Everett Heritage Court.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . I&] □ □ . STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEAL TH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20425 72nd Avenue S, Suite 400, Kent, WA 98032 Statement of Deficiencies License#: 2612 Compliance Determination # 67680 Plan of Correction Everett Heritage Court 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 10 /23/2025 of: Everett Heritage Court 4230 Colby Ave Everett, WA 98203 This document references the following complaint number(s): 196298 The following sample was selected for review during the unannounced on-site visit: 2 of 45 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Wesler Dumecquias, Community Complaint Investigator From: DSHS, Aging and Long-Term Support Administration 20425 72nd Avenue S, Suite 400 Kent, WA 98032 . 11.04.2025 11:21:22 State of Washington 6/11 Statement of Deficiencies License#: 2612 Compliance Determination# 67680 Plan of Correction Everett Heritage Court Completion Date Page2 of 4 Licensee: Greenlake Management Everett, LLC 11/04/2025 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. 11-04-2025 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. Isl~ 11 Date WAC 388-78A-2170 Required assisted living facility services. (1) The assisted living facility must provide housing and assume general responsibility for the safety and well-being of each resident, as defined in this chapter, consistent with the resident's assessed needs and negotiated service agreement. This requirement was not met as evidenced by: Based on observations, inteiviews and record reviews, the facility failed to ensure the safety and well-being for 1 of 1 resident (Resident 1) who left the facility unsupervised through an unlocked memory care unit secured exit door. This failure resulted in Resident 1 going missing and placed Resident 1 at risk of harm, injury and abuse. Findings included ... Review of facility policy dated titled "Elopement- Prevention for Memory care" and 02/15/2024 showed the memory care community was designed and maintained to prevent elopements. Resident 1 Review of face sheet showed Resident 1 moved to the facility on /2025 with multiple diagnoses including Review of Move in Assessment dated 07/24/2025 showed Resident 1 was assessed 11-04-2025 . Statement of Deficiencies License#: 2612 Compliance Determination # 67680 Plan of Correction Everett Heritage Court 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. ~:s~ 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-2170 Required assisted living facility services. (1) The assisted living facility must provide housing and assume general responsibility for the safety and well-being of each resident, as defined in this chapter, consistent with the resident's assessed needs and negotiated service agreement. This requirement was not met as evidenced by: Based on observations, interviews and record reviews, the facility failed to ensure the safety and well-being for 1 of 1 resident (Resident 1) who left the facility unsupervised through an unlocked memory care unit secured exit door. This failure resulted in Resident 1 going missing and placed Resident 1 at risk of harm, injury and abuse. Findings included ... Review of facility policy dated titled "Elopement- Prevention for Memory care" and 02/15/2024 showed the memory care community was designed and maintained to prevent elopements. Resident 1 Review of face sheet showed Resident 1 moved to the facility on /2025 with multiple diagnoses including . Review of Move in Assessment dated /2025 showed Resident 1 was assessed . Statement of Deficiencies License#: 2612 Compliance Determination # 67680 Plan of Correction Everett Heritage Court Completion Date having elopement potential. Review of Service Plan (SP) dated 08/24/2025 showed Resident 1 had Severe cognitive Impairment. Resident 1 was frequently disoriented and required frequent supervision and oversight from the staff. Staff were to maintain Resident 1 in common areas when awake. The SP showed Resident 1 had extensive wandering behavior issues. Resident 1 wanders outside and leaves immediate area. Resident 1 had history of leaving immediate area, getting lost, or being combative about returning. Staff would try and keep Resident 1 in common areas. Review of facility Occurrence Report (Report) dated 09/25/2025 showed Resident 1 was discovered missing on 09/25/2025 at 5:00 PM. The report showed Resident 1 was found by the Police on a nearby cemetery at 6:50 PM and returned to the facility. The report showed a door was unlocked. Observation on 10/23/2025 at 12:41 PM showed the facility had a memory care unit secured exit door (equipped with an alarm system and opened with the use of a key) located on the first floor of the building past the fireplace and by the hallway. The door, when opened, exits on the side of the building and leads to a multi-lane street. The door was equipped with two alarm systems. One was wired which was built in with the door and a secondary battery-operated alarm system. Both alarms were engaged and activated by a physical key. The alarms were engaged when the doors were locked and disarmed when unlocked and opened with a key. On 10/23/2025 at 11 :27 AM, Staff B, Health and Wellness Director, stated that they honestly believed Resident 1 exited the secured exit door located at the first-floor hallway near the fireplace. Staff A stated that the door was used by staff as an exit to throw trash outside in their dumpster. Staff A stated they believed the door was unlocked and the alarm did not activate. On 10/23/2025 at 12:20 