Kenmore Senior Living.

findings of deficient practice. 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 . . . . .

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 November 13, 2024 ELECTRONIC-FACSIMILE Administrator Kenmore Senior Living 7221 NE 182nd St Kenmore, WA 98028 Assisted Living Facility License #2566 Licensee: Pacifica Kenmore LLC IMPOSITION OF CIVIL FINE Dear Administrator: On October 30, 2024, the Department of Social and Health Services (DSHS), Residential Care Services completed a Full Inspection at your facility. This letter constitutes formal notice of a civil fine on the license for your assisted living facility, also known as Kenmore Senior Living, located at 7221 NE 182nd St, Kenmore, by the State of Washington, Department of Social and Health Services. These actions are taken under the authority granted pursuant to Laws of 1998, Chapter 272 and RCW 18.20.190. The civil fine on the license is based on the following violation of the RCW and/or WAC as described in the attached Statement of Deficiencies (SOD) report dated October 30, 2024. Civil Fine WAC 388-78A-2160 Implementation of negotiated service agreement. $700.00 The licensee failed to implement the Negotiated Service Agreement (NSA) for one resident who was prescribed to wear a compression stocking (TED hose) daily. This placed the resident at risk for compromised health. This is a recurring deficiency previously cited on January 11, 2024, August 3, 2023, and May 31, 2023. NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Administrator Kenmore Senior Living License #2566 November 13, 2024 Page 2 Attestation (Plan of Correction): Return the enclosed SOD within 10 calendar days with the following: • The date you have or will have each deficiency corrected. • A signature and date attesting that you are taking actions to correct and maintain correction for each cited deficiency. Return the signed and dated SOD to: Jamie Singer, Field Manager Region 2, Unit J 20311 52nd Avenue West Suite 100 Lynnwood, WA 98036 Phone: (253) 312-1446 / Fax: (206) 971-6791 rcsregion2email@dshs.wa.gov Appeal Rights: You have two appeal rights: Informal Dispute Resolution (IDR) and an Administrative Hearing. Each has a different request timeline. Informal Dispute Resolution [RCW 18.20.195] You have an opportunity to challenge the deficiencies and/or enforcement actions through the state's IDR process. All IDR requests must be in writing and include: • The deficiencies you are disputing; and • The method of review you prefer (face-to-face, telephone conference or documentation review). The written request must be received by the 10th working day from receipt of this letter. During the IDR process, you will have the opportunity to present written and/or oral evidence to dispute the deficiencies. Send your written request to: Informal Dispute Resolution Program Manager Residential Care Services PO Box 45600 Olympia, Washington 98504-5600 Administrator Kenmore Senior Living License #2566 November 13, 2024 Page 3 Formal Administrative Hearing You may contest the civil fine by requesting a formal administrative hearing to challenge the deficiency, which resulted in the civil fine. All hearing requests must be in writing and include: • A copy of this letter; and • A copy of the Statement of Deficiencies. The written request must be received within twenty-eight (28) calendar days of receipt of this letter. Send your written request to: Office of Administrative Hearings PO Box 42489 Olympia, Washington 98504-2489 Payment: If you do not request a formal administrative hearing, the civil fine is due to the Office of Financial Recovery twenty-eight (28) calendar days after receipt of this letter. Mail a check for $700.00 payable to the ‘Department of Social and Health Services’, and if you have or have had a Medicaid resident(s), please include your ProviderOne ID Number # on the check, to: DSHS Office of Financial Recovery PO Box 9501 Olympia, WA 98507-9501 (360) 664-5919 / FAX: (360) 664-8401 OFRMMISVendor@dshs.wa.gov If the Office of Financial Recovery has not received your payment within twenty-eight (28) days after receipt of this letter, interest will begin to accrue immediately on the balance, at the rate of one percent per month. If you do not submit a hearing request or make payment within twenty-eight (28) days, the balance due will be recovered. Administrator Kenmore Senior Living License #2566 November 13, 2024 Page 4 If you have any questions, please contact Jamie Singer, Field Manager, at (253) 312-1446. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 2, Unit J RCS Regional Administrator, Region 2 HCS Regional Administrator, Region 2 DDA Regional Administrator, Region 2 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW SN

allegations and witnessed incidents for four named residents touched by another resident on the memory care unit.. 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 . Investigation Summary Report Provider/Facility: Kenmore Senior Living Provider Type: Assisted Living Facility License/Cert.#: 2566 Compliance Determination #: 28588 Intake ID: 93604 Investigator: Michelle Mcglon Region/Unit #: RCS Region 2 / Unit J Investigation Date(s): 08/24/2023 through 09/07/2023 Complainant Contact Date(s): Allegation(s): 1. The Named Resident (NR) had a fall in their apartment during a power outage at the Assisted Living Facility (ALF), resulting in an injury. Investigation Methods: Sample: Total residents: 84 Resident sample size: 4 Closed records sample size: 0 Observations: Identified resident Resident rooms Residents Interviews: Residents Family members Nursing staff Record Reviews: Resident Records Incident Reports Investigation Summary: 1. Observation, interview, and record review showed the ALF failed to provide emergency lighting in the NR's apartment. This failure may have contributed to the NR's fall and injury. Interview and record review showed the ALF found the resident on the floor and called 911. Observation showed the NR had no emergency lighting in their apartment. In an interview, the Executive Director stated that the ALF were working to place emergency lighting in all resident apartments. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . . Statement of Deficiencies License #: 2566 Compliance Determination # 28588 Plan of Correction Kenmore Senior Living Completion Date Administrator (or Representative) Date WAC 388-78A-2980 Lighting. (1) The assisted living facility must provide emergency lighting in residents units, dining and activity rooms, laundry rooms, and other spaces where residents may be at the time of a power outage. (3) The assisted living facility must provide enough lighting in each resident's room to meet the resident's needs, preferences and choices. This requirement was not met as evidenced by: Based on observations, interviews and record review, the Assisted Living Facility (ALF) failed to provide emergency lighting in individual resident apartments for 2 of 3 sampled residents (Resident 1 and 2). This failure may have contributed to Resident 1 having a fall during a power outage and placed Resident 2 at risk of harm. Findings included… Record review of an undated Face sheet showed the ALF admitted Resident 1 on /2022 with multiple medical diagnoses. Review of a Needs and Services Plan (NSP equivalent to a Negotiated Services Agreement), dated 8/14/2023, showed interventions for Resident 1 included maintaining adequate lighting to and within all restrooms. Record review of an Unusual Incident Report (UIR), dated 08/12/2023 at 9:10 PM, showed the facility had a complete power outage on 8/12/2023. The UIR documented that during that power outage. Resident 1 had a fall while walking to the bathroom. The UIR showed that when Resident 1 was found on the ground she stated, “who turned off the lights I cannot see anything.” The fall resulted in Resident 1 sustaining a laceration (cut) that required emergency medical attention. Record review of an undated Face sheet showed the ALF admitted Resident 2 on /2022 with multiple medical diagnoses. Observation of Resident 1’s apartment with Staff B (Maintenance Director), on 08/24/2023 at 2:18 PM, showed no emergency lighting system was in place. On 08/24/2023 at 3:00 PM, observation of Resident 2’s apartment showed no emergency lighting system was in place. In an interview, on 08/24/2023 at 2:20 PM, Staff B stated that the ALF had renovated some . Statement of Deficiencies License #: 2566 Compliance Determination # 28588 Plan of Correction Kenmore Senior Living Completion Date of the apartments. Staff B stated that during the renovation the emergency light wall plate, that would illuminate during a power outage, was removed from Resident 1 and Resident 2’s apartments. Staff B stated the wall plate had not been replaced and Resident 1 and Resident 2 had no source of emergency lighting. In an interview, on 08/29/2023 at 11:18 AM, Staff A (Executive Director) stated the ALF was working to replace emergency lighting in the residents’ apartments. 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, Kenmore Senior Living 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 (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: . . Pacifica Kenmore LLC Kenmore Senior Living # 2566 05/31/2023 Jamie Singer, Field Manager Region 2, Unit J 20311 52nd Ave W, Suite 100 Lynnwood, WA 98036 • Complete correction(s) within 45 days, or sooner if directed by the Department, after review of your proposed correction dates. • Have your plan approved by the Department. You May: • Receive a letter of enforcement action based on any deficiency listed on the enclosed report. In Addition, You May: • Request an Informal Dispute Resolution (IDR) review within 10 working days after you receive this letter. Your IDR request must include: o What specific deficiency or deficiencies you disagree with; o Why you disagree with each deficiency; and o Whether you want an IDR to occur in-person, by telephone or as a paper review. o Send your request to: IDR Program Manager Department of Social and Health Services Olympia, WA 98504-5600 If You Have Any Questions: • Please contact me at (425)670-6070. Sincerely, Jamie Singer, Field Manager Region 2, Unit J Enclosure . STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20311 52nd Ave W, Suite 100, Lynnwood, WA 98036 Statement of Deficiencies License #: 2566 Compliance Determination # 23609 Plan of Correction Kenmore Senior Living 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 the unannounced on-site full inspection and complaint investigation on 05/01/2023 and 05/04/2023 of: Kenmore Senior Living 7221 NE 182nd St Kenmore, WA 98028 This document references the following complaint numbers: 78253. The following sample was selected for review during the unannounced on-site visit: 20 of 77 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Sunny Kent, Licensor Faith Le, NCI From: DSHS, Aging and Long-Term Support Administration 20311 52nd Ave W, Suite 100 Lynnwood, WA 98036 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 #: 2566 Compliance Determination # 23609 Plan of Correction Kenmore Senior Living Completion Date Administrator (or Representative) Date WAC 388-78A-2305 Food sanitation. The assisted living facility must: (1) Manage food, and maintain any on-site food service facilities in compliance with chapter 246-215 WAC, Food service; This requirement was not met as evidenced by: Based on observation, interview and record review, the Assisted Living Facility (ALF) failed to ensure dairy products stored in 1 of 1 refrigerator on the Memory Care Unit (MCU) and 1 of 1 refrigerator in the Activity Room were unexpired and safe for consumption by vulnerable residents. This placed 10 of 10 MCU residents and 67 ALF residents with access to the activity room at risk for foodborne illness. Findings included… Note: Washington Administrative Code (WAC) 246-215-03526 Temperature and time control—Ready-to-eat, time/temperature control for safety food, date marking (FDA Food Code 3- 501.17) (2) Except as specified in subsections (5) through (7) of this section, refrigerated, ready-to- eat, time/temperature control for safety food prepared and packaged by a food processing plant must be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than twenty-four hours, to indicate the date or day by which the food must be consumed on the premises, sold, or discarded, based on the temperature and time requirements specified in subsection (1) of this section and: (a) The day the original container is opened in the food establishment is counted as day one; and (b) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use- by date based on food safety. Record review of an undated Characteristic Roster showed the ALF provided care and services for 77 residents. Ten of the residents resided on the MCU. MCU Refrigerator Observation during the environmental tour, on 05/01/2023 at 11:15 AM, showed a white refrigerator in the kitchenette area of the MCU. Observation of the contents of the refrigerator showed a can of aerosol whipping cream. The can bore a "best by" date of 12/14/2022. Activity Room Refrigerator . Statement of Deficiencies License #: 2566 Compliance Determination # 23609 Plan of Correction Kenmore Senior Living Completion Date Observation, on 05/01/2023 at 11:35 AM, showed a white refrigerator in the Activity Room. Observation of the contents of the refrigerator showed a container of sour cream. The sour cream bore an expiration date of 12/2022. During an interview, on 05/04/2023 at 3:00 PM with Staff A (Executive Director) and Staff F (Resident Care Director), Staff A stated that there was a routine to check the refrigerators, but the staff assigned to each one was not keeping up with the checks. 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, Kenmore Senior Living 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-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: (8) Medical and nursing services provided by the assisted living facility for a resident, including: (a) A record of providing medication assistance and medication administration, which contains: (i) The medication name, dose, and route of administration; (ii) The time and date of any medication assistance or administration; (iii) The signature or initials of the person providing any medication assistance or administration; and This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure doses of a PRN (as-needed) medication were appropriately documented for 1 of 12 sampled residents (Resident 3). This left Resident 3 as risk of an increase in symptoms from chronic health issues. . Statement of Deficiencies License #: 2566 Compliance Determination # 23609 Plan of Correction Kenmore Senior Living Completion Date Findings included… Record review of a Face Sheet, dated 05/02/2023, showed the facility admitted Resident 3 on /2017 with diagnoses including . Record review of an electronic Medication Administration Record (eMAR) for April of 2023 showed Resident 3's Primary Care Provider (PCP) prescribed a PRN medication to treat excess swelling from fluid accumulation. The fluid accumulation was measured with daily weights. The medication was ordered as, "Take one tablet by mouth once a day as needed if weight is greater than 220 pounds." A review of daily weight measurements showed Resident 3's weight exceeded 220 pounds ten times from 04/18/2023 through 04/30/2023. Review of the eMAR for April 2023 showed no documentation regarding the PRN medication on 04/232023, 04/24/2023, and 04/30/2023. During an interview, on 05/12/2023 at 2:00 PM, with Staff A (Executive Director) and Staff H (Resident Care Director) both stated that they interviewed Medication Technicians (MTs) about the missing documentation for the PRN medication. The MTs explained that after they weighed Resident 3 and realized the PRN medication was required, they could not find Resident 3.

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