Fieldstone Memory Care of Marysville.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: Fieldstone Memory Care of Provider Type: Assisted Living Facility Marysville License/Cert.#: 2538 Intake ID: 189444 Compliance Determination #: 63966 Region/Unit #: RCS Region 2 / Unit D Investigator: Cynthia Chenot-Potter Investigation Date(s): 08/11/2025 through 09/15/2025 Complainant Contact Date(s): Allegation(s): 1. Named Resident (NR) appeared sedated. 2. NR was locked in their room and did not get lunch and dinner meals. 3. NR was not allowed visitors of their choice. 4. NR had multiple wounds on their arms, legs and a foot. Investigation Methods: Sample: Total residents: 61 Resident sample size: 3 Closed records sample size: 0 Observations: Identified resident Residents Resident rooms Staff to resident interactions Interviews: Identified resident Nursing staff Residents Family members Record Reviews: Medical records Facility policies Face sheets Investigation Summary: 1. NR was sleeping when the regulator visited in late morning, but woke up quickly and was cognizant and able to participate in the conversation during the visit. Reviewed progress notes and medication administration record. NR had not received any new medications while at the Assisted Living Facility. Medical provider notes reviewed. Facility met regulatory requirements. 2. NR denied not having access to meals and denied being locked in their room. Was able to show the regulator how to use their call bell, but stated they never use it. NR able to get up into their wheelchair independently, but requires assistance for safety. Observed NR having lunch meal. Reviewed care plan and assessment and resident weight record. Facility met regulatory requirement. . 3. NR confirmed they were allowed to have visitors of their choice. Reviewed visitor policy and visitor log. Facility met regulatory requirement. 4. NR had healing skin tears on arms, legs and a foot that occurred during falls. Appeared to be healing at time of regulator's visit. NR denied any other skin issues or concerns. Reviewed skin monitor and pictures of wounds. Nurse provided wound care routinely. Facility met regulatory requirement. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . .

Statement of Deficiencies License #: 2538 Compliance Determination # 59570 Plan of Correction Fieldstone Memory Care of Marysville Completion Date You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for the unannounced on-site full inspection on 05/14/2025 and 05/16/2025 of: Fieldstone Memory Care of Marysville 11015 State Ave Marysville, WA 98271 The following sample was selected for review during the unannounced on-site visit: 7 of 60 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Steven Kindle, Nursing Consultant Institutional Allison Nunn, Long Term Care Surveyor From: DSHS, Aging and Long-Term Support Administration 3906-172nd St NE, Suite #100 Arlington, WA 98223 . 05/30/2025 FRI 16i 31 FAX IZJ0ll/ 030 05.23.2025 09:18:27 State of Washington 71 Statement of Deficiencies License#: 2538 Compliance Determination# 59570 Pl-an of Correction Fieldstone Memory Care of Marysville Completi0rl Date Page2 of4 Licensee; Marysvllle Senior Community LLC 05/19/2025 As a result of u,e 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. t::;.!")"'~ ,..,t'\"')f." <..,ti.(._,\,,.!~\) --,.) Date I understand that to maintain an Assi-sted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. Administrator (or Re WAC 388-78A-2474 Training and home care aide certification requirements. (2) The assisted living facility must er~sure 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: (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. This requirement was not met as evidenced by: Based on interviews and record review, the Assisted Living Facility (ALF} failed to ensure 1 of 5 staff (Staff A} completed specialty training for dementia and mental health within 120 days of hire. 2 of 5 staff (Staff Band F) completed cardiopulmonary resuscitation (CPR) training, 3 of 5 staff (Staff B, D, and F) completed first aid training, 1 of 3 staff (Staff F) completed 12 hours of continuing education (CE) annually; and 1 of 5 staff (Staff D) received facility orientation. These failures resulted in Staff B, D, and F not having the necessary training related to their job duties and expectations and placed all 60 residents at risk for compromised care and safety. Findings included. .. Specialty Training for Dementia and Mental Health Re:view of WAC 388-112A~0490 (3) showed if an ALF serves one or more residents with 5/23/2025 . Statement of Deficiencies License #: 2538 Compliance Determination # 59570 Plan of Correction Fieldstone Memory Care of Marysville 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 regulations at all times. 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: (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. This requirement was not met as evidenced by: Based on interviews and record review, the Assisted Living Facility (ALF) failed to ensure 1 of 5 staff (Staff A) completed specialty training for dementia and mental health within 120 days of hire, 2 of 5 staff (Staff B and F) completed cardiopulmonary resuscitation (CPR) training, 3 of 5 staff (Staff B, D, and F) completed first aid training, 1 of 3 staff (Staff F) completed 12 hours of continuing education (CE) annually, and 1 of 5 staff (Staff D) received facility orientation. These failures resulted in Staff B, D, and F not having the necessary training related to their job duties and expectations and placed all 60 residents at risk for compromised care and safety. Findings included ... Specialty Training for Dementia and Mental Health Review of WAC 388-112A-0490 (3) showed if an ALF serves one or more residents with . Statement of Deficiencies License #: 2538 Compliance Determination # 59570 Plan of Correction Fieldstone Memory Care of Marysville Completion Date special needs, the ALF administrator or designee must complete specialty training and demonstrate competency within on hundred twenty days of date of hire. Review of the ALF's Resident Characteristic Roster dated 05/12/2025 showed 56 residents with dementia and three residents with a diagnosis of . Review of the ALF's employee files showed the following: Staff A, Executive Director, was hired on 09/27/2021. Staff A's file showed they completed specialty training for dementia and mental health on 03/25/2022, 179 days after their hire date. On 05/15/2025 at 9:36 AM, Staff A stated that they completed dementia and mental health specialty training, but they didn't have the certificates. Staff A stated that they took the classes over again so they would have the certificates. CPR and First Aid Training Review of WAC 388-112A-0720 (2)(a) showed all long-term care workers must have and maintain valid CPR and First Aid cards or certificates within 30 days of their date of hire. Review of the ALF's employee files showed the following: Staff B, Medication Aide, was hired on 09/11/2024. Staff B's file showed no record of completed CPR or First Aid training. Staff D, Caregiver, was hired on 07/15/2024. Staff D's file showed no record of completed First Aid Training. Staff F, Caregiver, was hired on 12/13/2022. Staff F's file showed no record of current CPR or First Aid training. On 05/15/2025 at 9:23 AM, Staff A, Executive Director (ED), stated that Staff B, D, and F would complete their CPR and First Aid training in July when they already had this training scheduled. On 05/16/2025 at 12:33 PM, Staff F, Caregiver, stated that they did not have current CPR and First Aid training and they were scheduled to take the class in July when it was offered at the ALF. . 05/30/2025 FRI 16: 32 FAX ~015/030 05.23.2025 09:18:27 State of Washington 9/ Statement of Deficiencies License#: 2538 Complience Determination # 59570 Plan of Correction Fieldstone Memory care of Marysville Completion Date Page 4 of4 Licensee: Marysville Senior Community LLC 05/19/2025 Continuing Education Review of WAC 388-112A-0611(1)(a)(i) showed long-term care workers, including certified horoe care aides, must complete 12 hours of CE by their birthday each year. Review of the ALF's employee files ·showed the following: Staff F's file showed that they had completed 1 0 hours of CE in the time between their birthday in 2024 and their birthday in 2025. On 05/16/2025 at 12:33 PM, Staff F stated that they completed their CE's in Relies (an online program of classes to earn CE). Staff F stated that'they did not have any additional CE's for the 2024-2025 year. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will tak.e active .measures to 0co~r1re· ct this deficjency. By taking this action, Fieldstone Memory Care of Marysville is ~~mpliance with this law and I or regulatiOf'I on "7 -~. (Date) I In addition, I will implement a system to monitor and ensure continued compliance with this requirement. ~ Administrator (or Representaliv•Jvl Date . Statement of Deficiencies License #: 2538 Compliance Determination # 59570 Plan of Correction Fieldstone Memory Care of Marysville Completion Date Continuing Education Review of WAC 388-112A-0611 (1 )(a)(i) showed long-term care workers, including certified home care aides, must complete 12 hours of CE by their birthday each year. Review of the ALF's employee files showed the following: Staff F's file showed that they had completed 10 hours of CE in the time between their birthday in 2024 and their birthday in 2025. On 05/16/2025 at 12:33 PM, Staff F stated that they completed their CE's in Relias (an online program of classes to earn CE).

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 . . .