Lynden Manor.

citation and first aid; and (e) Continuing education. . The Department staff who did the On Site verification: Melissa Phillips, Long Term Care Surveyor Cristina Gonzalez, Nursing Consultant Institutional Allison Nunn, Long Term Care Surveyor If you have any questions, please contact me at (253)312-1446. Sincerely, Jamie Singer, Field Manager Region 2, Unit J . 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 #: 2641 Compliance Determination # 69681 Plan of Correction Lynden Manor 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 12/05/2025 of: Lynden Manor 905 Aaron Dr Lynden, WA 98264 This document references the following SOD dated: 12/16/2025 The following sample was selected for review during the unannounced on-site visit: 14 of 87 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Melissa Phillips, Long Term Care Surveyor Cristina Gonzalez, Nursing Consultant Institutional Allison Nunn, Long Term Care Surveyor From: DSHS, Aging and Long-Term Support Administration 20311 52nd Ave W, Suite 100 Lynnwood, WA 98036 . Statement of Deficiencies License #: 2641 Compliance Determination # 69681 Plan of Correction Lynden Manor 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-2700 Emergency and disaster preparedness. (1) The assisted living facility must: (a) Maintain the premises free of hazards; This requirement was not met as evidenced by: Based on observation, record review and interview, the Assisted Living Facility (ALF) failed to ensure hazardous items were inaccessible to residents in 1 of 1 Memory Care Units (MCU). This failure placed residents with dementia at risk for accessing and ingesting potentially harmful substances. Findings included… Record review of an undated Resident Characteristic Roster showed the ALF provided care and services to 30 residents in their locked MCU, all 30 of whom were identified as having a diagnosis of or , or . An observation, on 12/05/2025 at 12:30 PM, in unlocked resident room 128, showed two bottles of calcium carbonate (a medication used for quick relief of heartburn and upset stomach), a bottle of ActivICE (a medicated cream used to relieve pain), a tube of butenafine hydrochloride cream (a medicated cream used to treat fungal infections such as Athlete’s foot), a bottle of eczema relief hand cream (a cream used to provide comfort from itchy, dry, irritated skin caused by the skin condition eczema) in an unlocked bathroom cabinet. Each item had a warning label that stated, “if swallowed, get medical help or contact a Poison Control Center right away.” An observation, on 12/05/2025 at 12:39 PM, in unlocked resident room 113, showed a bottle of hydrogen peroxide solution (a first aid anti-septic), a tube of hydrocortisone cream (a medicated cream used to relieve itchy skin), and witch hazel hemorrhoidal . Statement of Deficiencies License #: 2641 Compliance Determination # 69681 Plan of Correction Lynden Manor Completion Date pads (pads used to relieve symptoms caused by inflamed veins in the anus) in an unlocked bathroom cabinet. Each item had a warning label that stated, “if swallowed, get medical help or contact a Poison Control Center right away”. An observation, on 12/05/2025 at 12:43 PM, in unlocked resident room 107, showed three boxes of denture cleanser tablets with a warning label that stated “This product contains persulfates, which are a known allergen. In case of accidental ingestion, seek professional assistance or contact the Poison Control Center immediately at 1-800-222-1222” and a bottle of zinc oxide paste (a medicated cream used to help protect the skin) with a warning label that stated, “In case of accidental ingestion, get medical help or contact a Poison Control Center right away" on the bathroom counter. In an interview, on 12/05/2025 at 1:50 PM, Staff B, Caregiver, stated that the resident rooms mostly stay locked and that the staff are supposed to go into the rooms several times a day to ensure there are no safety hazards present. This is an uncorrected deficiency previously cited on 10/10/2025. 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, Lynden Manor 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-2474 Training and home care aide certification requirements. (2) The assisted living facility must ensure all assisted living facility administrators, or their designees, and caregivers hired on or after January 7, 2012 meet the long-term care worker training requirements of chapter 388-112A WAC, including but not limited to: (b) Basic; (c) Specialty for dementia, mental illness and/or developmental disabilities when serving residents with any of those primary special needs; (d) Cardiopulmonary resuscitation and first aid; and (e) Continuing education. . Statement of Deficiencies License #: 2641 Compliance Determination # 69681 Plan of Correction Lynden Manor Completion Date This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure 4 of 9 staff members (Staff B, F, G, and J) met the long-term care workers training requirements under Washington Administrative Code (WAC) 388-112A. This placed residents in the ALF at risk of not receiving proper care and services from staff members. Findings included…. NOTE: Washington Administrative Code (WAC) 388-78A-2450 Staff. (3) The assisted living facility must: (d) Maintain the following documentation on the assisted living facility premises, during employment, and at least two years following termination of employment: (i) Staff orientation and training or certification pertinent to duties, including, but not limited to: (A) Training required by chapter 388-112A WAC; (C) Cardiopulmonary resuscitation; (D) First aid; BASIC TRAINING NOTE: WAC 388-112A-0080 Who is required to complete the seventy-hour long-term care worker basic training and by when? (5) Long-term care workers in assisted living facilities within one hundred twenty days of their date of hire. Long-term care workers must not provide personal care without direct supervision until they have completed the seventy-hour long-term care worker basic training. Review of staff records showed the ALF hired Staff B, Caregiver, on 05/21/2025. Staff B had no record of basic training as of 198 days after their date of hire. In an interview, on 10/02/2025 at 12:11 PM, Staff A, Business Office Manager, stated that Staff B was still currently in the process of completing their basic training. CARDIOPULMONARY RESUSCITATION (CPR) AND FIRST AID CARD NOTE: WAC 388-112A-0720 What are the CPR and first-aid training requirements? (2) Assisted living facilities. (a) Assisted living facility administrators who provide direct care and long-term care workers must have and maintain a valid CPR and first-aid card or certificate within thirty days of their date of hire. NOTE: WAC 388-112A-0710 What is CPR/first-aid training? CPR/first-aid training is training that meets the guidelines established by the Occupational Safety and Health Administration (OSHA). Under OSHA guidelines, training must include hands-on skills development through the use of mannequins or trainee partners. . Statement of Deficiencies License #: 2641 Compliance Determination # 69681 Plan of Correction Lynden Manor Completion Date Review of staff records showed that the ALF hired Staff F, Caregiver, on 08/18/2025. Staff F did not have CPR or first aid training on file, as of 109 days after