The Watermark at Bellevue.

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 October 24, 2024 ELECTRONIC-FACSIMILE Administrator The Watermark at Bellevue 121 112th Ave NE Bellevue, WA 98004 Assisted Living Facility License # 2626 Licensee: US Alliance Holden of Bellevue Tenant, LLC IMPOSITION OF CIVIL FINES Dear Administrator: On October 11, 2024, the Department of Social and Health Services (DSHS), Residential Care Services completed a follow-up visit at your facility. This letter constitutes formal notice of civil fines on the license for your assisted living facility, also known as The Watermark at Bellevue, located at 121 112th Ave NE, Bellevue, by the State of Washington, Department of Social and Health Services. These actions are taken under the authority granted pursuant to Laws of 1998, Chapter 272 and RCW 18.20.190. The civil fines on the license are based on the following violation of the RCW and/or WAC as described in the attached Statement of Deficiencies (SOD) report dated October 11, 2024. Civil Fines WAC 388-78A-2483 (1)(2) Tuberculosis—One test. $200.00 The licensee failed to ensure two staff were screened for tuberculosis (TB). This failure placed all the residents at risk of potential exposure to tuberculosis, and infectious disease. This was an uncorrected deficiency previously cited on August 13, 2024. Administrator The Watermark at Bellevue License # 2626 October 24, 2024 Page 2 WAC 388-78A-2040 (1) Other requirements. $200.00 The licensee failed to follow the required federal and state regulations to conduct medical tests in long term care facilities for one resident. This failure placed the resident at risk of potential medication errors from possible misinterpretations of medical test results. This was an uncorrected deficiency previously cited on August 13, 2024. NOTE: These are the violations, which resulted in the fines; see the attached Statement of Deficiencies for any additional violations. Attestation (Plan of Correction): Return the enclosed SOD within 10 calendar days with the following: • The date you have or will have each deficiency corrected. • A signature and date attesting that you are taking actions to correct and maintain correction for each cited deficiency. Return the signed and dated SOD to: Laurie Anderson, Field Manager Region 2, Unit D 20425 72nd Ave S suite 400 Kent, WA 98032-2388 Phone: (253)234-6020 / Fax: (253) 395-5071 rcsregion2email@dshs.wa.gov Appeal Rights: You have two appeal rights: Informal Dispute Resolution (IDR) and an Administrative Hearing. Each has a different request timeline. Informal Dispute Resolution [RCW 18.20.195] You have an opportunity to challenge the deficiencies and/or enforcement actions through the state's IDR process. All IDR requests must be in writing and include: • The deficiencies you are disputing; and • The method of review you prefer (face-to-face, telephone conference or documentation review). The written request must be received by the 10th working day from receipt of this letter. Administrator The Watermark at Bellevue License # 2626 October 24, 2024 Page 3 During the IDR process, you will have the opportunity to present written and/or oral evidence to dispute the deficiencies. Send your written request to: Informal Dispute Resolution Program Manager Residential Care Services PO Box 45600 Olympia, Washington 98504-5600 Formal Administrative Hearing You may contest the civil fines by requesting a formal administrative hearing to challenge the deficiency, which resulted in the civil fines. All hearing requests must be in writing and include: • A copy of this letter; and • A copy of the Statement of Deficiencies. The written request must be received within twenty-eight (28) calendar days of receipt of this letter. Send your written request to: Office of Administrative Hearings PO Box 42489 Olympia, Washington 98504-2489 Payment: If you do not request a formal administrative hearing, the civil fines are due to the Office of Financial Recovery twenty-eight (28) calendar days after receipt of this letter. Mail a check for $400.00 payable to the ‘Department of Social and Health Services’, and if you have or have had a Medicaid resident(s), please include your ProviderOne ID Number # on the check, to: DSHS Office of Financial Recovery PO Box 9501 Olympia, WA 98507-9501 (360) 664-5919 / FAX: (360) 664-8401 OFRMMISVendor@dshs.wa.gov Administrator The Watermark at Bellevue License # 2626 October 24, 2024 Page 4 If the Office of Financial Recovery has not received your payment within twenty-eight (28) days after receipt of this letter, interest will begin to accrue immediately on the balance, at the rate of one percent per month. If you do not submit a hearing request or make payment within twenty-eight (28) days, the balance due will be recovered. If you have any questions, please contact Laurie Anderson, Field Manager, at (253) 234-6020. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 2, Unit D RCS Regional Administrator, Region 2 HCS Regional Administrator, Region 2 DDA Regional Administrator, Region 2 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW SN