Wellspring Centralia Llc.

Statement of Deficiencies License #: 2685 Compliance Determination # 65812 Plan of Correction Wellspring Centralia LLC 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 follow-up on 09/18/2025 of: Wellspring Centralia LLC 1215 S Tower Ave Centralia, WA 98531 This document references the following SOD dated: 10/01/2025 The following sample was selected for review during the unannounced on-site visit: 3 of 12 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Anissa Bearden, Licensor From: DSHS, Aging and Long-Term Support Administration 800 NE 136th Ave Ste 200 Vancouver, WA 98684 . Statement of Deficiencies License #: 2685 Compliance Determination # 65812 Plan of Correction Wellspring Centralia LLC Completion Date 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. Administrator (or Representative) Date WAC 388-78A-2160 Implementation of negotiated service agreement. The assisted living facility must provide the care and services as agreed upon in the negotiated service agreement to each resident unless a deviation from the negotiated service agreement is mutually agreed upon between the assisted living facility and the resident or the resident's representative at the time the care or services are scheduled. This requirement was not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that the resident’s Service Agreement (facility’s version of the negotiated service plan) was followed and implemented for 1 of 3 sampled memory care residents (Resident 3 [R3]). This failure placed R3 at risk for medical complications, decreased quality of life, and possible hospitalization. Findings included… Record review of the facility’s policy titled, “Change of Service for Resident”, undated, showed the policy applied to all staff involved in assessment, planning, and delivery of services to the residents at the facility. The section “procedure implementation” showed the interdisciplinary team shall implement the changes in services according to the resident’s care plan and individualized needs. Record review of R3’s Admission Record, dated 09/18/2025, showed R3 moved into the facility on /2025 with multiple medical diagnoses that included and . . Statement of Deficiencies License #: 2685 Compliance Determination # 65812 Plan of Correction Wellspring Centralia LLC Completion Date In an interview on 09/18/2025 at 12:26 PM, Staff C, Nursing Caregiver, stated the caregivers get paper copies of the resident’s service plans when they were updated and once the caregivers review the updated service plan, the caregivers sign and date them to show they were reviewed. Staff C stated that R3’s service plan just recently changed yesterday and provided R3’s updated service plan that was at the nurses station. The service plan showed caregiver’s signatures and dated 09/17/2025 on the front of the service plan. Record review of R3’s Resident Service Plan, undated, that was recently updated that caregivers signed off on 09/17/2025 and 09/18/2025, showed R3 demonstrated inappropriate judgement, behavior, and ability to function in social settings. On 05/07/2025 it was initiated that R3 requires a controlled carbohydrate diet with a pureed (food that is blended smooth) texture, and nectar (liquids that are thicker than honey) thick liquids. R3 had swallowing difficulties that required them to have a mechanically altered diet. Care staff were to report any changes in R3's ability to eat or drink. Record review of R3’s visual bedside individual service plan report, dated 09/18/2025, documented staff would report any changes in R3’s ability to eat or drink and was on a pureed diet with nectar thick liquids related to swallowing difficulties. In an interview and observation on 09/18/2025 at 12:36 PM, Staff C stated R3 could feed themselves and ate normal consistency of food that the caregivers had to chop up and regular thin liquids. At 12:47 PM in the dining room, R3 was sitting at a table with another female with two clear cups and one had regular consistency water with ice inside. At 1:08 PM, R3 was eating lunch that consisted of whole breaded chicken breast with white gravy on top, whole baked beans, and whole kernels of corn. None of the food R3 was observed eating was pureed consistency as the service plan directed. R3 was observed to pick up the cup of thin water and drink it. Staff E, Nursing Medication Technician, stood near R3 while they ate their lunch. In an interview on 09/18/2025 at 1:18 PM, in the kitchen, Staff F, Dietary, stated R3 was on a general regular diet with thin liquids. Staff F was unsure if R3 was to have mechanical soft food. In an interview and observation on 09/18/2025 at 2:57 PM, Staff B, Director of Nursing, reviewed R3’s service plan that was at the nurses station dated 09/17/2025 and stated that was R3 most updated service plan they had just completed yesterday. Staff B stated R3’s diet per the service plan was pureed with nectar thick liquids. Staff B stated the caregivers and the dietary staff were to serve the diet that was on the residents service plan. This is an uncorrected deficiency previously cited on 07/23/2025. . Statement of Deficiencies License #: 2685 Compliance Determination # 65812 Plan of Correction Wellspring Centralia LLC 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, Wellspring Centralia LLC 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-2665 Resident rights Notice Policy on accepting medicaid as a payment source. The assisted living facility must fully disclose the facility's policy on accepting medicaid payments. The policy must: (1) Clearly state the circumstances under which the assisted living facility provides care for medicaid eligible residents and for residents who become eligible for medicaid after admission; (2) Be provided both orally and in writing in a language that the resident understands; (3) Be provided to prospective residents, before they are admitted to the home; (4) Be provided to any current residents who were admitted before this requirement took effect or who did not receive copies prior to admission; (5) Be written on a page that is separate from other documents and be written in a type font that is at least fourteen point; and (6) Be signed and dated by the resident and be kept in the resident record after signature. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure residents were provided a Medicaid Policy for 2 of 4 sampled Residents (Resident 3 [R3], and Resident 4 [R4]). This failure placed both residents and their responsible party at risk of making uninformed decisions about placement with consideration of potential changes in their financial circumstances. Findings included… Record review of R3’s Admission Record, dated 09/18/2025, showed R3 moved into the facility on /2025. Record review of R4’s Admission Record, dated 09/26/2025, showed R4 moved into the facility on /2024. . . Statement of Deficiencies License #: 2685 Compliance Determination # 65812 Plan of Correction Wellspring Centralia LLC Completion Date On 09/18/2025 at 1:04 PM, the Department requested to review R3’s signed Medicaid policy. In an interview on 09/18/2025 at 1:32 PM, Staff A, Administrator, stated they did not have a signed Medicaid policy completed for R3. The Department requested to review R4’s signed Medicaid policy and Staff A stated it was not completed and that they were responsible for having the older residents sign a Medicaid policy. This is an uncorrected deficiency previously cited on 07/23/2025. 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, Wellspring Centralia LLC 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.