their date of hire. Review of staff records showed that the ALF hired Staff G, Caregiver, on 07/18/2023. Staff G did not have current first aid training on file. Review of staff records showed that the ALF hired Staff J, Caregiver, on 09/13/2025. Staff J did not have hands-on CPR or first aid training on file, as of 83 days after their date of hire. --- Findings included… Record Review of an undated face sheet showed the ALF admitted Resident 4 on /2025 with multiple diagnoses including and . . Statement of Deficiencies License #: 2641 Compliance Determination # 69718 Plan of Correction Lynden Manor Completion Date Record review of a Negotiated Service Agreement, dated 11/09/2025, showed Resident 4 was to receive assistance with medication administration. Record review of Physician Orders, dated 09/04/2025, showed Resident 4 was to receive a sliding scale dose of Humalog (Lispro) insulin (a medication used to lower blood sugar) based on their blood sugar level at bedtime. Review of Resident 4’s Medication Administration Record (MAR) dated 11/27/2025 at 8:00 PM, showed Resident 4’s blood sugar was unchecked, and their Humalog insulin injection was not given to Resident 4. Record review found no documentation as to why Resident 4’s blood sugar was not checked and insulin was not given on 11/27/2025. Review of a Progress Note (PN), dated 11/28/2025 at 7:23 AM, showed that Resident 4 received the following medications that belonged to another resident in error: celecoxib 50 mg (milligram) for pain and inflammation, duloxetine HCL (hydrochloride) 60 mg for depression, ferrous sulfate 325 mg for iron supplement, lisinopril 5 mg for high blood pressure, magnesium oxide 400 mg for dietary supplement, metformin HCL 500 mg for Type 2 diabetes, metoprolol 50 mg for high blood pressure, potassium chloride ER (extended-release) 10 MEQ (milliequivalent) for low potassium, vitamin D3 1,000 unit for supplement, pregabalin 50 mg for nerve pain and pramipexole 0.125 mg for restless legs syndrome. Review of a PN, dated 11/28/2025 at 5:49 PM, showed Resident 4 was complaining of nausea, sleepiness and had refused a meal. Interview, on 12/09/2025 at 2:19 PM, Staff A (Executive Director) stated that the two Medication Technicians (MT) had not followed the medication services policies. Staff A stated that one MTs was dispensing medications, while the second MT was delivering those dispensed medications. This resulted in Resident 4 receiving medications belonging to another resident. This was an uncorrected previously cited on 10/06/2025 and a recurring deficiency previously cited on 04/20/2023, 05/02/2024, 06/20/2024, and 06/09/2025. . Statement of Deficiencies License #: 2641 Compliance Determination # 69718 Plan of Correction Lynden Manor Completion Date 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, Lynden Manor 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 . Investigation Summary Report Provider/Facility: Lynden Manor Provider Type: Assisted Living Facility License/Cert.#: 2641 Compliance Determination #: 66299 Intake ID: 196304 Investigator: Helen Fisher Region/Unit #: RCS Region 2 / Unit J Investigation Date(s): 09/30/2025 through 10/06/2025 Complainant Contact D

Conclusion / Action: I&] Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written □ N/A □ . ST ATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEAL TH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 3906-172nd St NE, Suite #100, Arlington, WA 98223 Statement of Deficiencies License #: 2641 Compliance Determination# 61907 Plan of Correction Lynden Manor 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 07/02/2025 of: Lynden Manor 905 Aaron Dr Lynden, WA 98264 This document references the following complaint number(s): 184195 The following sample was selected for review during the unannounced on-site visit: 3 of 93 current residents and O former residents. The department staff that investigated the Assisted Living Facility: Helen Fisher, Complaint Investigator From: DSHS, Aging and Long-Term Support Administration 3906-172nd St NE, Suite #100 Arlington, WA 98223 . 07.22.2025 12:00:57 State of Washington 6/ Statement of Deficiencies License #: 2641 Compliance Determination# 61907 Plan of Correction Lynden Manor 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. Date I understand that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and reg1,.1lations at all times. Date WAC 388-78A-3090 Maintenance and housekeeping. {1) The assisted living facility must: (a) Provide a safe, sanitary and well-maintained environment for residents; This. requirement was not met as evidenced by: Based on observations. interviews, and record reviews, the Assisted Living Facility (ALF) failed to ensure a system was in place to maintain the cleanliness of 1 of 3 resident's (Resident 1's) rooms. This failure resulted in Resident 1 ·s room being unclean and unsanitary and placed Resident 1 at risk for a diminished quality of life. Findings included ... Review of the ALF's Title "Disclosure of Services" (DSHS 10-351 Rev. 03/2017) showed, "Housekeeping: All assisted living facilities must maintain your living quarters and other areas you may use in a safe, clean and comfortable condition." Record review showed Resident 1 was admitted to the Assisted Living Facility (ALF) on /2024 with multiple diagnoses. A Negotiated Service Agreement, dated 05/06/2025, showed Resident 1 needed assistance with weekly housekeeping and daily bed making. Observation, on 07/02/2025 at 10:45 AM, in Resident 1 's room showed their floor had scattered food and paper debris, and dresser drawers were smeared of feces. The bottom of the windowsill and window glass had splattered feces all over, and the curtain had a one and a half by two and a half inch feces mark. The bed was unmade. . 07.22.2025 12:00:57 State of Washington 71 Statement of Deficiencies License #: 2641 Compliance Determination# 61907 Plan of Correction Lynden Manor Completion Date In an interview, on 07/02/2025 at 11 :00 PM, Staff A (Caregiver) stated that they did not see the feces on the windowsill and on the curtain. Staff A stated that Resident 1's room was getting cleaned weekly and the care staff were supposed to clean in between the housekeeping schedule. Staff A was unable to state when Resident 1 's room was last cleaned. In an interview, on 07/02/2025 at 11:13 PM, Staff B (Director of Nursing) stated that they were not aware of Resident 1' s room condition. Staff B stated that Resident 1 had a history of throwing their dirty briefs o.ut the window, which may have been the reason why there were feces on the windowsill. Staff B stated that the care staff were instructed to check and clean the residents' room every day when there is a need. In an interview, on 07/21/2025 at 8:36 AM, Collateral Contact (CC - Resident 1 's Representative) stated that they have had an ongoing cleanliness problem with Resident 1 's room in the last four months. CC stated that they were finding feces on Resident 1 floor on a regular basis. Plan/A ttestation 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~~'.!n Manor is or will be in :::t ~I-'2..':;> . compliance with this law and/ or regulation on (Date) In addition, I will implement a system to monitor and ensure continued compliance with -:~ ------ ··--,fct5J25 __ _ Administrator (or Representative) Date .

