Bay Vista Commons Assisted Living Community.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . . STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION Statement of Deficiencies License #: 1983 Compliance Determination # 52928 Plan of Correction BAY VISTA COMMONS ASSISTED LIVING COMMUNITY Completion Date You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for an unannounced on-site complaint investigation on 01/13/2025 and 01/13/2025 of: BAY VISTA COMMONS ASSISTED LIVING COMMUNITY 191 Russell Road Bremerton, WA 98312 This document references the following complaint number(s): 160857, 156509, 146515 The following sample was selected for review during the unannounced on-site visit: 2 of 63 current residents and 1 former residents. The department staff that investigated the Assisted Living Facility: Nikolas Jennings, Community Nurse Complaint Investigator From: DSHS, Aging and Long-Term Support Administration Lakewood, WA 98496 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 enclosed report. I 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. . . Statement of Deficiencies License #: 1983 Compliance Determination # 52928 Plan of Correction BAY VISTA COMMONS ASSISTED LIVING COMMUNITY Completion Date Administrator (or Representative) Date WAC 388-78A-2120 Monitoring residents' well-being. The assisted living facility must: (3) Evaluate, in order to determine if there is a need for further action: (a) The changes identified in the resident per subsection (2) of this section; and (b) Each resident when an accident or incident that is likely to adversely affect the resident's well- being, is observed by or reported to staff persons. (4) Take appropriate action in response to each resident's changing needs. This requirement was not met as evidenced by: Based on interview and record review the facility failed to adequately monitor the resident’s well- being during a behavioral crisis for 1 of 3 sampled residents (Resident 1 [R1]). This failure placed the resident at risk for safety and further health complications. Findings included… Record review of progress notes for R1 dated 11/11/2024-01/04/2025 showed that on 11/21/2024 at 2:00PM it was noted “Due to R1 threatening an employee 911 was called at 1335”. Record review of progress notes for R1 dated 11/11/2024-01/04/2025 showed that on 11/21/2024 at 4:00PM it was noted “Two calls to 911 no officer at this time has showed up as of yet. R1 is in the building at 1600. A few minutes prior CC2 pulled up in his vehicle and started talking to R1.” In an interview with CC1 on 01/13/2025 at 11:20AM, stated they had been notified by Staff A, administrator, of an incident going on with R1 but not to the extent that it was occurring. Staff A stated that upon follow up with the front desk, was notified that R1 was locked outside in the cold and the rain, at which point they notified CC2 in an event to get someone to help with the situation. In an interview with R1 on 01/13/2025 at 12:12PM, stated that during that incident “It was raining pretty good outside, but they wouldn’t let me in, so I stood outside until CC2 got here and they let us in. I didn’t like it at all, I don’t think they should lock these doors at all.” . . Statement of Deficiencies License #: 1983 Compliance Determination # 52928 Plan of Correction BAY VISTA COMMONS ASSISTED LIVING COMMUNITY Completion Date In an interview with CC2 on 01/14/2024 at 2:14PM, stated R1 knew at the time of the incident that he was locked out of the facility and could not get in. CC2 stated that when they arrived at the facility, R1 was standing right outside the building trying to keep dry and that it was a “windy blustery day”. Stated that at no time did any facility staff come outside to check on R1. In an interview with Staff A on 01/13/2024 at 1:08PM, stated that during the confrontation with R1 no staff members were sent outside to speak to the resident or check on the resident. In an interview with Staff B, Assistant Director of Nursing, on 01/15/2024 at 10:46AM stated that during the confrontation with R1 they were observing R1, but that at no time was an employee sent outside to speak to R1. Staff B stated that they did not wish to let R1 into the facility until the situation was evaluated by law enforcement in order to protect the other residents and staff of the facility. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, BAY VISTA COMMONS ASSISTED LIVING COMMUNITY is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date . STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION HOUSING AUTHORITY OF THE CITY OF BREMERTON BAY VISTA COMMONS ASSISTED LIVING COMMUNITY 191 Russell Road Bremerton, WA 98312 RE: BAY VISTA COMMONS ASSISTED LIVING COMMUNITY # 1983 Dear Administrator: The Department completed a complaint investigation of your Assisted Living Facility on 01/16/2025 and found that your facility does not meet the Assisted Living Facility requirements. The Department: • Wrote the enclosed report; and • May take licensing enforcement action based on any deficiency listed on the enclosed report; and • May inspect the facility to determine if you have corrected all deficiencies; and • Expects all deficiencies to be corrected within the timeframe accepted by the department. You Must: • Begin the process of correcting the deficiency or deficiencies immediately; • Contact the Field Manager for clarifications related to the Statement of Deficiencies (SOD); • Within 10 calendar days after you receive this letter, complete and return the enclosed 'Plan/Attestation Statement'; o Sign and date the enclosed report; o For each deficiency, indicate the date you have or will correct each deficiency; o Next to each deficiency, sign and date certifying that you have or will correct each cited deficiency; and o Mail the Plan/Attestation Statement and report with original signatures to: Jody Just, Field Manager . BAY VISTA COMMONS ASSISTED LIVING COMMUNITY # 1983 01/16/2025 Region 3, Unit D Lakewood, WA 98496 • Complete correction(s) within 45 days, or sooner if directed by the Department, after review of your proposed correction dates. • Have your plan approved by the Department. Consultation(s): In addition, the Department provided consultation on the following deficiency or deficiencies not listed on the enclosed report. WAC 388-78A-2600 Policies and procedures. (2) The assisted living facility must develop, implement and train staff persons on policies and procedures to address what staff persons must do: (j) To appropriately respond to aggressive or assaultive residents, including, but not limited to: (i) Actions to take if a resident becomes violent; (ii) Actions to take to protect other residents; and (iii) When and how to seek outside intervention. The facility was unable to find a policy related to management of aggressive behavior or what to do if a resident became combative. The facility administrator is aware of the lack and is has been working to implement a policy. You Are Not: • Required to submit a plan of correction for the consultation deficiency or deficiencies stated in this letter and not listed on the enclosed report. 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: IDR Program Manager Department of Social and Health Services . . BAY VISTA COMMONS ASSISTED LIVING COMMUNITY # 1983 01/16/2025 Olympia, WA 98504-5600 If You Have Any Questions: • Please contact me at (360)397-9556.

Conclusion / Action: . Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION Statement of Deficiencies License #: 1983 Compliance Determination # 34871 Plan of Correction BAY VISTA COMMONS ASSISTED LIVING COMMUNITY Completion Date You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for an unannounced on-site complaint investigation on 01/08/2024 and 01/08/2024 of: BAY VISTA COMMONS ASSISTED LIVING COMMUNITY 191 Russell Road Bremerton, WA 98312 This document references the following complaint number(s): 109819 The following sample was selected for review during the unannounced on-site visit: 1 of 0 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Michael Goulet, Complaint Investigator From: DSHS, Aging and Long-Term Support Administration Lakewood, WA 98496 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 enclosed report. I 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. . Statement of Deficiencies License #: 1983 Compliance Determination # 34871 Plan of Correction BAY VISTA COMMONS ASSISTED LIVING COMMUNITY Completion Date Administrator (or Representative) Date WAC 388-78A-2600 Policies and procedures. (1) The assisted living facility must develop and implement policies and procedures in support of services that are provided and are necessary to: (b) Provide the necessary care and services for residents, including those with special needs; This requirement was not met as evidenced by: Based on interviews and record review, the Assisted Living Facility (ALF) failed to ensure that residents were able to be safely lifted from the floor in the event of a fall without the intervention of outside agency staff. This failure placed 1 of 1 resident (Resident 1) at risk of harm and of not having their care needs met effectively by facility staff. Findings Included... During an interview on 01/08/2024 at 9:35am, the Facility Director of Nursing Services (Staff A) stated that it is the facility’s policy to not lift a resident, but to “call the fire department” in order to lift residents from the floor. During an interview on 01/08/2024 at 9:50am, Resident 1 (R1) stated they had not fallen or been injured on 12-11-23, but that they had gotten onto the bathroom floor to clean the area and then had been unable to get up again. R1 stated that they were not hurt, and that unknown outside personnel (non-staff; fire department) had come to assist the resident off the floor. During an interview on 01/12/2024 at 10:25am, the Facility Med Tech (Staff B) who contacted Emergency Medical Services (EMS) / 9-11 on 12/11/2023 stated that it is the facility’s policy to contact EMS personnel for any resident lift needs, and that this is not the duty of facility staff members. Staff B stated they typically work the overnight (NOC) shift and are the only facility staff for the three floors of the Assisted Living residents during this shift, so that there is no way for this staff member to lift a resident from the floor without outside assistance. Record review on 01/08/2024 of the facility's Resident Fall Report from 12/11/2023 noted that there was "no injuries" to R1, and that the resident had “sat down and could not get up.” . Statement of Deficiencies License #: 1983 Compliance Determination # 34871 Plan of Correction BAY VISTA COMMONS ASSISTED LIVING COMMUNITY Completion Date Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, BAY VISTA COMMONS ASSISTED LIVING COMMUNITY is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date .