PM, Staff C, Med tech, stated that Resident 1 was discovered missing when it was dinner time. Staff A stated that they did not know Resident 1 was an elopement risk, but they knew Resident 1 wanders around and within the facility. Staff C stated that Resident 1 exited the secured door by the hallway. Staff A stated they did not hear any alarm being activated. Staff C stated that they checked the exit door at around 2:30 PM during the day and before the incident. On 10/23/2025 at 12:26 PM, Staff D, Caregiver, stated that Resident 1 wanders and staff needed to stay with them when not in bed. Staff D stated that they did not know Resident 1 was an elopement risk. Staff D stated that they believed Resident 1 does not have exit-seeking behavior but wanders and would go around other residents' room pushing doors. On 10/23/2025 at 12:31 PM, Staff E, Caregiver, stated that they were assigned with . 11.04.2025 II :21 :22 State of Uashi119ton 8/11 Statement of Deficiencies License#: 2612 Compliance Determination# 67680 Plan of Correction Everetl Heritage Court Completion Date Resident 1 at the time of the incident. Staff Estated that Resident 1 wanders and walks around the hallway. Staff Estated that Resident 1 showed exit-seeking behavior and would go push doors including other residents' doors. Staff E statEld that before the incident, they went to check the :C9 ee!:1 l ... t'\n r"lvit Mrv,r ... t ~:'""'\ Dl\11' C.::f.-, C: e-f-'"'>tr.1" ti-v?t thnH f"lili ,...,,..,,,• .... hl"\,...1,-thn rlr"ln .. ..,,,...,1/IV\r"I,',..., -:i#rw ~ff_.q:~.- -- Staff E stated that after they checked the secured exit door, they were at the Dining Room with Resident 1 seated with other residents. Staff E stated that they stood up and left Resident 1 to get juice. Staff E stated they noticed that Resident 1 stood up and walked away from the chair. Staff E stated that they did not follow Resident 1 because they thought Resident 1 would just go walk in the hallway as they would usually do. Staff Estated they noticed Resident 1 was missing around 4:45 PM when they were looking for them for dinner. On 10/23/2025 at 12:53 PM, Staff G, Caregiver, stated that they were the ones that discovereo the secured exit door lights were not blinking.

Statement of Deficiencies License #: 2612 Compliance Determination # 65684 Plan of Correction Everett Heritage Court 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-2466 Background checks Washington state name and date of birth background check Valid for two years National fingerprint background check Valid indefinitely. (1) A Washington state name and date of birth background check is valid for two years from the initial date it is conducted. The assisted living facility must ensure: (a) A new DSHS background authorization form is submitted to the department's background check central unit every two years for all administrators, caregivers, staff persons, volunteers and students; and (b) There is a valid Washington state name and date of birth background check for all administrators, caregivers, staff persons, volunteers and students. This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure 2 of 2 staff (Staff E and F) had a valid Washington State name and date of birth background check completed every two years. This failure resulted in Staff E and F not having a cleared background check and placed all residents at risk of being cared for by a staff person with a potentially disqualifying background. Findings included… Review of the ALF’s employee files showed the following: Staff E, Medication Technician, was hired on 07/01/2023. Staff E had a Washington State name and date of birth background check dated 07/11/2023 that was valid until 07/11/2025. Review of another Washington State name and date of birth background check showed it was not completed until 09 /16/2025, which was 67 days late. . . Statement of Deficiencies License #: 2612 Compliance Determination # 65684 Plan of Correction Everett Heritage Court Completion Date Staff F, Caregiver, was hired on 10/11/2021. Staff F had a Washington State name and date of birth background check dated 09/14/2021 that was valid until 09/14/2023. Review of another Washington State name and date of birth background check showed it was not completed until 08/15/2024, which was 336 days late. On 09/17/2025 at 9:04 AM, Staff H, Business Office Manager, stated that during a change in management companies things had been lost or not done. Staff H stated that they had completed a re-audit of the employee files but missed that Staff E and F did not have an updated background check. On 09/17/2025 at 3:25 PM, Staff F stated that they completed the initial background check as part of the hiring process and completed the second background when the facility asked them to complete it. 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, Everett Heritage Court 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-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 E) had a Washington State name and date of birth background check that was submitted within one business day after their date of hire. This failure placed all residents at risk of being cared for by a staff person with a potentially disqualifying background. . . Statement of Deficiencies License #: 2612 Compliance Determination # 65684 Plan of Correction Everett Heritage Court Completion Date Findings included… Review of the ALF’s employee files showed the following: Staff E, Medication Technician, was hired on 07/01/2023. Staff E had a Washington State name and date of birth background check dated 07/11/2023, which was 10 days after their date of hire. On 09/17/2025 at 9:06 AM, Staff H, Business Office Manager, stated that they didn’t know why the background had been completed late for Staff E. On 09/18/2025 at 1:12 PM, Staff E stated that they completed the background when the facility asked them to do it. 