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: Lynden Manor Provider Type: Assisted Living Facility License/Cert.#: 2641 Compliance Determination #: 60045 Intake ID: 179703 Investigator: Helen Fisher Region/Unit #: RCS Region 2 / Unit A Investigation Date(s): 05/23/2025 through 07/07/2025 Complainant Contact Date(s): Allegation(s): 1) Medications were kept in the Named Staff 1 (NS1's) office to be used for other residents later. Medications were left by the residents who moved out. 2) Medications were left on the cart and the nurse’s station unattended and accessible by staff and residents. 3) Medications were handed to the non-delegated staff to give to residents. 4) Three Named Residents (NR1, NR2 & NR3's) medications were placed on hold without an order. 5) Many medications were not available and medication errors. 6) NS1 did not like people with different ethnicities and wrongfully terminated staff. NS1 fired the Unnamed Staff (US) for not carrying a pager. 7) The med techs were asked to administer medications without an order. Investigation Methods: Sample: Total residents: 82 Resident sample size: 5 Closed records sample size: Observations: Medication pass, medication storage. Residents, Environment. Interviews: Nursing staff. Residents. Collateral Contacts. Other not associated with the facility. Record Reviews: Residents' records, nurse delegation policy and procedures. Medication services policy and procedures. Investigation Summary: 1) Interviews indicated that the medications being kept at NS1’s office were to be destroyed and not for other residents’ use. The leftover medications belonging to former residents were destroyed as per ALF’s procedures. No failed practice was identified. 2) Medications were locked in the medication cart were observed during unannounced onsite visit at the Assisted Living Facility (ALF). The nursing staff denied seeing medications outside to the medication cart unattended. No failed . practice was identified. 3) Interviews indicated that medications including insulin injections were handed over by the facility’s nurse to the non-delegated staff to administer to the resident. Failed practice was identified. A citation was written for noncompliance with WAC 388-78A-2320 Intermittent nursing services system. 4) The nursing staff indicated that they tried to place medication on hold when the medication had not arrived for 1 day. The practice was reversed the following day. No failed practice was identified. 5) According to the nursing staff the medications that were not available were new orders waiting to be filled and delivered by the pharmacy. Review of the sampled residents’ medication administration records showed no medication discrepancies found. No failed practice was identified. 6) Employees were terminated due to noncompliance of the ALF policy and procedures. NS1 denied the report that they wrongfully terminated staff. No failed practice was identified. 7) Three med techs denied being asked to administer medications without an order. No failed practice was identified. 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 Home and Community Living Administration PO Box 45600, Olympia, WA 98504-5600 December 30, 2025 ELECTRONIC-FACSIMILE Administrator Lynden Manor 905 Aaron Dr Lynden, WA 98264 Assisted Living Facility License # 2641 Licensee: Lynden ALC LLC IMPOSITION OF CIVIL FINES Dear Administrator: On December 16, 2025, the Department of Social and Health Services (DSHS), Residential Care Services completed a follow-up visit at your facility. This letter constitutes formal notice of civil fines on the license for your assisted living facility, also known as Lynden Manor, located at 905 Aaron Dr, Lynden, 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 fines on the license are based on the following violation of the RCW and/or WAC as described in the attached Statement of Deficiencies (SOD) report dated December 16, 2025. Civil Fines WAC 388-78A-2700 (1)(a) Emergency and disaster preparedness. $400.00 The licensee failed to ensure hazardous items were inaccessible to residents in one Memory Care Units (MCU). This failure placed residents with dementia at risk for accessing and ingesting potentially harmful substances. This is an uncorrected deficiency previously cited on October 10, 2025. Administrator Lynden Manor License #2641 December 30, 2025 Page 2 WAC 388-78A-2474 (2)(b)(c)(d)(e) Training and home care aide certification $400.00 requirements. The licensee failed to ensure four staff members met the long-term care workers training requirements under Washington Administrative Code (WAC) 388-112A. This placed residents in the facility at risk of not receiving proper care and services from staff members. This is an uncorrected deficiency previously cited on October 10, 2025. NOTE: These are the violations, which resulted in the fines; see the attached Statement of Deficiencies for any additional violations. 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: (425) 977-6821 / 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. Administrator Lynden Manor License #2641 December 30, 2025 Page 3 During the IDR process, you will have the opportunity to present written and/or oral evidence to dispute the deficiencies. You can make an IDR request and find directions on the IDR web page at: http://www.dshs.wa.gov/altsa/idr. Formal Administrative Hearing You may contest the civil fines by requesting a formal administrative hearing to challenge the deficiency, which resulted in the civil fines. 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 fines are due to the Office of Financial Recovery twenty-eight (28) calendar days after receipt of this letter. Mail a check for $800.00 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 Lynden Manor License #2641 December 30, 2025 Page 4 NOTICE: State and federal law provide protections to defendants who are in military service, and to their dependents. Dependents of a service member are the service member’s spouse, the service member’s minor child, or and individual for whom the service member provided more than one-half of the individual’s support for one hundred eight days immediately preceding an application for relief. One protection provided is the protection against the entry of a default judgment in certain circumstances. This notice pertains only to a defendant who is a dependent of a member of the National Guard or a military reserve component under a call to active service, or a National Guard member under a call to service authorized by the governor of the state of Washington, for a period of more than thirty consecutive days. Other defendants in military service also have protections against default judgments not covered by this notice. If you are the dependent of a member of the national guard or a military reserve component under a call to active service, or a national guard member under a call to service authorized by the governor of the state of Washington, for a period of more than thirty consecutive days, you should notify the Department in writing of your status as such within twenty days of the receipt of this notice. If you fail to do so, then a court or an administrative tribunal may presume that you are not a dependent of an active duty member of the national guard or reserves, or a national guard member under a call to service authorized by the governor of the state of Washington, and proceed with the entry of an order of default and/or a default judgment without further proof of your status. Your response to the Department about your status does not constitute an appearance for jurisdictional purposes in any pending litigation nor a waiver of your rights. If you have any questions, please contact Jamie Singer, Field Manager, at (425) 977-6821. 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

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 3906-172nd St NE, Suite #100, Arlington, WA 98223 Statement of Deficiencies License #: 2641 Compliance Determination # 56787 Plan of Correction Lynden Manor 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 03/24/2025 of: Lynden Manor 905 Aaron Dr Lynden, WA 98264 This document references the following complaint number(s): 169050, 171872, 171918, 172533 The following sample was selected for review during the unannounced on-site visit: 5 of 86 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Helen Fisher, Complaint Investigator From: DSHS, Aging and Long-Term Support Administration 3906-172nd St NE, Suite #100 Arlington, WA 98223 . Statement of Deficiencies License #: 2641 Compliance Determination # 56787 Plan of Correction Lynden Manor 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-2371 Investigations. The assisted living facility must: (3) When necessary, institute and document appropriate measures to prevent similar future situations if the alleged incident is substantiated; and This requirement was not met as evidenced by: Based on interviews and record reviews, the Assisted Living Facility (ALF) failed to ensure measures were in place to prevent 1 of 3 residents (Resident 1) from leaving the secured memory care unit unsupervised. This failure resulted in Resident 1 leaving the building without detection, walking 1.1 miles away from the ALF and placed all memory care residents at risk of leaving the ALF undetected. Findings included… Review of the ALF's “Elopement- Missing Resident” policy and procedures, with an effective date of 10/07/2020 showed elopement was defined as: The process of leaving protected and safe surroundings with no focused designation, or the inability to return safely after exiting facility. For residents assessed as unable to leave facility without supervision: Any/All Staff, upon noticing resident is missing: Verify whether resident has signed out on social leave, had an appointment outside the facility, etc., if the resident is past estimated time of return, contact resident’s responsible party. If the resident is not located, continue search, include all areas or resident room such as bathroom, closets, etc. With in 5 minutes, Notify the ED/LN if on site. Notify Med Tech on duty to initiate building search (common areas, outside areas, other resident rooms, etc. The Med-Tech will gather the following information from the staff member that last saw the resident. Approximately what time was the resident last seen what they were wearing, what was their physical, mental and emotional status, notify LN if after hours. Search complete in 10-15 minutes. Executive Director, LN, Med Tech in maximum of 15 minutes Once staff have reported back to Manager/Med Tech on site, and the resident is . Statement of Deficiencies License #: 2641 Compliance Determination # 56787 Plan of Correction Lynden Manor Completion Date still missing, call 911 and report a missing resident. Provide all information required for a police search. An undated face sheet showed Resident 1 was admitted into the ALF's memory care unit on /2016 with multiple diagnoses including A negotiated service agreement dated 12/20/2024 showed Resident 1 had an exit seeking and wandering behavior that required redirection. ALF’s preventative measures were to check and monitor the latch in Resident 1’s room to assure the window was secured. Review of the investigation dated 02/26/2025 at 10:52 AM showed Resident 1 removed the screen, window’s latch and exited through the window. Review of incident report dated 02/26/2025 showed that Resident 1 had exit seeking behavior since 6:00 AM that morning. Resident 1 was seen walking near the middle school about 1.1 mile away from the ALF by a staff member who informed their supervisor Staff A (Executive Director). Review of the previous elopement incidents showed Resident 1 had previously left the ALF through the window on 12/15/2023. In an interview on 03/24/2025 at 11:20 AM, Staff A, Executive Director, stated that on 02/26/2025 they received a call from a staff member that Resident 1 was found walking near the middle school. Staff A stated that they investigated the incident and they instructed the maintenance staff to replace the broken window opening restrictor and placed a window alarm. In an interview on 03/24/2025 at 1:10 PM, Staff B, Resident Care Coordinator, stated that Resident 1 had been actively exit seeking to try to find their wife and dog the morning before they were found. In an interview on 04/25/2025 at 12:21 PM, Collateral Contact (CC) stated that they were concerned that there were not enough staff to check on residents who were trying to leave the ALF. Review of the previous elopement incident showed that Resident 1 left the ALF undetected two times, first was on 12/15/2023 when they left the ALF through the window and the second time was on 04/29/2024 when they followed a visitor out and was found law enforcement a few streets over. . Statement of Deficiencies License #: 2641 Compliance Determination # 56787 Plan of Correction Lynden Manor Completion Date Review of prior interventions in preventing elopement reoccurrences were ineffective. - On 04/29/2024 a new signage was made at the doorway for visitors to watch that a resident would not follow them out. - On 12/15/2023 the maintenance added a clip on the window to limit the opening. This is a reoccurring deficiency previously cited on 09/26/2024. 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, Lynden Manor 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 . Investigation Summary Report Provider/Facility: Lynden Manor Provider Type: Assisted Living Facility License/Cert.#: 2641 Compliance Determination #: 52788 Intake ID: 162370 Investigator: Helen Fisher Region/Unit #: RCS Region 2 / Unit A Investigation Date(s): 01/09/2025 through 02/14/2025 Complainant Contact Date(s): 01/10/2025 Allegation(s): 1) The Named Resident (NR) was left in feces for six plus hours. 