Riverside Place.

Statement of Deficiencies License #: 2363 Compliance Determination # 63288 Plan of Correction Riverside Place 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 07/29/2025 of: Riverside Place 1649 Broadway Ave Hoquiam, WA 98550 This document references the following SOD dated: 08/01/2025 The following sample was selected for review during the unannounced on-site visit: 3 of 22 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 #: 2363 Compliance Determination # 63288 Plan of Correction Riverside Place Completion Date or home care aide in Washington state without restriction; (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; (d) Has evidence as required by the department of social and health services of successful completion of nurse delegation special focus on diabetes training when providing insulin injections to a diabetic client; and (e) Is willing and able to perform the task in the absence of direct or immediate nurse supervision and accept responsibility for their actions. (9) Assess the ability of the nursing assistant or home care aide to competently perform the delegated nursing task in the absence of direct or immediate nurse supervision…12) Provide specific, written delegation instructions to the nursing assistant or home care aide with a copy maintained in the patient's record that includes: (b) The delegated nursing task is specific to one patient and is not transferable to another patient;(c) The delegated nursing task is specific to one nursing assistant or one home care aide and is not transferable to another nursing assistant or home care aide.” Record review of the undated facility policy titled, “Medication Administration,” stated that medication administration was the most restrictive medication category and required administration only by “an LPN [licensed practical nurse], RN [registered nurse], ARNP [advanced registered nurse practitioner], physician, pharmacist, certified nursing assistant or nursing assistant registered following RN delegation protocols.[The] RN must assure the medication service category is planned, directed, and supervised by… providing training to all medication administration staff and documenting the training, [and] observing , evaluating, and documenting each staff person administering medication annually, or more often as needed.” Record review of the facility’s plan of correction, dated 05/15/2025, showed the facility would immediately review and update all nurse delegation records to ensure each staff member was clearly and individually delegated to each resident’s specific task to be incompliance with the WAC and delegation regulations. The delegating RN was required to maintain and update the delegation logs to show staff to resident assignments and review them monthly. All medication administration by delegated staff would be audited weekly for 90 days to ensure full compliance. Record reviews of the undated resident roster showed 20 of 22 memory care residents received nurse delegation services. Record review of the facility’s employee HR (human resources) list, undated, showed Staff C, Medication Aide, started employment at the facility on 06/13/2025. Record review of the facility provided worked staffing schedules, dated 06/29/2025 through 08/02/2025, showed Staff C was scheduled for 12-hour shifts as the medication technician from 6:00 PM until 6:00 AM every Thursday, Friday, and Saturday. Record review of the facility’s delegated staff list, dated 07/28/2025, showed Staff B, Resident Care Nurse, was the delegating nurse, and had reviewed all credentials to Statement of Deficiencies License #: 2363 Compliance Determination # 63288 Plan of Correction Riverside Place Completion Date ensure all were accurate, current, and in good standing. It also included that Staff B had observed, trained, and felt confident in the delegate’s ability to perform delegated tasks. The document did not have Staff C listed as a delegate. R1 Record review of R1’s delegation assessment, dated 06/26/2025, showed R1 was delegated for their oral, topical (on the skin), patch, and rectal suppository medications related to R1’s dementia (a progressive brain disorder that affects a person’s memory, judgement, reasoning, and ability to perform activities of daily living needs). Review of the listed delegated medication aides showed Staff C was not listed for oral and topical medications related to R2’s dementia. R2 Record review of R2’s delegation assessment, dated 06/26/2025, showed R2 was delegated for their oral and topical medications related to R2’s dementia. Review of the listed delegated medication aides showed Staff C was not listed for oral and topical medications related to R2’s dementia. R3 Record review of R3’s delegation assessment, dated 06/26/2025, showed R3 was delegated for their oral medications related to R3’s dementia. Review of the listed delegated medication aides showed Staff C was not listed for oral medications related to R3’s dementia. Record review of R1, R2, and R3’s Medication Administration Record (MAR), dated 07/01/2025 through 07/29/2025, showed Staff C administered all three residents delegated medication tasks for 12 of 28 days. In an interview on 07/30/2025 at 11:02 AM, Staff B stated Staff C was not RN delegated to administer residents delegated tasks. Staff B stated Staff C did not have all their required documentation to be delegated. This is a recurring deficiency previously cited on 01/23/2025 and an uncorrected deficiency previously cited on 04/01/2025 and 01/23/2025. STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION Statement of Deficiencies License #: 2363 Compliance Determination # 56579 Plan of Correction Riverside Place 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 03/19/2025 of: Riverside Place 1649 Broadway Ave Hoquiam, WA 98550 This document references the following SOD dated: 04/01/2025 The following sample was selected for review during the unannounced on-site visit: 7 of 20 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Emily Boniface, Community Program Nurse Licensor Megan Zerby, Community ALF/AFH Licensor From: DSHS, Aging and Long-Term Support Administration Lakewood, WA 98496 Statement of Deficiencies License #: 2363 Compliance Determination # 56579 Plan of Correction Riverside Place 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 provide care agreed upon in the service plan (negotiated service agreement [NSA]) for 2 of 5 sampled residents (Resident 3 [R3], and Resident 7 [R7]). This failure placed both residents at risk for unmet care needs by not receiving the care agreed upon in their NSA. Findings included... Record review of the undated facility policy titled “Medication Administration,” stated that the facility RN “must assure the medication service category [was] planned, directed, and supervised by.” Record review of the facility plan of correction, signed 02/14/2025, showed that Staff A, Administrator, attested that the facility would be back in compliance with WAC 388-78A-2160 by 03/08/2025. <Resident 3> Statement of Deficiencies License #: 2363 Compliance Determination # 56579 Plan of Correction Riverside Place Completion Date Record review of the undated resident roster showed that R3 moved in /2024, had a diagnosis of and was receiving hospice services. Record review of R3’s NSA, dated 03/04/2025, showed that R3 required full assistance with showers and staff would assist with showers until the service is provided by hospice. The document also showed that showers are to be conducted on Tuesday mornings and Saturday mornings.

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 . . .