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, Everett Heritage Court 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-2485 Tuberculosis Positive test result. When there is a positive result to tuberculosis skin or blood testing the assisted living facility must: (1) Ensure that the staff person has a chest X-ray within seven days; This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure 1 of 1 staff (Staff C) completed a chest X-ray within seven days after they had a positive result on their tuberculosis (TB) blood test. This failure placed all residents at risk of possible exposure to a communicable disease. . . Statement of Deficiencies License #: 2612 Compliance Determination # 65684 Plan of Correction Everett Heritage Court Completion Date Findings included… Review of the ALF’s employee files showed the following: Staff C, Caregiver, was hired on 05/10/2025. Staff C had a positive TB blood test on 05/06/2025. There was no documentation that Staff C had done a chest X-ray after their positive result on their TB blood test. On 09/17/2025 at 1:52 PM, Staff C stated that they were unable to recall if they had a chest X-ray after their positive result on their TB blood test. On 09/17/2025 at 4:18 PM, Staff G, Health Services Director/Licensed Practical Nurse, stated that they could not recall why Staff C didn’t have a chest Xray after they tested positive with a blood test. Staff G also stated that they though chest Xrays were good enough for proof of a positive test. 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, Everett Heritage Court 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. (2) For purposes of WAC 388-78A-2481 through 388-78A-2489 , "staff person" means any assisted living facility employee or temporary employee of the assisted living facility, excluding volunteers and contractors. This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure 2 of 4 staff (Staff B and Staff D) completed tuberculosis (TB) testing within three days of . . Statement of Deficiencies License #: 2612 Compliance Determination # 65684 Plan of Correction Everett Heritage Court Completion Date hire. This failure placed all residents at risk of exposure to a communicable disease. Findings included… Review of the ALF’s employee files showed the following: Staff B, Caregiver, was hired on 07/24/2025. There was no documentation in Staff B’s file that showed they had TB testing within three days of hire. Staff D, Medication Technician, was hired on 04/15/2025. There was no documentation in Staff D’s file that showed they had TB testing within three days of hire. --- findings for any alleged or suspected abuse, neglect, or financial exploitation; or accident or incident jeopardizing or affecting a resident health or life; (2) Determine the circumstances of the event; (3) When necessary, institute and document appropriate measures to prevent similar future situations if the alleged incident is substantiated; and The Department staff who did the On Site verification: Jodi Condyles, Nursing Consultant Institutional If you have any questions, please contact me at (206)305-3489. Sincerely, ~s~ imes Sherman, Field Manager Region 2, Unit D Investigation Summary Report Provider/Facility: Everett Heritage Court Provider Type: Assisted Living Facility License/Cert.#: 2612 Intake ID: 180159 Compliance Determination #: 61005 Region/Unit #: RCS Region 2 / Unit A Investigator: Wesler Dumecquias Investigation Date(s): 06/12/2025 through 07/21/2025 Complainant Contact Date(s): 06/12/2025 Allegation(s): 1. The Named Resident (NR) did not have a call light or button for three days after they moved in. The emergency call button was not working. The Assisted Living Facility (ALF) staff did not have their pagers with them to respond to residents' calls. 2. The NR was moved to the ALF without being informed that the ALF had a delayed egress. 3. The NR’s bed was too short for their height. 4. The ALF failed to contact the case manager and the Power of Attorney (POA) when they made an assessment to increase the NR services. Investigation Methods: Sample: Total residents: 45 Resident sample size: 5 Closed records sample size: Observations: Identified resident Residents Resident rooms Residents bed ADL Equipment Emergency call button locations Interviews: Identified resident Residents Family members Nursing staff Administrator Record Reviews: Facility policies Staff patterns Incident investigation Medical records Care plans Progress notes . Investigation Summary: 1. Named Resident's (NR) prior room had a working emergency call button installed by the side of their bed. NR's new apartment had a working emergency call button installed on the wall by their bed. The ALF staff did not have their pagers with them during the unannounced visit. The ALF staff failed to respond to the emergency call lights when activated. Failed practice was identified. A citation was issued for no compliance with WAC 388-78A-2930 (1) (a) (ii)- Communication system. 2. NR admitted to the Assisted Living Facility (ALF) from the hospital. The NR was aware that they were moved into the ALF temporarily. The NR stated the ALF was not preventing them from moving to another facility. The NR stated their Power of Attorney was looking for another facility where they can transfer. 3. Observation showed the NR original apartment had a hospital bed. The NR stated their bed was fine. The NR was moved to another apartment. The apartment was furnished with a bed. The NR fits in the bed and staff were putting a pillow at the foot part as a support when the NR would stretched their legs. 4. The Assisted Living Facility Nurse made a change of condition assessment without involving the NR's case manager. There were no documentation showing the ALF nurse involved the Resident and their representative when they made a change of condition assessment. Failed practice was identified. A citation was issued for non-compliance with WAC 388-78A-21