2) The Assisted Living Facility (ALF) left the NR sitting on and standing in their own urine multiple times. 3) The NR was not taken to the dining room until an hour after. 4) The NR was tested and diagnosed for . 5) The management was ignoring a request for NR’s care plan change. Investigation Methods: Sample: Total residents: 89 Resident sample size: 3 Closed records sample size: 0 Observations: Residents, environment, staff to resident interaction. Interviews: Residents, Collateral contact, Executive Director, Director of Nursing, Medication Technician, Caregiver. Record Reviews: Residents' records. Abuse and neglect policy and procedure Investigation Summary: 1) The NR was cognitively impaired and unable to make their needs known. Interview indicated that the NR had a bowel incontinence and was left in feces while lying in bed for approximately six hours. The staff stated that they were aware that the NR had a bowel incontinence and had asked another staff to attend to the NR but was ignored. The staff was unable to provide the other staff's name. The staff stated that the NR had feces all over them and on the floor and toilet. The ALF did an investigation and the NS was reprimanded Failed practice was identified. A citation was written for noncompliance with Washington Administrative Code 388-78A-2660 Resident rights. 2) The staff stated that they have been offering every 2-hour toileting. The staff stated that the NR would occasionally refuse to be toileted. It was unknown on how long the NR was left on wet brief and on how long the NR was standing on their own urine. The ALF did an investigation, additional training was provided to staff. Failed practice was identified. A citation was written for noncompliance with Washington . Administrative Code 388-78A-2660 Resident rights. 3) The staff stated that lunch is at 1:00 PM and they always made sure residents were taken to meals. No failed practice was identified. 4) The staff stated that the NR was taken by their family to the doctor and was tested for bladder infection due to behavior issues. The staff stated that the NR was prescribed an antibiotic. The staff stated that they encouraged the NR to increase their fluid intake during meals. No failed practice was identified. 5) The ALF denied ignoring request for NR care changes. The ALF stated that normally a care conference was warranted to update the care plan. The ALF stated the NR's care plan was updated during the care conference with the NR's family. Review of the recent care plan showed toileting supervision and monitoring was updated as requested by the NR’s family to address the NR's changing needs. No failed practice was identified. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: Lynden Manor Provider Type: Assisted Living Facility License/Cert.#: 2641 Compliance Determination #: 52788 Intake ID: 162690 Investigator: Helen Fisher Region/Unit #: RCS Region 2 / Unit A Investigation Date(s): 01/09/2025 through 02/14/2025 Complainant Contact Date(s): 01/13/2025, 02/05/2025 Allegation(s): 1) The Named Resident (NR) went missing and was found in another resident’s room. 2) The NR wandered out the memory care unit through the locked door. 3) The ALF was leaving the NR completely soaked in urine for hours. 4) The Named Resident (NR) was completely covered for at least six hours. 5) Request for additional services was ignored by the ALF. Investigation Methods: Sample: Total residents: 89 Resident sample size: 3 Closed records sample size: 0 Observations: Residents, environment, staff to resident interaction. Interviews: Residents, Collateral contact, Executive Director, Director of Nursing, Medication Technician, Caregiver. Record Reviews: Residents' records. Abuse and neglect policy and procedure Investigation Summary: 1) The NR was cognitively impaired. The staff stated that the NR wandered in the memory care unit and into another residents’ room. The staff stated that since residents’ doors were not locked, we often found the NR inside other residents’ room. The staff stated that they redirected the NR without a problem. The staff stated the NR was adjusting to a new environment. No failed practice was identified. 2) The staff responded when exit door alarm was set off and found the NR at the second floor. The staff stated that the NR was unharmed and agreeable to return to the unit. The ALF stated that the exit doors when pushed it would open and alarmed for 15 seconds until it was reset by staff. The staff stated that after that event the NR’s care plan was updated. No failed practice was identified. 3) The staff stated that they have been offering every 2-hour toileting. The staff stated that the NR would occasionally refuse to be toileted. It was unknown on how long the NR was left on wet brief and on how long the NR was standing on their own urine. The ED stated that they did an investigation as they became aware of the . event and retrained staff. Failed practice was identified. A citation was written for noncompliance with Washington Administrative Code 388-78A-2660 Resident rights. 4) Interview indicated that the NR had urine and bowel incontinence and was left covered in feces for approximately five hours. The staff stated that they were aware that the NR had a bowel incontinence and had asked another staff to attend to the NR but was ignored. The staff stated that the NR had feces all over them and on the floor and toilet. The ALF did an investigation and the NS was reprimanded. Failed practice identified. A citation was written for noncompliance with Washington Administrative Code 388-78A-2660 Resident rights. 5) The ALF denied ignoring request for NR care changes. The ALF stated that normally a care conference was warranted to update the care plan. Review of the care plan showed toileting supervision and monitoring was updated during the care conference between the ALF and the NR's family to address the NR's changing needs. No failed practice was identified. 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: Lynden Manor Provider Type: Assisted Living Facility License/Cert.#: 2641 Compliance Determination #: 50452 Intake ID: 155026 Investigator: Helen Fisher Region/Unit #: RCS Region 2 / Unit A Investigation Date(s): 11/20/2024 through 12/26/2024 Complainant Contact Date(s): 11/19/2024 Allegation(s): 1) The Assisted Living Facility (ALF) was not providing nursing care to the Named Resident (NR). 2) The ALF was not following the doctor’s order. 