Guardian Angel Homes Liberty Lake.

Statement of Deficiencies License #: 2035 Compliance Determination # 68143 Plan of Correction GUARDIAN ANGEL HOMES LIBERTY LAKE Completion Date CO LLC 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-2950 Water supply. The assisted living facility must: (5) Provide hot and cold water under adequate pressure readily available throughout the assisted living facility; (6) Provide all sinks in resident rooms, toilet rooms and bathrooms, and bathing fixtures used by residents with hot water between 105 F and 120 F at all times; and This requirement was not met as evidenced by: Based on observation, interview and record review, the facility failed to maintain water temperatures between 105 degrees Fahrenheit and 120 degrees Fahrenheit for 1 of 9 residents (Resident 7), and in 2 of 5 buildings (Cottage and Craftsman memory care buildings). The facility failed to ensure kitchenette water was supplied to 1 of 9 residents (Resident 3 ). These failures resulted in water temperatures that ranged outside of requirements and placed the residents at risk for skin injury and a decreased quality of life. Findings included… < Resident 7> Review of Resident 7’s Service Plan Report (the facility’s titled negotiated service agreement), dated 05/28/2025, showed that the resident was incontinent of urine and stool. Further review showed that Resident 7 required daily showers using a Hoyer Lift (a large mechanical device used to safely lift and transfer people with limited mobility). Review of Resident 7’s face sheet, dated 10/31/2025, showed the resident was diagnosed with . . Statement of Deficiencies License #: 2035 Compliance Determination # 68143 Plan of Correction GUARDIAN ANGEL HOMES LIBERTY LAKE Completion Date CO LLC purchased. <Resident 3 > Observation on 11/03/2025 at 10:00 AM showed that the kitchenette faucet in Resident 3’s room did not work. In an interview at that time, Resident 3 stated they notified maintenance last week about their faucet constantly dripping. Resident 3 further stated that maintenance turned the water supply off to their sink and they had not heard back from them on when the faucet would be repaired. 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, GUARDIAN ANGEL HOMES LIBERTY LAKE 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-2210 Medication services. (1) An assisted living facility providing medication service, either directly or indirectly, must: (b) Develop and implement systems that support and promote safe medication service for each resident. (2) The assisted living facility must ensure the following residents receive their medications as prescribed, except as provided for in WAC 388-78A-2230 and 388-78A-2250 : (a) Each resident who requires medication assistance and his or her negotiated service agreement indicates the assisted living facility will provide medication assistance; and This requirement was not met as evidenced by: Based on observation, interview and record review, the facility failed to administer the correct medication to 1 of 10 sampled residents (Resident 9). This failure resulted in Resident 9 receiving the wrong medication and placed them at risk of health complications. Findings included… . . Statement of Deficiencies License #: 2035 Compliance Determination # 68143 Plan of Correction GUARDIAN ANGEL HOMES LIBERTY LAKE Completion Date CO LLC inhaler, not fluticasone-propionate nasal spray, Staff I indicated that they were unaware that it was the wrong medication. Review of the medication policy titled Guidelines for Medication, dated 2008, showed that facility staff were to follow the listed steps when they administered the medications: a. Check name of resident. b. Match with medication on card/bottle. c. Read orders on MAR. d. Read orders on card/bottle. e. Assist resident as directed per MAR. This is a recurring deficiency previously cited on 02/29/2024 for subsections (1)(b)(2) and 03/30/2023 for subsections (2)(a). 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, GUARDIAN ANGEL HOMES LIBERTY LAKE 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-2240 Nonavailability of medications. When the assisted living facility has assumed responsibility for obtaining a resident's prescribed medications, the assisted living facility must obtain them in a correct and timely manner. This requirement was not met as evidenced by: Based on observation, interview and record review, the facility failed to obtain medication in a timely manner for 1 of 10 sampled residents (Resident 9). This failure resulted in missed medication and placed the resident at risk of health complications due to not receiving their scheduled medication. Findings included… . . Statement of Deficiencies License #: 2035 Compliance Determination # 68143 Plan of Correction GUARDIAN ANGEL HOMES LIBERTY LAKE Completion Date CO LLC This is a recurring deficiency previously cited on 02/29/2024 . 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, GUARDIAN ANGEL HOMES LIBERTY LAKE 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-2484 Tuberculosis Two step skin testing. Unless the staff person meets the requirement for having no skin testing or only one test, the assisted living facility choosing to do skin testing, must ensure that each staff person has the following two-step skin testing: (2) A second test done one to three weeks after the first test. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure tuberculosis test results were read within 48 to 72 hours for 2 of 3 staff (Staff A and C). This failure placed residents at risk for exposure to a communicable disease. Findings included... Review of personnel records for Staff A, Medication Technician (MT)/Caregiver, showed a hire date of 02/03/2025. Further review showed that the first step Tuberculosis (TB, a respiratory illness caused by a bacterial infection) test was initiated on 02/03/2025, but the record showed no documentation of the TB test results. Review of personnel records for Staff C, MT/Caregiver, showed a hire date of 09/30/2024. Further review showed that Staff J’s second TB test was initiated on 10/14/2024, and that the results were not read. In an interview on 11/03/2025 at 12:32 PM, Staff K, Business Office Manager, stated that they had some issues with completing TB testing on time and that Staff A and C’s tests were not completed on time. . . Statement of Deficiencies License #: 2035 Compliance Determination # 68143 Plan of Correction GUARDIAN ANGEL HOMES LIBERTY LAKE Completion Date CO LLC 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, GUARDIAN ANGEL HOMES LIBERTY LAKE 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 facility failed to ensure a chest x-ray was completed within seven days after a positive tuberculosis test as required for 1 of 1 staff (Staff A). This failure placed residents at risk for exposure to a communicable disease. Findings included... Review of personnel records for Staff A, Medication Technician/Caregiver, showed a hire date of 02/03/2025.

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 8517 E Trent Ave, Ste 102, Spokane Valley, WA 99212 Statement of Deficiencies License #: 2035 Compliance Determination # 57650 Plan of Correction GUARDIAN ANGEL HOMES LIBERTY LAKE Completion Date CO LLC 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 04/08/2025 of: GUARDIAN ANGEL HOMES LIBERTY LAKE 23102 E MISSION AVE LIBERTY LAKE, WA 99019 This document references the following complaint number(s): 172764 The following sample was selected for review during the unannounced on-site visit: 3 of 76 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Amy Wright, NCI Complain Investigator From: DSHS, Aging and Long-Term Support Administration 8517 E Trent Ave, Ste 102 Spokane Valley, WA 99212 . Statement of Deficiencies License #: 2035 Compliance Determination # 57650 Plan of Correction GUARDIAN ANGEL HOMES LIBERTY LAKE Completion Date CO LLC 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-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: (b) The plan to provide assistance with activities of daily living, if provided by the assisted living facility; This requirement was not met as evidenced by: Based on interview and record review, the facility failed to clearly document in the resident’s negotiated service agreement the plan to assist the resident with transferring from one surface to another for one of three residents (Resident 1). This failed practice resulted in injuries, discomfort, a hospital trip, and medication changes for Resident 1. Findings included… Review of an undated current Negotiated Service Agreement (NSA, competed prior to 03/24/2025) for Resident 1 showed that the resident was to remain bedbound until they were assessed by physical therapy for safe transfers. Further review of the NSA showed that staff were to transfer the resident by pivoting them. The NSA did not indicate how many staff were required to safely transfer Resident 1 or if a gait belt was required. Review of a facility investigation, dated 03/24/2025, showed that swelling to Resident 1’s left axilla (armpit) was noted on 03/23/2025, and extensive bruising to the area was noted on 03/24/2025. Further review of the investigation showed that Resident 1’s bruising extended from their axilla to their inner elbow. The investigation showed that the area of swelling was tender when touched. The investigated cause of injury was . Statement of Deficiencies License #: 2035 Compliance Determination # 57650 Plan of Correction GUARDIAN ANGEL HOMES LIBERTY LAKE Completion Date CO LLC suspected from improper transferring. In an interview on 04/08/2025 at 10:36 AM, Staff A, Registered Nurse, stated they determined Resident 1’s injuries were caused by improper transfers by Staff B and Staff C, Medication Technicians, who had transferred Resident 1 improperly. Staff A stated that Staff B and Staff C transferred Resident 1 alone, without the use of a gait belt. Staff A stated that gait belts were required for resident transfers. Staff A stated that Staff B and Staff C were transferring Resident 1 by pulling up on the resident’s underarms and the waistband of the resident’s pants. Staff A stated they had updated the NSA prior to Resident 1’s injuries (bruising), their NSA required the assistance of two staff with transfers due to the non-weight bearing status of the resident’s left leg. Staff A stated that Resident 1 was sent out to the hospital via ambulance because their primary care provider wanted to rule out a blood clot in the area of the resident’s bruising. Staff A stated that the physician at the hospital ordered Resident 1 to stop their blood thinner medication for four days. Continued review of the undated current NSA showed no update of Resident 1's transfer status of a two person assist due to non-weight bearing. 