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Ii □ □ STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20425 72nd Avenue S, Suite 400, Kent, WA 98032 Statement of Deficiencies License #: 2612 Compliance Determination # 56761 Plan of Correction Everett Heritage Court 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 03/21/2025 and 04/23/2025 of: Everett Heritage Court 4230 Colby Ave Everett, WA 98203 This document references the following complaint number(s): 172176, 170721, 170714, 170926 The following sample was selected for review during the unannounced on-site visit: 7 of 42 current residents and 3 former residents. The department staff that investigated the Assisted Living Facility: Wesler Dumecquias, Community Complaint Investigator From: DSHS, Aging and Long-Term Support Administration 20425 72nd Avenue S, Suite 400 Kent, WA 98032 . Statement of Deficiencies License #: 2612 Compliance Determination # 56761 Plan of Correction Everett Heritage Court 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-3090 Maintenance and housekeeping. (1) The assisted living facility must: (c) Keep facilities, equipment and furnishings clean and in good repair; and This requirement was not met as evidenced by: Based on observations and interviews, the Assisted Living Facility (ALF) failed to ensure the facility, equipment and furnishings were in good repair for 1 of 3 residents. These failures resulted in Resident 1 not being able to summon help through their emergency call light system, not having proper lighting in the bathroom and placed Resident 1 at risk for compromised safety. Findings included… On 03/20/2025 at 9:30 AM, Collateral Contact 1 stated that they visited on 03/07/2025 and 03/10/2025 and found out that the lights in Resident 1’s room were not working. Observations on 03/21/2025 at 1:53 PM, the emergency pull cord in Resident 1’s room by their bed showed the string to pull and activate was missing. On 03/21/2025 at 1:55 PM, Resident 1’s bathroom light did not light up when switched on. In an observation and interview on 03/21/2025 at 1:49 PM, Resident 1 was observed alert and oriented to self, place, time and situation. Resident was able to recall how . Statement of Deficiencies License #: 2612 Compliance Determination # 56761 Plan of Correction Everett Heritage Court Completion Date they moved into the ALF and past events. Resident 1 stated that their emergency pull cord string had been missing for a month and their bathroom light had been broken and was not working. Resident 1 stated that they informed the ALF staff, but nobody had fixed it. On 03/21/2025 at 3:50 PM, Staff A, Executive Director, went to Resident 1’s room and confirmed the light was not working and the ALF would fix it. On 04/15/2025 at 4:00 PM, Collateral contact 2 stated that they observed the emergency pull cord string in Resident 1’s room was missing. This is a recurring citation previously cited on 06/15/2023 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, Everett Heritage Court 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 .

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

Findings included… A review of the facility features in STARS showed the ALF was licensed to operate for 47 beds as Specialized Dementia and Enhanced Adult Residential care and assisted living for the bottom and top floors. On 10/25/2024 at 11:55 AM, it was observed that the ALF had two floors. The top floor was street level, and the bottom floor was accessible through stairs and an elevator from the top floor going down. The ALF's bottom floor had a door marked as an emergency exit that was supposed to exit into an outdoor area, but it had a permanent lock that only the ALF staff could access using their issued key. The emergency exit door leads to a small outdoor area. The top floor had an outdoor area with a courtyard and a space that residents would use as an outdoor area for all the residents of the bottom and top floors. The outdoors area consisted of a courtyard, and a garden with outdoor chairs and plants. The outdoor area was secured by a fence that enclosed the ALF's perimeter and an egress-secured door leading to the ALF's parking lot. In an interview on 10/25/2024 at 11:48 AM, Staff D, Med tech/Caregiver, stated that the emergency exit door on the bottom floor was always locked and only care staff could open it using their issued keys. Staff D stated that they would not use the bottom floor outside the emergency exit door for their outdoor activities because it was a narrow area. Staff D stated that it would accompany residents wanting to use the outdoor area on the top floor. In an interview on 10/25/2024 at 12:55 PM, Staff B, Health Services Director (HSD), stated that there was no outdoor area on the bottom floor. The HSD stated that the ALF’s care staff had to escort and bring the residents of the bottom floor to the top floor outdoor area for their outdoor activities. Staff B stated that the ALF planned to build a courtyard for the bottom floor. . .

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Ii □ □ STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 3906-172nd St NE, Suite #100, Arlington, WA 98223 Statement of Deficiencies License #: 2612 Compliance Determination # 45128 Plan of Correction Everett Heritage Court 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 08/02/2024 and 08/02/2024 of: Everett Heritage Court 4230 Colby Ave Everett, WA 98203 This document references the following complaint number(s): 141151 The following sample was selected for review during the unannounced on-site visit: 4 of 45 current residents and 1 former residents. The department staff that investigated the Assisted Living Facility: Wesler Dumecquias, Community Complaint Investigator From: DSHS, Aging and Long-Term Support Administration 3906-172nd St NE, Suite #100 Arlington, WA 98223 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 #: 2612 Compliance Determination # 45128 Plan of Correction Everett Heritage Court Completion Date Administrator (or Representative) Date WAC 388-78A-2410 Content of resident records. The assisted living facility must organize and maintain resident records in a format that the assisted living facility determines to be useful and functional to enable the effective provision of care and services to each resident. Active resident records must include the following: (9) Documentation consistent with WAC 388-78A-2120 Monitoring resident well-being. This requirement was not met as evidenced by: Based on the interview and records review, the Assisted Living Facility (ALF) failed to document in the Residents' records observations and assessments for 2 of 2 Residents (Resident 1 and 2) with skin issues. These failures resulted in the ALF not being able to show that they were monitoring and assessing the Residents' skin issues in order to determine and timely address potential complications or worsening of the skin issues. These failures placed Residents 1 and 2 at risks of developing increased skin complications. Findings included… A review of the ALF's "Skin Care Management" policy dated 02/15/2024 showed the Health Services Director (HSD) would ensure that they would complete documentation of the appropriate interventions, follow-up, Service Plan updates, and progress notes. The policy showed the HSD would at least do a weekly assessment and documentation in Resident 1's progress note until the skin problem was resolved. The policy showed the ALF staff would monitor the food intake and place the residents on weekly weights. The Community nursing staff would continue to monitor and document the progress of the wound, even if an outside agency were providing the treatment. Resident 1 Resident 1 was admitted on /2024 with multiple diagnoses, including . A review of an undated Care Plan (CP) showed Resident 1 had a stage 2 sacral pressure ulcer related to immobility. The CP showed that a care manager (CM) would do weekly treatment documentation to include measurements for each area of skin breakdown, including width, length, depth, type of tissue and exudate (a fluid released through . Statement of Deficiencies License #: 2612 Compliance Determination # 45128 Plan of Correction Everett Heritage Court Completion Date pores or a wound), and any other notable changes or observations. A review of the ALF's Weekly Wound Care Report dated 07/19/2024 showed on 07/18/2024 the ALF identified Resident 1’s Stage 2 pressure ulcer on their sacral area on /2024 and an outside home health provider would perform the wound care. The Report showed that an assessment should be documented in the residents' health records each week. The documentation should include a brief description of the wound, including current treatment, how the resident tolerated the healing process, and any concerns. No other entries were entered on the Weekly Wound Report. On 08/07/2024 at 9:47 AM, Staff B, HSD, stated that the Home Health (HH) was doing the wound care, and they were not in charge. Staff B said they would not do anything about the wound. Staff B stated that they do not do weekly weights. Staff B stated that HH informed them that the wound deteriorated, and a new pressure wound developed. Staff B stated that right after HH informed them of the deteriorating wound and newly discovered wound, they put Resident 1 in hospice. A review of the home health's Outside Provider's outcome of the visit dated 07/30/2024 showed Resident 1's wound deteriorated, and a new wound formed above the original wound. The latest wound measured 0.4x1x0.1 cm (centimeters). A review of Progress notes from Resident 1's admission date of /2024 to /2024 showed no documentation of a weekly assessment, including measurements for each area of skin breakdown, width, length, depth, type of tissue and exudate, and any other notable changes or observations. There was no documentation in the progress notes showing a brief description of the wound, including current treatment, how the resident tolerated the healing process or any concerns. Resident 2 Resident 2 was admitted into the ALF on /2024 with multiple diagnoses, including A review of the CP dated 07/16/2024 showed Resident 2 could get redness on their buttocks and peri area. Resident 2 had potential impairment to skin integrity