3) The NR had a pressure wound on their foot and the ALF asked the family to provide wound care. Investigation Methods: Sample: Total residents: 88 Resident sample size: 4 Closed records sample size: 0 Observations: NR's appearance and mentation, living quarter, staff to resident interaction. Interviews: NR, collateral contacts, resident care coordinator (RCC), registered nurse (RN), director of nursing (DNS). Record Reviews: NR's negotiated service agreement, progress notes, medication administration record. Physician's order, admission order. Investigation Summary: 1) Interviews indicated that the NR was assessed and was placed on alert charting when the NR had signs and symptoms of illness. The RCC stated that the NR was monitored, and vital signs were taken when the NR had behavior changes and urinary frequency. The NR's Representative stated the No failed practice was identified. 2) The nurse stated that the med techs were notifying the doctor via fax when the NR’s blood sugar level was above 400. The staff stated that the NR’s urine sampled was collected on 09/30/2024, 7 days after it was ordered to be collected. Failed practice was identified. A citation was written for non-compliance with Washington Administrative Code 388-78A- 2350 Coordination of health care services. 3) The staff stated that they were not delegated to do the pressure wound care tasks. The RCC stated that they asked the NR’s daughter to do the wrapping until they received the doctor’s order. The RCC stated that after they received the . doctor's order the DNS had been managing the NR's heels. The DNS stated that the med techs were not delegated to manage the NR’s heels’ pressure injuries wrapped dressing. The DNS stated that they managed the heels on weekdays but on weekends the family would rewrapped the NR's heels when the wrap became undone or when the NR removed them. The DNS stated that the NR's family was not obligated by the ALF to do any tasks. No failed practice was identified. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: Lynden Manor Provider Type: Assisted Living Facility License/Cert.#: 2641 Compliance Determination #: 50452 Intake ID: 154590 Investigator: Helen Fisher Region/Unit #: RCS Region 2 / Unit A Investigation Date(s): 11/20/2024 through 12/26/2024 Complainant Contact Date(s): 11/19/2024 Allegation(s): 1) The Assisted Living Facility (ALF) was not following the Named Resident (NR’ s) prescribed diabetic diet. 2) The NR’s pressure injuries were not managed by the ALF. The ALF told the NR’s daughter that they were not able to manage the NR’s pressure injuries on heels. Investigation Methods: Sample: Total residents: 88 Resident sample size: 4 Closed records sample size: 0 Observations: NR's appearance and mentation, living quarter, staff to resident interaction. Interviews: NR, collateral contacts, resident care coordinator (RCC), registered nurse (RN), director of nursing (DNS), executive director (ED). Record Reviews: NR's negotiated service agreement, progress notes, medication administration record. Physician's order, admission order. Investigation Summary: 1) Interviews indicated that the NR had been served a regular diet with sugar free dessert and juice. Review of the NR’s signed doctor's diet order showed the NR to be on diabetic diet. Review of the NR’s negotiated service agreement showed the NR was on a regular diet. Failed practice was identified. A citation was written for noncompliance with Washington Administrative Code 388-78A-2350 Coordination of health care services. 2) The staff stated that they were not sure what caused the NR to develop pressure sores on their heels since the NR was walking constantly. The staff stated that NR was not turning when in bed and got agitated when asked to turn. The ALF did an investigation and found out the location of the pressure injuries may have been caused by the NR’s footwear. The staff stated that since the NR had some ankle edema the NR’s tennis shoes had gotten too tight and may have caused the pressure injuries to the NR’s heels. The DNS stated that the NR's heel wrap . supposed to stay in place, but the NR was removing them. The DNS stated that they were applying a lotion for moisture and wrapped the heels as per the doctor's order. The family would come and do the wrapping on weekend and when the NR removed the wrap. The DNS were managing the NR’s heels pressure injuries, and they were doing better. The RCC stated that they told the NR’s daughter to do the heels’ wrapping until they received the doctor’s order. The RCC stated that the DNS was in charged when it comes to skin issues. The staff stated that the NR’s pressure sores were being managed by the family at first because they were not delegated for wound care. No failed practice was identified. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Ii □ □ STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 3906-172nd St NE, Suite #100, Arlington, WA 98223 Statement of Deficiencies License #: 2641 Compliance Determination # 50452 Plan of Correction Lynden Manor 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 11/20/2024 and 11/20/2024 of: Lynden Manor 905 Aaron Dr Lynden, WA 98264 This document references the following complaint number(s): 153091, 154590, 155026, 155944 The following sample was selected for review during the unannounced on-site visit: 4 of 88 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Helen Fisher, Complaint Investigator From: DSHS, Aging and Long-Term Support Administration 3906-172nd St NE, Suite #100 Arlington, WA 98223 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 #: 2641 Compliance Determination # 50452 Plan of Correction Lynden Manor Completion Date Administrator (or Representative) Date 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. (7) When coordinating care or services, the assisted living facility must: (a) Integrate relevant information from the external provider into the resident's preadmission assessment and reassessment, and when appropriate, negotiated service agreement; and This requirement was not met as evidenced by: Based on observation, interviews, and record reviews the Assisted Living Facility (ALF) failed to coordinate with the external health care provider, add the changed orders to the care plan, and respond appropriately when 1 of 3 residents (Resident 1’s) blood sugar level exceeded the ordered parameters, when a doctor ordered to collect a urine sample for analysis, and a new diabetic diet was received. These failures resulted in Resident 1’s doctor being unaware of Resident 1’s high blood sugar level, a delayed in urine analysis, and being served a regular diet and placed Resident 1 at risk for untreated infection and diabetes complications. Findings included… Review of the ALF's undated title "Disclosure of Services" showed: Food and Diets: All assisted living facilities must provide three meals per day, nutritious snacks, and prescribed general low sodium diets, general diabetic diets, and mechanical soft diets, Additionally, we are not required but have chosen to provide the following diets: Yes to puree diets, Yes, to no added salt no concentrated sweets at request, No, to calorie controlled diets for people with diabetes. Resident 1 Resident 1 was admitted at the ALF on /2024 with multiple diagnoses including and .

