa.gov; or lf You Have Any Questions: « Please contact me at (360)651-6846. Kimberley Ripley, Field Manager Region 2, Unit A Sincerely, ‘@YSGOM JOJEIO7 OU} JO} SBDIAIOS Bled jelUepisey Aq peedeid sem jUSWNDOP sIy|

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . . .