Jefferson House Memory Care Community.

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 20425 72nd Avenue S, Suite 400, Kent, WA 98032 Statement of Deficiencies License #: 2548 Compliance Determination # 47076 Plan of Correction Jefferson House Memory Care Community 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 09/06/2024, 09/12/2024 and 09/12/2024 of: Jefferson House Memory Care Community 12217 NE 128th Street Kirkland, WA 98034 This document references the following complaint number(s): 144886 The following sample was selected for review during the unannounced on-site visit: 0 of 36 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Kailash Sharma, ALF 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 #: 2548 Compliance Determination # 47076 Plan of Correction Jefferson House Memory Care Community Completion Date Administrator (or Representative) Date WAC 388-78A-2040 Other requirements. (1) The assisted living facility must comply with all other applicable federal, state, county and municipal statutes, rules, codes and ordinances, including without limitations those that prohibit discrimination. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure 36 of 36 residents (Residents 1 to Resident 36) resided in a safe environment that is approved of by the State Fire Marshal. This failure placed all residents at risk of harm, injury, and potential fire hazards related to unsafe environmental conditions. Findings included… Review of document titled, "Washington State Patrol Fire Protection Bureau", dated 08/20/2024 showed multiple fire safety violations. The document showed the facility failed to meet the required fire safety regulations. During an interview on 09/06/2024 at 11:30 AM, Staff A, Director of Resident Services (DRS), stated that they were aware the facility was out of compliance with the state fire marshal regulations. Staff A stated that the facility worked to correct many of the physical deficiencies initially cited by the fire marshal. During an interview on 09/06/2024 at 12:30 PM Staff B, Maintenance Director stated that they were aware the facility was out of compliance with the state fire marshal regulations. Staff B stated that at the time of the fire marshal’s second inspection on 08/20/2024, they had corrected several of the issues identified in the fire marshal report dated 07/11/2024. Staff B stated that they worked to correct all deficiencies cited in the August 2024 report. Staff B stated that the notified the state fire marshal. 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, Jefferson House Memory Care Community 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. . . Statement of Deficiencies License #: 2548 Compliance Determination # 47076 Plan of Correction Jefferson House Memory Care Community Completion Date Administrator (or Representative) Date .

Conclusion / Action: Ii Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written □ N/A □ . 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 #: 2548 Compliance Determination # 42673 Plan of Correction Jefferson House Memory Care Community 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 05/17/2024, 05/17/2024 and 06/20/2024 of: Jefferson House Memory Care Community 12217 NE 128th Street Kirkland, WA 98034 This document references the following complaint number(s): 130970 The following sample was selected for review during the unannounced on-site visit: 1 of 39 current residents and 1 former residents. The department staff that investigated the Assisted Living Facility: Kailash Sharma, ALF 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. 07/11/2024 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. . ', 11 .2024 08:52:53 State of Washington Statement of Deficiencies License#: 2548 Compliance Determination# 42673 Plan of Correction Jefferson House Memory Care Community Completion Date Jt 71 1011.\ Administrator (or Representative) l\ \ Date WAC 388-78A-2350 Coordination of health care services. (7) When coordinating care or services, the assisted living facility must: (b) Respond appropriately when there are observable or reported changes in the resident's physical, mental, or emotional functioning. WAC 388-78A-2350 Coordination of health care services. (1) The assisted living facility must coordinate services with external health care providers to meet the residents' needs, consistent with the resident's negotiated service agreement. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to notify the physician and resident's representative for 1 of 1 resident (Resident 1) when there was a significant change of condition. This failure place Resident 1 at risk of a decline in their medical condition and a diminished quality of life. Findings included ... Review of the facility's undated policy titled, "Change of Condition", showed that any change in a resident's condition that is observed or suspected by any staff member must be reported to licensed nurse. The Licensed Nurse will ensure appropriate evaluation and follow up take place and will be responsible to notify the resident's family or responsible party and physician. The policy listed changes in resident's condition that needed to be reported included weight gain or loss. Review of Resident 1's records showed the facility admitted Resident 1 in 2023. The records showed an Evergreen Health referral, dated 06/14/2023, listed Resident 1 's weight as 237 pounds (lbs). The records showed on 07/21/2023, the facility recorded Resident 1 's weight as 227 lbs. Review of the aftervisit summary records, 08/03/2023, showed Resident 1' s weight as 220 lbs on 08/01/2023, 209 lbs on 08/02/2023, and 208 lbs on 08/03/2023. Review of the Evergreen Health physician after visit summary, dated 09/14/2023, showed Resident 1's weight as 197 lbs. Review of Resident 1's Medication Administration Records (MARs) showed Resident 1's weight ranged between 197 to 193 lbs in October2023; 195 to 185 in November 2023; 185 to 177 in December 2023; 176 to 165 in January 2024; and 165 to 164 in February 2024. There was no documentation that showed the facility provided weight updates to the physician or resident representative, as required. The records showed that the facility did not notify the physician of any weight loss until February 13, 2024. . '.11.2024 08:52:53 State of Washington Statement of Defipiencies License#: 2548 Compliance Determination # 42673 Plan of Correction Jefferson House Memory Care Community Completion Date During an interview on 03/19/2024 at 4:45 PM, Staff A, Regional Director of Operations, stated that they believed Resident 1 's weight loss was related io the diuretic medication (medication that increases production of urine) taken daily by Resident 1. Staff A stated that they did not work at the facility during the time of Resident 1 's weight loss and were unable to explain why no one notified the physician or family of Resident 1 's change of condition. During an interview on 05/10/2024 at 2:00PM, Collateral Contact 1 (CC 1, resident representative) stated that the physician informed CC1 that the facility did not notify them of Resident 1's weight loss. CC1 stated that the facility never informed them of Resident 1's weight loss. 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, Jefferson House Memory Care 1·s?f Community w~ be in compliance. with this law and/ or regulation on (Date) 8' 11£4'2.~ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. ··································· \ b. ........................•... .... ...... 1\11\ 2912-~L Administrator~resentative) Date .

Statement of Deficiencies License #: 2548 Compliance Determination # 42612 Plan of Correction Jefferson House Memory Care Community 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 on 06/12/2024 and 06/18/2024 of: Jefferson House Memory Care Community 12217 NE 128th Street Kirkland, WA 98034 The following sample was selected for review during the unannounced on-site visit: 7 of 39 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Claudia Allis, Community Complaint Investigator Jane Hermano, NCI 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. . '.03.2024 08:09:34 State of Hash in gton 9, StritHmt:-nt .;rf Def1d-s::nGie s Pian ,:}f Corn:t{·. . tion Pag:a: 2 of '13 WAC 388~78A-2420 Recoro re:te11tion. {';) The ar;;£h~~tcd frvinf! tat:jW.'/ n1ust rnaintain on th~- 2.1ss~rted ~ivi.ng facfity-prerniu.es in a res~lient1s , ~ ~ : . ,r ._ -- , t , ~ } v , ·,,~ . . 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' t , / ; J ,A ,. , - ~ ~ ., , •. 1 . ' 1 .. ; . , f t ,. h ,, , - g ..~ . · l f, t ·; ·· I '~ .,- ~ ,} - ,, · ~ "J ,_ /i ,: : ; , > ur , 1 ~ ,1 ~ <" - : : i ,; U t~ ti - ~. , j l , .. · > t - ( _ 'l .•1, tl'·' , . s : . ~ ..• } •} '\ ~ t, ~ 1 ~- ·1 . f - t . . . ... . .. ,\ ,~ > il 1 p· , µ . . c r · • ~ : - d - ~' ~ ( - o -~ ' ' t " t - . \ f . ° , " , : , 1 ~ ,~ - c ~ - , .. ~ ._ ~ .__ r ; - ,, 1 rit l ' . A ,... : . - : - •- i i : : · . -·· \ , / , l , l f ·1 l ~ e - . 1 t , b , · . J : ,• ~ , - _ : , · c ;: , ; 1 : _ .: ; ~ ;, i . · , , l ! '' l - ' .. l F?esid~nt He:a:3thcare:- F~t::conJ': s~wv•..ied tf13t th-?. racm~~1 hi::pt tfl:B i3st three 1T1cnth2 rn~cfo::.ation t~cknit1l~;;tratk1n reGtJnis (M,t-...Rg} vith the ~k:nns~d t1tffr;e s~911~tun~ J~ag~ in the r~sldent-s-~ h~.t~§thc.t~r-e t"t::c::orJ. The docurnent -shovw:d that ntd i'-AA.Hs, thrt:f.? rnonths or c:if:der, ~.\t~:ffe ia.a-ged er n1Ht.ov~:d fro_n-~ the resc~c:nts:· re(~orj. 11~e reskfonfs purned hea!~h r(:conls VVfl'e filed lnto a tile t1nx ln r1lphat1c.:tict.1l ord1;::r. The~- docw--r1:ent sht.1:V\l~?d th1:. Wes t,·vere r1:.,~ta~ned on:. ... -s~te fDr -ut ~t~;~:st Owe~ years tD :3:HO\·V th~~ fadli~,/ stHff to act8ss ~frsto.rkai rnedic.aI infnnnation V\1fn€ ne0dBd. f~~vievv o-f the- fnci~iti./·s Chnr~dsristi-c,s. F<-oster .s.hovved th.at-~ 6 res~dBnts resid.e:::i .on the third fbor of n tht~ fstiM)l. Th:e r-::.1:-stef si'H)V'-fod that 1 resickH1ts r~Geiv~{t n1~di:eatinn t:~drnfnistration t-itss.i~tKH'lCf~ frrn-r1 fo ciiiiy staff Db-ser,..,;afr:~n in HH.:· corrnnon din~ng art a on 0(}:/"~ 3/2Qj"'4 betv11·een 10: 1! ) A:M and ·HJ: 3f3 Atvl stwvved i Staff I=· Ucensed r::-~ractk:31 f'!urse. ass~sted .an(i Bdn1~nis:tare-d rn~r.fa::atkms t:J: f•}LH' res~c§ents:. t-\frer et.Kh :rer;rzh~nt rrmdK<~Uon ~~drninistratll:1n ilsf;istanc~ prnvidtNJ, Sli~1ff ii dt.H::twnenti::d t.h~l 2~ainn in t1acl'l re-st=t!2:nt's f,1Af~. 1 Fh:vi'03h' of the fru:.f~ity-~s rnedlc~:1tinn reo)rds sh,}\•ved cnly th~ Ma'/ 2024 and ,.hin0. 2024 M.4F<s ~-'\ere 1 a\/ait:~bk:·. 'Thetf: \:'\ff.:re nn Gther-· rvtAF?½ ff•/~iilaMe for tile tnontt1s f$rior t~:i M-ilY 2U24. Dttr~nn an inh~tv~Ev-.r nn 06/-17"/2024 ~~t i: 12 PM Staff 8 .. ~tat:ed th~y V-l~re unable tn find the .Apr~! 2{)2.l\ 1 M,D,l:Zs for· any .of the re--sidents. on th~n1 fh:.ior. Stt:ff E.{ state-ti that the .April 2024 M.Af~s for rf:~hJe.nts nn t::e:::c~nd nno.r \iV>~~f>:S ~~vai.h~bte~. Slaff 8 8tat~d th(~t they \,\tY;r& unsu!· € v-lrry the thir.d-.flo-t1r tfi ::s:idents1 l;p~H 2024 M·Af.Zs. vver.:€ fK!-t in th.:~ res~d.ents' n~{'.;ords. Plan/A ttest<1tlon Statement . Statement of Deficiencies License #: 2548 Compliance Determination # 42612 Plan of Correction Jefferson House Memory Care Community Completion Date Administrator (or Representative) Date WAC 388-78A-2420 Record retention. (1) The assisted living facility must maintain on the assisted living facility premises in a resident's active record(s) all relevant information and documentation necessary for meeting a resident's current assessed needs. This requirement was not met as evidenced by: Based on observation, interview, and record review the facility failed to retain resident’s medication administration record for 16 of 16 residents (Resident 1 through Resident 16). This placed these 16 residents at risk for health complications due to unknown medication management history. Findings included… Review of the facility’s undated document, titled “Resident Care Services – What to Keep in a Resident Healthcare Record”, showed that the facility kept the last three months medication administration records (MARs) with the licensed nurse signature page in the residents’ healthcare record. The document showed that old MARs, three months or older, were purged or removed from the residents’ record. The resident’s purged health records were filed into a file box in alphabetical order. The document showed the files were retained on-site for at least three years to allow the facility staff to access historical medical information when needed. Review of the facility’s Characteristics Roster showed that 16 residents resided on the third floor of the facility. The roster showed that 16 residents received medication administration assistance from facility staff. Observation in the common dining area on 06/13/2024 between 10:15 AM and 10:36 AM, showed Staff I, Licensed Practical Nurse, assisted and administered medications to four residents. After each resident medication administration assistance provided, Staff I documented the action in each resident’s MAR. Review of the facility’s medication records showed only the May 2024 and June 2024 MARs were available. There were no other MARs available for the months prior to May 2024. During an interview on 06/17/2024 at 1:12 PM, Staff B, stated they were unable to find the April 2024 MARs for any of the residents on third floor. Staff B stated that the April 2024 MARs for residents on second floor were available.

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