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, GUARDIAN ANGEL HOMES LIBERTY LAKE 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 . . STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 8517 E Trent Ave, Ste 102, Spokane Valley, WA 99212 Statement of Deficiencies License #: 2035 Compliance Determination # 52055 Plan of Correction GUARDIAN ANGEL HOMES LIBERTY LAKE Completion Date CO LLC 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 12/24/2024 and 12/24/2024 of: GUARDIAN ANGEL HOMES LIBERTY LAKE 23102 E MISSION AVE LIBERTY LAKE, WA 99019 This document references the following complaint number(s): 158859 The following sample was selected for review during the unannounced on-site visit: 6 of 78 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Veronica Jackson, Assisted Living Facility Licensor From: DSHS, Aging and Long-Term Support Administration 8517 E Trent Ave, Ste 102 Spokane Valley, WA 99212 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 #: 2035 Compliance Determination # 52055 Plan of Correction GUARDIAN ANGEL HOMES LIBERTY LAKE Completion Date CO LLC 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 obtain a medical testing site waiver license to perform on-site covid 19 testing for 6 of 6 residents (Resident 1, 2, 3, 4, 5, and 6). Due to this failure, the facility performed covid 19 testing for six residents without oversite which placed the residents at risk of receiving inaccurate test results. Findings included… Review of a Department of Social and Health Services provider letter dated 11/15/2024, showed that certain types of medical testing require a state Medical Test Site Waiver (MTSW) license. One type of activity requiring a MTSW license is rapid testing for covid 19 (a contagious respiratory virus) for a resident. Per Department of Health WAC 246-338 Medical Test Site Rules, under sections 246-338-001 through 246-338-020, facilities that performed on-site medical tests were required to obtain a test waiver for tests that may indicate medical treatment and were required to follow chapter 70.42 RCW Medical Test Sites. Review of RCW 70.42 Medical Test Sites, showed it was established to regulate licensing standards for medical test sites, consistent with federal law and regulation, related to quality control, quality assurance, records, personnel requirements, proficiency testing, and licensure waivers. Review of the Department of Health online database as of 12/24/2024, showed the facility did not have a MTSW license. Review of the facility’s Resident Characteristic Roster dated 12/24/2024, stated that Resident’s 1, 2, 3, 4, 5, and 6 were residents who resided in the Bungalow unit. In an interview on 12/24/2024 at 11:45 AM, Staff B, Licensed Practical Nurse, stated that the facility had completed rapid covid 19 testing residents that resulted in positive results for Resident’s 1, 2, 3, 4, 5, and 6. Staff B, further stated that those results were communicated to the resident’s medical providers who then ordered Paxlovid (antiviral . . Statement of Deficiencies License #: 2035 Compliance Determination # 52055 Plan of Correction GUARDIAN ANGEL HOMES LIBERTY LAKE Completion Date CO LLC medication) for the residents based on those test results. In an interview on 12/30/2024 at 1:35 PM, Staff A, Administrator, stated that they were aware of the exemption during the covid 19 pandemic where license renewals had been waived, and they had not been aware that the exemption had been lifted, and that the medical test site waiver licenses were required again. Review of Resident 1’s Medication Administration Record (MAR) dated December 2024 showed an order for Paxlovid (antiviral medication to treat Covid 19) to be administered on 12/12/2024 through 12/18/2024. Review of Resident 2’s facility nursing notes dated 12/13/2024 at 5:24 AM showed that Resident 2 had tested positive for Covid 19, charted by Staff D, Caregiver. Review of Resident 3’s MAR dated December 2024 showed an order for Paxlovid to be administered on 12/13/2024 through 12/17/2024. Review of Resident 4’s MAR dated December 2024 showed an order for Paxlovid to be administered on 12/14/2024 through 12/17/2024. Review of Resident 5’s facility nursing notes dated 12/13/2024 showed that Resident 5 had tested positive for Covid 19, charted by Staff D. Review of Resident 6’s facility nursing notes dated 12/12/2024 showed that Resident 6 had tested positive for Covid 19, charted by Staff D. 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, GUARDIAN ANGEL HOMES LIBERTY LAKE 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 .

This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website.

