Lacamas Heights Memory Care.

This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 800 NE 136th Ave Ste 200, Vancouver, WA 98684 Statement of Deficiencies License #: 2748 Compliance Determination # 68817 Plan of Correction Lacamas Heights Memory Care Completion Date Page 1 of 10 Licensee: Lacamas Heights Memory Care LLC 11/20/2025 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 the unannounced on-site full inspection on 11/17/2025 and 11/19/2025 of: Lacamas Heights Memory Care 3401 NW Lake Rd Camas, WA 98607 The following sample was selected for review during the unannounced on-site visit: 4 of 11 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Kyle Gehlen, ALF Licensor - LTC Jennifer Siharath, ALF Licensor From: DSHS, Aging and Long-Term Support Administration Residential Care Services, Region 3 , Unit E 800 NE 136th Ave Ste 200 Vancouver, WA 98684 This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2748 Compliance Determination # 68817 Plan of Correction Lacamas Heights Memory Care Completion Date Page 2 of 10 Licensee: Lacamas Heights Memory Care LLC 11/20/2025 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 enclosed report. Residential Care Services Date 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. Administrator (or Representative) Date WAC 388-78A-2310 Intermittent nursing services. (2) The assisted living facility may choose to provide any of the following intermittent nursing services through appropriately licensed and credentialed staff; however, the facility may or may not need to provide additional intermittent nursing services to comply with the reasonable accommodation requirements in federal or state law: (f) Nurse delegation consistent with chapter 18.79 RCW. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure the nurse delegation requirements were met when the nurse delegator failed to verify that 3 of 3 delegated Medication Technicians (Staff C, F, and G) had completed or had documentation of completing the nurse delegation core training. The facility failed to obtain written consent from the resident or representative prior to implementing nurse delegation for 1 of 1 sampled resident (Resident 2). The facility failed to re- evaluate delegation for 1 of 1 sampled resident (Resident 2) every 90 days. These failures placed this resident at risk for harm and injury due to untrained and unsupervised care staff. Findings included… WAC 246-840-930 Criteria for delegation: (8) Verify that the nursing assistant or home care aide: (b) Has completed both the basic caregiver training and core delegation training before performing any delegated task; (c) Has evidence as required by the department of social and health services of successful completion of nurse delegation core training; (10) If the registered nurse delegator determines delegation is appropriate, the nurse: (a) Discusses the delegation process with the patient or authorized representative, This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2748 Compliance Determination # 68817 Plan of Correction Lacamas Heights Memory Care Completion Date Page 3 of 10 Licensee: Lacamas Heights Memory Care LLC 11/20/2025 including the level of training of the nursing assistant or home care aide delivering care. (b) Obtains written consent. The patient, or authorized representative, must give written, consent to the delegation process under chapter 7.70 RCW. Documented verbal consent of patient or authorized representative may be acceptable if written consent is obtained within 30 days; electronic consent is an acceptable format. Written consent is only necessary at the initial use of the nurse delegation process for each patient and is not necessary for task additions or changes or if a different nurse, nursing assistant, or home care aide will be participating in the process. (18) The registered nurse delegator ensures safe and effective services are provided. Reevaluation and documentation occur at least every 90 days. Frequency of supervision is at the discretion of the registered nurse delegator and may be more often based upon nursing assessment. Resident 2 (R2) On 11/19/2025 at 9:15 AM, R2’s records showed that they admitted to the facility on /2025 with various diagnoses including . Record review of R2’s negotiated service agreement (NSA), dated 08/01/2025, showed documentation that R2 requires nurse delegation. Record review of R2’s nurse delegation documents showed that R2 had nurse delegation for suppository and as needed medication administration. Documentation was found to show that Staff F and G had been evaluated for nurse delegation for R2 on 07/24/2025 and Staff C had been evaluated for nurse delegation on 07/30/2025. No other documentation was found to show that Staff C, F, and G had been reevaluated for nurse delegation for R2 within 90 days of their first evaluation. No documentation was found to show that R2 and/or their representative had agreed to and consented to nurse delegation. On 11/19/2025 at 11:05 AM, the department reviewed the facility’s nurse delegation binder. No documentation was found to show that Staff C, F, and G had completed the nurse delegation core training prior to being delegated for R2. On 11/19/2025 at 1:30 PM, Staff A confirmed acknowledged the department’s findings. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2748 Compliance Determination # 68817 Plan of Correction Lacamas Heights Memory Care Completion Date Page 4 of 10 Licensee: Lacamas Heights Memory Care LLC 11/20/2025 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, Lacamas Heights Memory Care 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 WAC 388-78A-24701 Background checks Employment Nondisqualifying information. (1) If the background check results show that an employee or prospective employee has a criminal conviction or pending charge for a crime that is not a disqualifying crime under chapter 388-113 WAC, then the assisted living facility must determine whether the person has the character, competence and suitability to work with vulnerable adults in long-term care. (2) Nothing in this section should be interpreted as requiring the employment of any person against the better judgment of the assisted living facility. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure a character, competence, and suitability (CCS) determination was completed when an employee’s background check came back with a “reviewed required” result for 1 of 1 sampled staff (Staff F). This failure placed all residents and staff at risk for harm by possibly employing staff with a disqualifying criminal conviction(s) or pending charge(s) for a disqualifying crime(s). Findings included… WAC 388-113-0060 How and when must a character, competence, and suitability determination be conducted by the department or an authorized entity? (1) The department or an authorized entity must conduct a character, competence, and suitability determination of an employee, prospective employee, or other individual who is required to undergo a background check when the applicant has received a "review required" result as defined in WAC 388-113-0101(b). (2) If the department or an authorized entity is required to conduct a character, competence, and suitability determination under this section, the person or entity responsible must document in writing the following information: (a) Reason for the decision; This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2748 Compliance Determination # 68817 Plan of Correction Lacamas Heights Memory Care Completion Date Page 5 of 10 Licensee: Lacamas Heights Memory Care LLC 11/20/2025 (b) Whether or not the applicant may have unsupervised access to minors and vulnerable adults; (c) The date the character, competence, and suitability determination was completed; and (d) The name and signature of the person or persons who performed the determination. (3) If an applicant is required to have a character, competence, and suitability determination under this section, the applicant may not have unsupervised access to minors or vulnerable adults unless the character, competence, and suitability determination has: (a) Been completed and documented in writing. (b) Concluded the applicant may have unsupervised access to minors or vulnerable adults. (4) A character, competence, and suitability determination may not be conducted if an applicant has an automatically disqualifying conviction or pending charge under WAC 388-113-0020 or has an automatically disqualifying negative action under WAC 388-113-0030. During an unannounced licensing full inspection on 09/17/2025 at 12:30 PM, the department received the requested staff documents. Staff E Record review for Staff E, Medication Technician/Caregiver, showed that Staff E was hired on 07/30/2025. Review of Staff E’s employee documents showed a Washington State name and date of birth background check completed on 07/30/2025 with results of the background check requiring a CCS review before employment. No CCS review was found or provided for Staff E. On 11/19/2025 at 12:15 PM, Staff A confirmed that a CCS review had not been completed for Staff E. 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, Lacamas Heights Memory Care 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 This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2748 Compliance Determination # 68817 Plan of Correction Lacamas Heights Memory Care Completion Date Page 6 of 10 Licensee: Lacamas Heights Memory Care LLC 11/20/2025 WAC 388-78A-2090 Full assessment topics. The assisted living facility must obtain sufficient information to be able to assess the capabilities, needs, and preferences for each resident, and must complete a full assessment addressing the following, within fourteen days of the resident's move-in date, unless extended by the department for good cause: (1) Individual's recent medical history, including, but not limited to: (a) A licensed medical or health professional's diagnosis, unless the resident objects for religious reasons; (b) Chronic, current, and potential skin conditions; or (c) Known allergies to foods or medications, or other considerations for providing care or services. (2) Currently necessary and contraindicated medications and treatments for the individual, including: (a) Any prescribed medications, and over-the-counter medications commonly taken by the individual, that the individual is able to independently self-administer, or safely and accurately direct others to administer to him/her; (b) Any prescribed medications, and over-the-counter medications commonly taken by the individual, that the individual is able to self-administer when he/she has the assistance of a caregiver; and (c) Any prescribed medications, and over-the-counter medications commonly taken by the individual, that the individual is not able to self-administer, and needs to have administered to him or her. (3) The individual's nursing needs when the individual requires the services of a nurse on the assisted living facility premises. (4) Individual's sensory abilities, including: (a) Vision; and (b) Hearing. (5) Individual's communication abilities, including: (a) Modes of expression; (b) Ability to make self understood; and (c) Ability to understand others. (6) Significant known behaviors or symptoms of the individual causing concern or requiring special care, including: (a) History of substance abuse; (b) History of harming self, others, or property; or (c) Other conditions that may require behavioral intervention strategies; (d) Individual's ability to leave the assisted living facility unsupervised; and This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2748 Compliance Determination # 68817 Plan of Correction Lacamas Heights Memory Care Completion Date Page 7 of 10 Licensee: Lacamas Heights Memory Care LLC 11/20/2025 (e) Other safety considerations that may pose a danger to the individual or others, such as use of medical devices or the individual's ability to smoke unsupervised, if smoking is permitted in the assisted living facility. (7) Individual's special needs, by evaluating available information, or if available information does not indicate the presence of special needs, selecting and using an appropriate tool, to determine