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, Washington 98504-5600 November 15, 2024 (email) Licensee: Lynden ALC LLC Lynden Manor 905 Aaron Dr Lynden, WA 98264 IDR RESULTS ALF #2641 Dear Provider: Thank you for participating in the Informal Dispute Resolution (IDR) process. During the IDR we addressed your dispute identified in your IDR Request in response to the Statement of Deficiencies (SOD) report dated 10/02/2024. As discussed during the IDR, the following information was considered:  All materials presented by the Assisted Living Facility ;  All oral statements and explanations offered by the Assisted Living Facility;  Records gathered by the Residential Care Services (RCS) regional staff. After careful review and consideration, I have decided not to make any changes to SOD report dated 10/02/2024. Next Steps:  If you have not done so already, begin the process of correcting the disputed deficiency or deficiencies immediately.  Contact the local field manager if you need clarification related to the SOD report.  Within 10 calendar days after you receive this letter, complete, and return the “Plan/Attestation Statement” for all disputed deficiencies. o For each disputed deficiency, indicate the date you have or will have corrected each one. o Next to each disputed deficiency, sign and date certifying that you have or will correct each disputed deficiency. o Mail the “Plan/Attestation Statement” with original signatures to: Kimberley Ripley, Field Manager Residential Care Services Region 2, Unit A 3906-172nd St NE, Suite #100 Arlington, WA 98223 Fax: (360) 651-6940  You must complete corrections within 45 days or less if directed by the department after review of your proposed correction dates. If you have any questions, please contact me at Scotti.Bower1@dshs.wa.gov. Sincerely, Scotti Bower IDR Program Manager Residential Care Services cc: Regional Administrator, Region 2 Field Service Administrator, Region 2 Field Manager, Region 2 Unit A Statewide Long Term Care Ombudsman Regional Long Term Care Ombudsman Central File IDR File Field File

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: Lynden Manor Provider Type: Assisted Living Facility License/Cert.#: 2641 Compliance Determination #: 44357 Intake ID: 138359 Investigator: Helen Fisher Region/Unit #: RCS Region 2 / Unit A Investigation Date(s): 07/19/2024 through 09/26/2024 Complainant Contact Date(s): 07/18/2024 Allegation(s): 1. The Named Resident (NR) was involved in an altercation with another resident. 2. The NR had left the Assisted Living Facility (ALF) secured memory care undetected and was found by the police 5 miles away from the ALF. Investigation Methods: Sample: Total residents: 88 Resident sample size: 3 Closed records sample size: 0 Observations: The NR appearance, demeanor, exit doors, environment, the NR social interaction, living quarter. Interviews: NR, other not associated with ALF, med tech, resident care coordinator, caregiver, director of nursing (DNS). Record Reviews: NR's negotiated service agreement, progress notes, electronic medication administration record, incident investigation. Missing resident policy and procedures. Investigation Summary: 1. The staff intervened and separated both residents. The NR was unharmed and was redirected. No failed facility practice was identified. 2. The staff stated that they did not know that the NR had left the memory care unit until the police officers were knocking on the door with the NR at midnight. The staff stated that the NR was last seen at 10:10 PM sleeping in their chair. The NR was observed as upset following an incident with another resident. The NR had no recollection of what happened when asked. The DNS stated that the NR must have followed someone out the memory care door and went outside through the silent alarm door. The ALF did not make a determination on how the NR got out of the ALF aside from assumptions. Failed practice was identified. A citation was written for noncompliance with Washington Administrative Code 288-78A (2371) Investigation. 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 . . .

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 HEALT H SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 3906-172nd St NE, Suite #100, Arlington, WA 98223 Statement of Deficiencies License #: 2641 Compliance Determination # 38914 Plan of Correction Lynden Manor 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 03/28/2024 and 03/28/2024 of: Lynden Manor 905 Aaron Dr Lynden, WA 98264 This document references the following complaint number(s): 123087, 123633, 124588 The following sample was selected for review during the unannounced on-site visit: 3 of 83 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Helen Fisher, Complaint Investigator From: DSHS, Aging and Long-Term Support Administration 3906-172nd St NE, Suite #100 Arlington, WA 98223 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 #: 2641 Compliance Determination # 38914 Plan of Correction Lynden Manor Completion Date Administrator (or Representative) Date WAC 388-78A-2210 Medication services. (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: This requirement was not met as evidenced by: Based on interviews and record reviews, the Assisted Living Facility (ALF) failed to ensure 1 of 3 residents (Resident 1) received medication as prescribed by the physician. This failure resulted in Resident 1 receiving wrong dosages of their anti-anxiety medication for 26 days and placed Resident 1 at risk for medical complications. Findings included ... Resident 1 Resident 1 was admitted to the Assisted Living Facility (ALF) on /2022 with multiple diagnosis including . A negotiated service agreement dated 01/22/2022 showed Resident 1 had a cognitive impairment and was to receive medication administration. The physician's order dated 03/31/2023 showed Resident 1 was to receive: Lorazepam 0.50 mg (milligram) 1 tablet by mouth at 8:00 PM daily for anxiety Lorazepam 0.25 mg 1 tablet by mouth every 3 hours as an additional dose when needed for anxiety. Review of the electronic medication administration records (EMAR) for January and February 2024 showed Resident 1 had a medication listed as: Lorazepam 0.50 mg (milligram) 1 tablet by mouth at 8:00 PM daily. Medication was marked as given daily at 8:00 PM from 1/25/2024 through 02/29/2024. Review of the narcotic book dated 01/19/2024 showed a PRN (as needed) (in addition to the 0.50 mg daily dose) sticker with Resident 1' s full name, the number of tablets as 30 and the named of medication as Lorazepam ½ tablet 0.25 mg by mouth every 3 hours as needed for anxiety. There were 26 staff initials belonging to 3 medication technicians (Staff B, E & F). . Statement of Deficiencies License #: 2641 Compliance Determination # 38914 Plan of Correction Lynden Manor Completion Date Interview on 03/28/2024 at 11 :00 AM, Staff A, Resident Care Coordinator, stated that they were unaware of the medication error until a medication audit was done and it was found that Resident 1 had been receiving 0.25 mg instead of 0.50 mg of the anti-anxiety medication for 26 days between January and February 2024. Staff A stated that three med techs (Staff B, E, and F) made the errors. Staff made one error and received counseling. Staff E and F were no longer employed at the ALF. Interview on 03/28/2024 at 12:26 PM, Staff B, Med Tech, stated that they made one mistake by administering Lorazepam 0.25 mg instead of 0.50 mg to Resident 1 but did not realize the mistake until a few days later. Staff B stated that she did not make a report. Interview on 03/28/2024 at 1 :12 PM, Staff C, Director of Nursing, stated that they received a medication error report from a staff member and did an investigation which resulted to Staff F termination of employment for committing 18 medication errors on Resident 1' s antianxiety medication. On 03/28/2024 at 1 :36 PM, Staff D, Executive Director, stated that they were not aware that the medication errors were committed until it was reported to Staff C. On 03/29/2024 at 8:51 AM, Collateral contact, (CC) stated that they noted Resident 1's condition had been declining in the last 3 months. CC stated that missing their full medication dosage was not helpful as the Resident condition continued to decline. 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, Lynden Manor 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 .