Corrective Action form Staff safety training documentation Investigation Summary: The facility investigated the alleged abuse and determined that the Alleged Victim was not provided care consistent with their preferences. Review of staff records showed that the Alleged Perpetrator had not met training requirements prior to caring for residents. Failed facility practice was cited under WAC 388-78A-2510 Specialized training for dementia, and WAC 388-78A-2660 Resident Rights. 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 8517 E Trent Ave, Ste 102, Spokane Valley, WA 99212 Statement of Deficiencies License #: 2035 Compliance Determination # 30613 Plan of Correction GUARDIAN ANGEL HOMES LIBERTY LAKE 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 10/06/2023, 10/06/2023 and 10/06/2023 of: GUARDIAN ANGEL HOMES LIBERTY LAKE 23102 E MISSION AVE LIBERTY LAKE, WA 99019 This document references the following complaint number(s): 100884, 99357, 98530 The following sample was selected for review during the unannounced on-site visit: 3 of 75 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Amy Wright, NCI Complain Investigator From: DSHS, Aging and Long-Term Support Administration 8517 E Trent Ave, Ste 102 Spokane Valley, WA 99212 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 #: 2035 Compliance Determination # 30613 Plan of Correction GUARDIAN ANGEL HOMES LIBERTY LAKE Completion Date Administrator (or Representative) Date WAC 388-78A-2510 Specialized training for dementia. The assisted living facility must ensure completion of specialized training, consistent with chapter 388-112A WAC, to serve residents with dementia, whenever at least one of the residents in the assisted living facility has a dementia that is the resident's primary special need and has symptoms consistent with dementia as assessed per WAC 388-78A-2090 (7). This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure that staff completed required specialty training prior to caring for residents with dementia for 1 of 1 staff (Staff B) reviewed for dementia training. This failure placed residents diagnosed with at risk for inadequate care by untrained staff. Findings included… Review of a facility characteristic roster, dated 10/09/2023, showed that all 13 residents residing in the Bungalow, a memory care house, were diagnosed with or . In an interview on 10/06/2023 at 10:40 AM, Staff A, Executive Director, stated that Staff B, Caregiver, usually worked in the memory care. In an interview on 12/15/2023 at 10:52 AM, Staff A stated they were unsure if Staff B completed their specialty dementia training. In an interview on 12/18/2023 at 1:37 PM, Staff A stated they had no documentation of dementia training for Staff B. No documentation of specialty dementia training was provided for Staff B. Plan/Attestation Statement . Statement of Deficiencies License #: 2035 Compliance Determination # 30613 Plan of Correction GUARDIAN ANGEL HOMES LIBERTY LAKE Completion Date 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, GUARDIAN ANGEL HOMES LIBERTY LAKE 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-2660 Resident rights. The assisted living facility must: (1) Comply with chapter 70.129 RCW, Long-term care resident rights; (2) Ensure all staff persons provide care and services to each resident consistent with chapter 70.129 RCW; This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure that staff provided care consistent with maintaining resident dignity for 1 of 1 resident (Resident 1). This failure resulted in pain and discomfort for the resident. Findings included: A care plan for Resident 1, dated 08/31/2023, showed they preferred that staff allow them to turn themselves when in bed. The care plan stated that it caused Resident 1 pain when staff turned them. Review of a facility investigation, dated 09/17/2023, showed that during the night shift beginning on 09/16/2023 and ending on 09/17/2023 at 6:10 AM, Staff B, Caregiver, assisted Resident 1 with turning. The investigation showed that Resident 1 complained of pain during the care, asked Staff B to stop, and Staff B did not stop. The investigation showed that a skin assessment revealed two fingertip sized bruises on the top of Resident 1’s right thigh. It was documented that Staff C, Licensed Practical Nurse, thought the bruises were likely the result of being turned by Staff B. In a verbal statement provided by Staff B on 09/18/2023, they stated Resident 1 told them they were hurting them during the care. In a verbal statement provided by Resident 1 on 09/17/2023, they stated they didn’t want Staff B in their room because they were afraid of Staff B. . Statement of Deficiencies License #: 2035 Compliance Determination # 30613 Plan of Correction GUARDIAN ANGEL HOMES LIBERTY LAKE Completion Date In an interview on 10/06/2023 at 11:59 AM, Resident 1 stated they had not felt safe with Staff B providing their care because Staff B was rough, forceful, and caused them pain and bruising. 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, GUARDIAN ANGEL HOMES LIBERTY LAKE 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 .