Mirror Lake Village.

Statement of Deficiencies, with a completion date of 11/13/2025, under Washington Administration Chapter 388-78A-2210 - Medication services. 2) Failed facility practice found. 2) During the full licensing inspection conducted on 10/22/2025 through 10/27/2025, on-site facility investigation found facility failed practice related to quality of care and services related to insufficient staff to provide safe medication services. This finding of failed facility practice was cited in the Statement of Deficiencies, with a completion date of 11/13/2025, under Washington Administration Chapter 388-78A-2210 - Medication services. Conclusion / Action: . Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . . . .

Statement of Deficiencies License #: 2564 Compliance Determination # 49841 Plan of Correction Mirror Lake Village 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 11/06/2024 and 11/06/2024 of: Mirror Lake Village 31000 9th Pl SW Federal Way, WA 98023 This document references the following SOD dated: 11/06/2024 The following sample was selected for review during the unannounced on-site visit: 15 of 65 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Claudia Allis, ALF Licensor Steven Garrett, LTC Licensor From: DSHS, Aging and Long-Term Support Administration 20425 72nd Avenue S, Suite 400 Kent, WA 98032 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 #: 2564 Compliance Determination # 49841 Plan of Correction Mirror Lake Village Completion Date Administrator (or Representative) Date WAC 388-78A-2140 Negotiated service agreement contents. The assisted living facility must develop, and document in the resident's record, the agreed upon plan to address and support each resident's assessed capabilities, needs and preferences, including the following: (1) The care and services necessary to meet the resident's needs, including: (a) The plan to monitor the resident and address interventions for current risks to the resident's health and safety that were identified in one or more of the following: (i) The resident's preadmission assessment; (ii) The resident's full assessments; (iii) On-going assessments of the resident; (b) The plan to provide assistance with activities of daily living, if provided by the assisted living facility; (c) The plan to provide necessary intermittent nursing services, if provided by the assisted living facility; (e) The resident's preferences for how services will be provided, supported and accommodated by the assisted living facility. This requirement was not met as evidenced by: Based on observation, interview, and record review, the facility failed to document in 5 of 15 residents’ (Resident 4, Resident 5, Resident 7, Resident 10, and Resident 14) Negotiated Service Agreements (NSA), the care needs and interventions for diagnoses and physician ordered medical treatments. This failure placed Resident 4, Resident 5, Resident 7, Resident 10, and Resident 14 at risk for unmet care needs and worsening of diagnosed conditions. Findings included… Record review of the Department’s, “Secure Tracking and Reporting Systems” (STARS) showed the Assisted Living Facility (ALF) received an initial citation for this regulation on 05/07/2024, a second citation on 08/07/2024, and a third citation on 09/17/2024 for Resident 2, Resident 4, Resident 5, Resident 7, and Resident 10. The ALF signed an attestation statement that stated the facility would have a system in place and the deficiency corrected by 06/21/2024, 08/17/2024, and again on 10/21/2024. RESIDENT 4 . Statement of Deficiencies License #: 2564 Compliance Determination # 49841 Plan of Correction Mirror Lake Village Completion Date Review of Resident 4’s November 2024 Medication Administration Record (MAR) showed that Resident 4 received 50 milligrams (mg) of Sertraline (medication used to treat depression) daily, by mouth, for depression. Review of Resident 4’s assessment and service plan (also known as an NSA), dated 10/05/2024, showed no guidance for the staff about the signs and symptoms of depression. There was no guidance for the staff about the type of interventions used when Resident 4 showed signs and symptoms of depression. RESIDENT 5 Review of Resident 5's record showed documentation of a completed feeding and swallowing evaluation, dated 06/17/2021. The feeding and swallowing evaluation results included a section titled, “CAREGIVER GUIDELINES FOR SAFE FEEDING”. Review of Resident 5’s assessment and service plan, dated 06/18/2024, showed that Resident 5 received a mechanical soft diet (easily chewed and swallowed foods) and nectar thickened liquids (liquids with a thickener added). The plans showed no guidance for the staff about the type of actions to be taken when Resident 5 experienced swallowing or choking difficulties. The plans showed no instructions for staff about the documentation needed for incidences of swallowing difficulty and the monitoring of Resident 5’s dietary intake. There were no instructions about what signs of increased swallowing difficulties to report to the nurse. RESIDENT 7 Review of the facility characteristic roster showed that Resident 7 resided in the memory care unit. The roster showed that Resident 7 exhibited exit-seeking behaviors. Review of Resident 7’s assessment and service plan, dated 06/18/2024, showed no instructions for staff about how to manage Resident 7’s exit-seeking behaviors when observed. The plans showed no instructions for staff about what documentation was needed for incidences of exit-seeking. RESIDENT 10 Review of Resident 10’s pre-admission assessment, dated 01/02/2024, showed that Resident 10 required one staff person assistance with transfers. The assessment showed that Resident 10 was verbally and physically resistive to care assistance and required cuing and encouragement. Review of Resident 10’s admission assessment and service plan, dated 06/18/2024, showed no instructions for staff about how to manage behaviors when Resident 10 demonstrated resistance to care and exhibited verbal and physical aggressive behaviors. The plans showed no instructions for staff about what documentation was needed for incidences of resistance to care and aggressive behaviors. . Statement of Deficiencies License #: 2564 Compliance Determination # 49841 Plan of Correction Mirror Lake Village Completion Date Resident 14 Review of Resident 14’s November 2024 MAR showed Resident 14 received 2.5 mg of Eliquis (blood thinning medication) twice daily, by mouth, for the prevention of blood clots. The MAR showed Resident 14 received 25 mg of Sertraline (medication used to treat depression) daily, by mouth, for a diagnosis of . Review of Resident 14’s pre-admission assessment, dated 10/22/2024, showed no documentation that Resident 14 had a diagnosis. The assessment showed no indication that Resident 14 received blood thinning medications. Review of Resident 14’s NSA, dated 11/06/2024, showed no diagnosis of . The NSA showed that Resident 14 had a diagnosis of The NSA showed no guidance for the staff about the possible side effects from the use of Eliquis, such as an increased risk for bleeding or bruising. The NSA showed no instructions for staff about what actions were needed for any side effects or the reporting of any signs and symptoms of side effects to the nurse. The NSA showed no guidance for the staff about managing the signs and symptoms of depression. The NSA showed no instructions for staff about what actions were needed for any worsening of depression symptoms or reporting of worsening symptoms to the nurse. There were no instructions about what side effects to monitor for the Sertraline medication and when to report any side effects to the nurse. During an interview on 11/06/2024 at 1:40 PM, Staff X, Director of Wellness, stated that they were aware that Resident 14 received services for medication assistance, which included their Eliquis and Sertraline medications. Staff X stated that they were aware that Resident 14’s NSA lacked documented instructions and guidance for caregivers regarding the diagnosis and Eliquis and Sertraline medications. This is an uncorrected deficiency cited on 09/17/2024 a recurring deficiency previously cited on 07/19/2024 and 05/07/2024. 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, Mirror Lake Village 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 . Statement of Deficiencies License #: 2564 Compliance Determination # 49841 Plan of Correction Mirror Lake Village Completion 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 observation, interview, and record review, the facility failed to ensure 2 of 4 residents (Resident 4 and Resident 15) side bed rails, attached to the residents’ beds, were free from safety risks.