The Cottages at Marysville.

Conclusion / Action: ~ Failed Provider Practice Identified/ Citation(s) Written D Failed Provider Practice Not Identified / No Citation Written □ N/A . Investigation Summary Report Provider/Facility: THE COTTAGES AT Provider Type: Assisted Living Facility MARYSVILLE License/Cert.#: 2149 Intake ID: 147533 Compliance Determination #: 50282 Region/Unit#: RCS Region 2 / Unit A Investigator: Karen Glover Investigation Date(s): 09/20/2024 through 02/10/2025 Complainant Contact Date(s): 11/15/2024 Allegation(s): 1-The Named Resident (NR) NR had fallen which resulted in a fractured collarbone and bruising. 2-The NR was shaken and disheveled. 3-The NR was diabetic, and the facility refused to accommodate the NR with a diabetic diet. Investigation Methods: Sample: Total residents: 42 Resident sample size: 6 Closed records sample size: 0 Observations: Residents Dining Resident rooms Staff to resident interactions Interviews: Family members Nursing staff Administration Medical provider Record Reviews: Hospital records Medical records Incident investigation Facility policies Investigation Summary: 1. The Named Resident (NR) was a recent admit to the facility and had been living independently with a history of falls at home. On the second day, the NR was found on the floor in front of the refrigerator in the cottage. No injuries were noted at the time of the fall. The following day the NR developed some bruising on their left shoulder and left forearm. The NR started to complain of pain with movement of the left arm. The NR's family was called and they provided transportation to the hospital for evaluation. The facility initiated an investigation and notified the medical provider and the department's hotline. After the fall, the facility had placed the NR . on alert charting ( charting done by facility staff per shift to monitor changes with the NR) and had requested a physical therapy evaluation. Review of hospital records showed the NR had a fractured clavicle and multiple healed rib, vertebral and pelvic fractures, with bruising representing different stages of healing. No failed practice was identified. 2. The facility stated that the NR was sent to the hospital following a fall. The NR was wearing a sweatshirt that had a stain, and the family declined to have facility staff change the NR into a clean sweatshirt before they left the facility. The NR was observed at the emergency room and the hospital records showed the NR was not "ill-appearing or toxic appearing." No failed practice was identified. 3. The disclosure of services show the facility did not provide diabetic management. The NR did not have medical provider orders for a diabetic diet or glucose monitoring. The NR did have an order for non-concentrated sweets. Failed practice was found regarding non-concentrated sweets not being available. A citation was issued for noncompliance with WAC 388-78A-2710 (2) Disclosure of services. Conclusion / Action: ~ Failed Provider Practice Identified/ Citation(s) Written D Failed Provider Practice Not Identified / No Citation Written □ NIA . Investigation Summary Report Provider/Facility: THE COTTAGES AT Provider Type: Assisted Living Facility MARYSVILLE License/Cert.#: 2149 Intake ID: 147475 Compliance Determination #: 50282 Region/Unit#: RCS Region 2 / Unit A Investigator: Karen Glover Investigation Date(s): 09/20/2024 through 02/10/2025 Complainant Contact Date(s): Allegation(s): 1. The Named Resident (NR) had a fall with a clavicle fracture. 2. The NR had a blood sugar over 800 and was admitted to the hospital for diabetic complications. 3. The NR "almost had a heart attack". Investigation Methods: Sample: Total residents: 42 Resident sample size: 6 Closed records sample size: 0 Observations: Residents Activities Resident rooms Staff to resident interactions Interviews: Nursing staff Residents Family members Administration Record Reviews: Facility policies Incident investigation Negotiated Service Agreement Investigation Summary: 1.The Named Resident (NR) was a recent admit to the facility and had been living independently with a history of falls at home. The NR was found on the floor in front of the refrigerator in the cottage. No injuries were noted at the time of the fall. The following day the NR developed some bruising on their left shoulder and left forearm. The NR started to complain of pain with movement of the left arm. The NR's family was called and they provided transportation to the hospital for evaluation. The facility initiated an investigation and notified the medical provider and the department's hotline. After the fall, the facility had placed the NR on alert charting and had requested a physical therapy. Review of hospital records showed the NR had a fractured clavicle and bruising from the fall, Bruising represented . different stages of healing and multiple healed rib, vertebral and pelvic fractures. No failed practice was identified. 