the presence of symptoms consistent with, and implications for care and services of: (a) Mental illness, or needs for psychological or mental health services, except where protected by confidentiality laws; (b) Developmental disability; (c) Dementia. While screening a resident for dementia, the assisted living facility must: (i) Base any determination that the resident has short-term memory loss upon objective evidence; and (ii) Document the evidence in the resident's record. (d) Other conditions affecting cognition, such as traumatic brain injury. (8) Individual's level of personal care needs, including: (a) Ability to perform activities of daily living; (b) Medication management ability, including: (i) The individual's ability to obtain and appropriately use over-the-counter medications; and (ii) How the individual will obtain prescribed medications for use in the assisted living facility. (9) Individual's activities, typical daily routines, habits and service preferences. (10) Individual's personal identity and lifestyle, to the extent the individual is willing to share the information, and the manner in which they are expressed, including preferences regarding food, community contacts, hobbies, spiritual preferences, or other sources of pleasure and comfort. (11) Who has decision-making authority for the individual, including: (a) The presence of any advance directive, or other legal document that will establish a substitute decision maker in the future; (b) The presence of any legal document that establishes a current substitute decision maker; and (c) The scope of decision-making authority of any substitute decision maker. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to complete a full assessment within 14 days of the resident admission to the facility for 4 of 4 sampled residents This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2748 Compliance Determination # 68817 Plan of Correction Lacamas Heights Memory Care Completion Date Page 8 of 10 Licensee: Lacamas Heights Memory Care LLC 11/20/2025 (Residents 1, 2, 3, and 4). This failure placed these four residents at risk of their care needs not being met. Findings included… Resident 1 (R1) On 11/17/2025 at 12:30 PM, R1’s records showed that they admitted to the facility on /2025 with various diagnoses including . Record review of R1’s assessments showed a preadmission assessment completed on 09/04/2025. No other assessments were found to show that another full assessment was completed within 14 days of R1’s admission into the facility. Resident 2 (R2) On 11/19/2025 at 9:15 AM, R2’s records showed that they admitted to the facility on /2025 with various diagnoses including . Record review of R2’s assessments showed a preadmission assessment completed on 07/17/2025. No other assessments were found to show that another full assessment was completed within 14 days of R2’s admission into the facility. Resident 3 (R3) On 11/17/2025 at 1:00 PM, R3’s records showed that they admitted to the facility on /2025 with various diagnoses including . Record review of R3’s assessments showed a preadmission assessment completed on 07/26/2025. No other assessments were found to show that another full assessment was completed within 14 days of R3’s admission into the facility. Resident 4 (R4) On 11/17/2025 at 12:30 PM, R4’s records showed that they admitted to the facility on /2025 with various diagnoses including . Record review of R4’s assessments showed a preadmission assessment completed on This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2748 Compliance Determination # 68817 Plan of Correction Lacamas Heights Memory Care Completion Date Page 9 of 10 Licensee: Lacamas Heights Memory Care LLC 11/20/2025 08/15/2025. No other assessments were found to show that another full assessment was completed within 14 days of R4’s admission into the facility. On 11/19/2025 at 1:30 PM, Staff A stated that the assessment provided for each resident was their preadmission assessment. Staff A stated that they were not aware that another full assessment was to be completed withing 14 days of admission to 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, Lacamas Heights Memory Care 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 WAC 388-78A-2480 Tuberculosis Testing Required. (1) The assisted living facility must develop and implement a system to ensure each staff person is screened for tuberculosis within three days of employment. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to complete tuberculosis (TB) (an infectious bacterial disease that often attacks the lungs) testing within three days of hire for 3 of 4 sampled staff (Staff C, D and E).This failure placed all staff and residents at risk for possible exposure and harm from a communicable disease. Findings included… On 11/19/2025 at 11:45 AM, the department received the requested staff documents. Staff C Record review for Staff C, Medication Technician/Caregiver, showed that Staff C was hired on 07/29/2025. No documentation was found or provided to show that a TB test had been completed withing 3 days of hire for Staff C. Staff D This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2748 Compliance Determination # 68817 Plan of Correction Lacamas Heights Memory Care Completion Date Page 10 of 10 Licensee: Lacamas Heights Memory Care LLC 11/20/2025 Record review for Staff D, Medication Technician/Caregiver, showed that Staff D was hired on 09/23/2025. No documentation was found or provided to show that a TB test had been completed within 3 days of hire for Staff D. Staff E Record review for Staff E, Medication Technician/Caregiver, showed that Staff E was hired on 07/30/2025. No documentation was found or provided to show that a TB test had been completed within 3 days of hire for Staff E. On 11/19/2025 at 1:30 PM, Staff A acknowledged that the TB tests for Staff C, D, and E were not completed per regulation. 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, Lacamas Heights Memory Care 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 This document was prepared by Residential Care Services for the Locator website.