related to fragile skin and dementia. On 08/02/2024 at 3:20 PM, Staff F, Caregiver, stated that Resident 2 had a skin irritation in their private area. Staff F stated Resident 2 stays mostly in their bed and needed two-person assist. On 08/02/2024 at 3:23 PM, Staff G, Caregiver, stated that Resident 2 had sensitive skin . Statement of Deficiencies License #: 2612 Compliance Determination # 45128 Plan of Correction Everett Heritage Court Completion Date and mostly slept on their back. Staff G stated that Resident 2 had skin irritation and a small scratch on their vaginal area. Staff G stated they would turn Resident 2 at least every two hours and apply a barrier cream. On 08/02/2024 at 3:29 PM, Staff E, Med Tech, stated that Resident 2 had rashes in their private area and bottom. Staff E described Resident 2’s skin issue in their private area and bottom as a bedsore (Pressure ulcer). Staff E stated they knew of the skin problem when changing Resident 2’s brief and was applying barrier cream. Staff E stated they had informed the HSD of the pressure ulcer. A review of progress notes dated 06/18/2024 and 06/19/2024 showed Resident 2 developed a rash on their bottom and needed the application of a barrier cream, and nystatin powder was being applied. There were no documentation showing weekly assessments and monitoring of the skin issue from 06/25/2024 to 08/02/2024. 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, Everett Heritage Court 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-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 the interview and records review, the Assisted Living Facility (ALF) failed to follow and implement their policy when it did not monitor the food intake and place on weekly weights 1 of 1 Resident (Resident 1) with a stage 3 pressure ulcer (an injury in the outer surface or more profound layer of the skin with a red or pink wound bed) of the sacral region (the portion of your spine between your lower back and tailbone). The failure resulted in the ALF not having documentation to provide the primary care physician (PCP) and consider dietary and physical therapy consults. This failure placed Resident 1 at risk of worsening pressure wounds or developing skin complications. .

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: Everett Heritage Court Provider Type: Assisted Living Facility License/Cert.#: 2612 Intake ID: 122801 Compliance Determination #: 38428 Region/Unit #: RCS Region 2 / Unit A Investigator: Karen Glover Investigation Date(s): 03/18/2024 through 07/22/2024 Complainant Contact Date(s): 07/16/2024 Allegation(s): The Named Resident (NR) was found with a black eye and injury to the side of their face. Investigation Methods: Sample: Total residents: 47 Resident sample size: 4 Closed records sample size: 0 Observations: Identified resident Resident rooms Staff to resident interactions Residents Interviews: Hospice staff Nursing staff Residents Family members Record Reviews: Incident investigation Progress Notes Investigation Summary: The NR was on Hospice services and would be in pain and become agitated at night. Care staff noted the black eye and bruise to the forehead. The facility initiated an investigation and notified the NR's family, Hospice team, and the department's hot line. Review of the NR's progress notes showed the NR had multiple incidents over the last few weeks including a bruise noted on the NR's left hip. Review showed no incident report had been completed for the bruise and no alert charting had been completed for the incidents as directed by facility policy. The facility will be cited for WAC 388-78A-2600 Policy and Procedures, WAC 388-78A-2371 Investigations. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written . Failed Provider Practice Not Identified / No Citation Written N/A . . Statement of Deficiencies License #: 2612 Compliance Determination # 38428 Plan of Correction Everett Heritage Court Completion Date Administrator (or Representative) Date WAC 388-78A-2371 Investigations. The assisted living facility must: (1) Investigate and document investigative actions and findings for any alleged or suspected abuse, neglect, or financial exploitation; or accident or incident jeopardizing or affecting a resident health or life; (2) Determine the circumstances of the event; (3) When necessary, institute and document appropriate measures to prevent similar future situations if the alleged incident is substantiated; and (4) Protect residents during the course of the investigation. This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to investigate, document findings, determine the circumstances of the event, and protect 1 of 3 sampled residents (Resident 1) when staff found a bruise on their left hip. This failure resulted in the ALF not being able to rule out abuse and neglect and placed Resident 1 at risk for future incidents. Findings included… Review of the Assisted Living Facility Guidebook Partners in Protection, dated February 2018, contained guidelines intended to assist facilities in developing and implementing policies and procedures to help prevent resident abuse, neglect, abandonment, significant injuries of unknown source, or personal and/or financial exploitation by any person. Chapter 2 and Appendix F showed