citation was written for noncompliance with WAC 388-78A-2665 Resident Rights-Notice-Policy on accepting Medicaid as a payment source. 2) The Named Resident had medication inconsistencies with medication orders. A citation was written for noncompliance with WAC 388-78A-2210 Medication Services. 3) The Named Resident's bathroom was clean and had toilet paper. No failed practice. 4 & 5) The Named Resident was wearing personal clothing, had socks and shoes on. The Named Resident's feet were observed to be dry and intact. The Named Resident had a Podiatry appointment scheduled. No failed practice. 6) The Named Resident had an altercation with another Resident, was previously investigated. No failed practice. 7) The Assisted Living Facility had frozen water pipes that burst during a severe weather ice storm. Previously investigated. 8) The Named Resident was dressed appropriately, hygiene care and supplies were available. The Named Resident had shower documentation completed. No failed practice. 9) Residents were supervised and staff were present to provide Resident care services. Staffing schedules reviewed and met the minimum staffing guidelines. No failed 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 . Investigation Summary Report Provider/Facility: Lynden Manor Provider Type: Assisted Living Facility License/Cert.#: 2641 Compliance Determination #: 24699 Intake ID: 84153 Investigator: Helen Fisher Region/Unit #: RCS Region 2 / Unit A Investigation Date(s): 05/31/2023 through 08/16/2023 Complainant Contact Date(s): 06/29/2023, 07/03/2023 Allegation(s): The Name Resident (NR) was found on the floor in the living room of their apartment with bloody big toe abrasions, smeared dried feces on NR's thighs and hands, and on the floor around NR. It appeared that the NR struggled for a long time on the floor. Investigation Methods: Sample: Total residents: 96 Resident sample size: 3 Closed records sample size: 1 Observations: NR was not observed (NR was deceased). Apartment emergency pull cord. Interviews: Collateral contacts, Director of Nursing, Resident Care Coordinator, Executive Director, Med Techs, Caregiver. Record Reviews: NR records Facility records Hospital record Investigation Summary: The facility staff called 911 when they found the NR on the living room floor with some blood on the NR and on the carpeting. The facility staff noted the emergency pull cord in the bathroom was pulled down. In an interview the staff stated that the call light had a glitch, and it was going on and off on the system. Review of the alert response report dated 05/28/2028 showed no report from the emergency pull cord. A citation was issued for noncompliance with WAC 388- 78A-2930 Communication systems. 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 3906-172nd St NE, Suite #100, Arlington, WA 98223 Statement of Deficiencies License #: 2641 Compliance Determination # 23931 Plan of Correction Lynden Manor 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 05/15/2023, 05/31/2023 and 05/31/2023 of: Lynden Manor 905 Aaron Dr Lynden, WA 98264 This document references the following complaint number(s): 81555, 81905, 81485, 83943, 83020 The following sample was selected for review during the unannounced on-site visit: 4 of 98 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Helen Fisher, Complaint Investigator From: DSHS, Aging and Long-Term Support Administration 3906-172nd St NE, Suite #100 Arlington, WA 98223 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 #: 2641 Compliance Determination # 23931 Plan of Correction Lynden Manor Completion Date Administrator (or Representative) Date RCW 70.129.140 Quality of life -- Rights. (2) Within reasonable facility rules designed to protect the rights and quality of life of residents, the resident has the right to: (d) Wear his or her own clothing and determine his or her own dress, hair style, or other personal effects according to individual preference; WAC 388-78A-2660 Resident rights. The assisted living facility must: (1) Comply with chapter 70.129 RCW, Long-term care resident rights; (4) Promote and protect the residents' exercise of all rights granted under chapter 70.129 RCW; This requirement was not met as evidenced by: Based on interview and record review the Assisted Living Facility (ALF) failed to protect 1 of 4 resident's (Resident 1) rights to refuse to remove compression stockings at night. This failure prevented Resident 1 from being able to exercise their rights to refuse. Findings included... Review of RCW 70.129.1409(2)(d) showed (2) Within reasonable facility rules designed to protect the rights and quality of life of residents, the resident has the right to (d) Wear his or her own clothing and determine his or her own dress, hair style, or other personal effects according to individual preference; Resident 1 was admitted to the ALF on /2021 with multiple diagnoses including and Review of an NSA dated 04/23/2023, showed Resident 1 did not have any identified guidance for staff when Resident 1 refused to have compression socks removed. In an interview on 05/15/2023 at 8:16 AM, Collateral Contact 1 (CC1) stated that they brought in compression stockings for Resident 1. Resident 1 told CC1 that Resident 1 "tussled" with Staff A, Caregiver, and when Staff A tried to remove Resident 1's compression stockings on the night of 05/05/2023 Staff A was unkind to Resident 1. In an interview on 05/15/2023 at 10:38 AM, Resident 1 stated that they told Staff A to leave their bed clothing and stockings alone, but Staff A insisted ignoring their request, so they "tussled" with the removal of the compression stockings. Staff A pulled the blankets off of Resident 1's feet and Resident 1 pulled the blankets back. Resident 1 stated they did not fall out of bed and the stocking were removed. . Statement of Deficiencies License #: 2641 Compliance Determination # 23931 Plan of Correction Lynden Manor Completion Date In an interview on 05/15/2023 at 11:47 AM, Staff E, Caregiver stated that they were aware that Resident 1 occasionally refused to remove compression stockings and clothing at night, so they would leave without taking clothing off. In an interview on 05/15/2023 at 12:06PM, Staff B, Director of Nursing, (DNS) stated that Staff A had a "no-nonsense" approach and that may have been the reason why Resident 1 refused to cooperate. Staff B stated that Staff A should have walked away. In an interview on 05/31/2023 at 3:30PM, Staff A stated that Resident 1 resisted having their stockings removed and told Staff A to get out. Staff A stated they were told by the Med Techs to remove stockings and wash at night. 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, Lynden Manor 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 .