State law required the assisted living facility to do a thorough investigation when there has been some type of impermissible, unjustifiable, harmful, offensive, or unwanted contact with a resident. Review of the ALF's "General Policy 20-Internal Incident Report and State Incident Report" policy dated 08/10/2021, showed an internal incident report is completed by staff for all unusual occurrences, injury, and incidents. The ALF must: - investigate and document investigative actions for any accident or incident jeopardizing or affecting a resident’s health or life. -determine the circumstances of the event. Resident 1 was admitted to the ALF on / /2023 with multiple diagnoses including ( ). Review of Resident 1's progress note dated 03/07/2024, showed Resident 1 had bruising noted on their left hip and the hospice (a program that gives special care to . Statement of Deficiencies License #: 2612 Compliance Determination # 38428 Plan of Correction Everett Heritage Court Completion Date residents who are near the end of life) team had been notified. There was no evidence of an incident report or investigation being completed. In an interview on 03/18/2024 at 12:45 PM, Staff B, Health Services Director, stated that they thought since Resident 1 was on hospice services that the bruise did not need to be investigated or reported to the state. 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, Everett Heritage Court 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-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: (a) Related to suspected abandonment, abuse, neglect, exploitation, or financial exploitation of any resident; (f) In response to medical emergencies; This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to implement their policy and place 2 of 4 sampled residents (Resident 1 and 2) on alert charting for multiple falls and a change of condition. This failure resulted in the Residents not being put on alert charting and placed Resident 1 and Resident 2 at risk for unrecognized complications following a fall or change of condition. Findings included… Record review of the ALF's policy, "Alert Charting" dated 08/10/2021 showed: Alert charting will be implemented for residents who have had a recent change in their expected or customary function or other reason that initiates a need for closer . Statement of Deficiencies License #: 2612 Compliance Determination # 38428 Plan of Correction Everett Heritage Court Completion Date monitoring. 1. Alert charting procedures will be initiated if a resident: a-new to the community b-exhibits a change in condition c-is returning from the hospital, ER or urgent care d-has fallen 2. The alert charting process includes: a-the resident's name and concern will be placed in a discreet location readily visible to care staff or alert charting reminder is turned on in the service planning program. b- each resident placed on alert charting will be monitored for at least 48 hours following the initiation of alert charting. Record review of ALF's policy, "Fall Response Procedures" dated 08/10/2021 showed: Policy: Should a resident experience a fall, staff will provide immediate care and follow through with Negotiated Service agreement. Procedure: For 48 hours after any fall, the Wellness Director or Nurse/Med Tech on each shift will monitor the resident and make a brief narrative charting entry. Resident 1 Resident 1 was admitted to the ALF on / /2023 with multiple diagnoses including ( ). Review of Resident 1's progress notes dated 03/07/2024, 03/09/2024, 03/14/2024 and 03/15/2024 showed only a nursing note had been made on each of those dates identifying a fall had happened with no alert charting noted following the falls. Resident 2 Resident 2 was admitted to the ALF on / /2022 with multiple diagnoses including . Review of Resident 2's progress notes dated 02/02/2024 showed Resident 2 returned to the community from a hospital stay. There was no evidence of any alert charting following Resident 2's return to the community from the hospital. In an interview on 03/18/2024 at 12:56 PM, Staff B, Health Services Director, stated that alert charting had not been completed since last May when they started in the Health Services Director position. . Statement of Deficiencies License #: 2612 Compliance Determination # 38428 Plan of Correction Everett Heritage Court 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, Everett Heritage Court 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-2630 Reporting abuse and neglect. (1) The assisted living facility must ensure that each staff person: (a) Makes a report to the department's Aging and Disability Services Administration Complaint Resolution Unit hotline consistent with chapter 74.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written . N/A . Investigation Summary Report Provider/Facility: Everett Heritage Court Provider Type: Assisted Living Facility License/Cert.#: 2612 Compliance Determination #: 26242 Intake ID: 88582 Investigator: Karen Glover Region/Unit #: RCS Region 2 / Unit A Investigation Date(s): 07/10/2023 through 10/31/2023 Complainant Contact Date(s): 06/29/2023 Allegation(s): The Named Resident (NR) had a 30 pound weight loss and the only intervention was one can of ensure a day which the resident must pay for. Investigation Methods: Sample: Total residents: 44 Resident sample size: 6 Closed records sample size: 2 Observations: Identified resident Residents Dining Resident rooms Staff to resident interactions Interviews: Identified resident Nursing staff Residents Record Reviews: weight records negotiated service agreement Investigation Summary: 1. Record review of the NR's weight showed a 15 pound weight loss over 4 months. The ALF was not identifying the weigh losses. Review of the medical provider chart notes showed the medical provider was not aware of the weight loss. Failed practice was identified and the ALF was cited for WAC 388-78A-2120 Monitoring residents well-being. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: Everett Heritage Court Provider Type: Assisted Living Facility License/Cert.#: 2612 Compliance Determination #: 26242 Intake ID: 87345 Investigator: Karen Glover Region/Unit #: RCS Region 2 / Unit A Investigation Date(s): 07/10/2023 through 10/31/2023 Complainant Contact Date(s): 07/06/2023, 09/18/2023 Allegation(s): 1. The Named Resident (NR) was neglected due to extreme weight loss and neglectful care. 2. The NR fell at the facility and had a head injury. Investigation Methods: Sample: Total residents: 44 Resident sample size: 6 Closed records sample size: 2 Observations: Residents Dining Resident rooms Staff to resident interactions Interviews: Nursing staff Guardian Administration Record Reviews: Facility policies Incident investigation Negotiated Service Agreement Investigation Summary: 1. The NR was weighed every month. In the past six months the NR had lost 6 pounds. The NR's body mass index (BMI) was documented as 15.97 kg/m2 at the hospital and hospital staff observed and documented the NR to be "thin and malnourished". Failed practice was identified and the ALF was cited for WAC 388-78A-2120 Monitoring residents well-being. 2. The NR had a witnessed fall and as requested by the medical provider at the facility, 911 was called and the NR was transported to the local hospital. The facility initiated an incident report and investigation and notified family, complaint resolution unit and the medical provider was at the facility at the time of the incident. The NR will not be returning to the facility. No failed practice identified. Conclusion / Action: . Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: Everett Heritage Court Provider Type: Assisted Living Facility License/Cert.#: 2612 Compliance Determination #: 26242 Intake ID: 92440 Investigator: Karen Glover Region/Unit #: RCS Region 2 / Unit A Investigation Date(s): 07/10/2023 through 10/31/2023 Complainant Contact Date(s): 08/09/2023, 08/17/2023, 08/31/2023, 09/05/2023 Allegation(s): 1. The Named Resident (NR) was not fed or given fluids or medications for more than 4 days. 2. The NR laid in bed with diarrhea all over him. 3. The NR was so dehydrated the family requested the NR be sent to the hospital. 4. The NR had pneumonia from sleeping in bedroom with the windows open. Investigation Methods: Sample: Total residents: 44 Resident sample size: 6 Closed records sample size: 2 Observations: Residents Resident rooms Staff to resident interactions Interviews: Nursing staff Residents Identified staff Record Reviews: Medical records Hospital records Physician records Investigation Summary: 1. Record review showed the NR had not received medications for 5 days before the NR was sent to the hospital for unrelated issues. Failed practice was found, however the ALF could not be cited as the ALF was under a plan of correction for WAC 388-78A-2240 Nonavailability of medication. 2. Staff reported that the NR had diarrhea and they had been cleaning him up as needed. Record and interview showed the NR received showers on a daily basis. The NR's family was doing the laundry and found multiple bags of dirty laundry in the NR's room showing the staff were changing the NR. 3. The NR was sent to the hospital as requested by the family. Review of hospital records showed lab values were appropriate for a patient with multiple days of diarrhea. The NR had not established with a medical provider at the time of the diarrhea and missed medications. The facility was cited for WAC 388-78A-2640 . reporting significant change in resident's condition. 4. Staff reported they would open the bedroom window to air out the room. No determination could be made regarding how long the window was open or how it impacted the NR. 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 3906-172nd St NE, Suite #100, Arlington, WA 98223 Licensee: Greenlake Management Everett, LLC Everett Heritage Court 4441 W. Airport FWY Ste 160 Oriving, TX 75062 RE: Everett Heritage Court License # 2612 Dear Administrator: The Department completed a full inspection and a complaint investigation of your Assisted Living Facility on 07/28/2023 and found that your facility does not meet the Assisted Living Facility licensing requirements. The Department: • Wrote the enclosed Statement of Deficiencies (SOD) 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. 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: . . . . . . . . . . . . .

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

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