2. Review of hospital records showed the NR's blood sugar was 847 (normal range 60-100) and A 1C (blood test that measures your average blood sugar level over the past 3 months) drawn at the hospital was high at 11.5. (the higher the number, the higher your blood glucose levels have been on average. High is over 9.0) Failed practice was found regarding non concentrated sweets not being available. A citation was issued for non-compliance of WAC 388- 78A-2710 (2) Disclosure of services. 3.Review of hospital records showed no indication of the NR having a heart attack. Troponin level (cardiac enzyme) was drawn, which was within normal limits. No failed practice was identified. Conclusion/ Action: D Failed Provider Practice Identified/ Citation(s) Written ~ Failed Provider Practice Not Identified / No Citation Written □ N/A . Investigation Summary Report Provider/Facility: THE COTTAGES AT Provider Type: Assisted Living Facility MARYSVILLE License/Cert.#: 2149 Intake ID: 162124 Compliance Determination #: 50282 Region/Unit#: RCS Region 2 / Unit A Investigator: Karen Glover Investigation Date(s): 09/20/2024 through 02/10/2025 Complainant Contact Date(s): Allegation(s): The Named Resident (NR) did not receive medications as prescribed. Investigation Methods: Sample: Total residents: 42 Resident sample size: 6 Closed records sample size: 0 Observations: Resident rooms Staff to resident interactions Medication administration Interviews: Family members Nursing staff Administrator Record Reviews: Medical records Incident investigation MAR Investigation Summary: NR was receiving assistance with medication management and administration. Staff discovered NR had not received medication as ordered by prescribing medical provider. Facility notified the medical provider and the NR's family. Facility initiated an incident report and placed resident on alert charting. Medical provider ordered weekly lab draw to monitor for any adverse effects. NR required a blood transfusion. Failed practice was identified. A citation was issued for non compliance with WAC 388-78A-2210 (2)(b) Medication Services. Conclusion / Action: ~ Failed Provider Practice Identified/ Citation(s) Written D 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 #: 2149 Compliance Determination # 50282 Plan of Correction THE COTTAGES AT 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 an unannounced on-site complaint investigation on 09/20/2024 and 01/16/2025 of: THE COTTAGES AT MARYSVILLE 1216 GROVE STREET MARYSVILLE, WA 98270 This document references the following complaint number(s): 147689, 147533, 147475, 162124 The following sample was selected for review during the unannounced on-site visit: 6 of 42 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Karen Glover, Complaint Investigator Cynthia Chenot-Potter, Nursing Consultant Institutional From: DSHS, Aging and Long-Term Support Administration 3906-172nd St NE, Suite #100 Arlington, WA 98223 . Statement of Deficiencies License #: 2149 Compliance Determination # 50282 Plan of Correction THE COTTAGES AT 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. 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-2210 Medication services.

citation and first aid; and . 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. WAC 388-78A-2305 Food sanitation. The assisted living facility must: (2) Ensure employees working as food service workers obtain a food worker card according to chapter 246-217 WAC; and WAC 388-78A-2300 Food and nutrition services. (2) The assisted living facility must plan in writing, prepare on-site or provide through a contract with a food service establishment located in the vicinity that meets the requirements of chapter 246-215 WAC, and serve to each resident as ordered: (a) Prescribed general low sodium, general diabetic, and mechanical soft food diets according to a diet manual. The assisted living facility must ensure the diet manual is: (ii) Approved by a dietitian; and (iii) Reviewed and updated as necessary or at least every five years. WAC 388-78A-3090 Maintenance and housekeeping. (1) The assisted living facility must: (a) Provide a safe, sanitary and well-maintained environment for residents; The Department staff who did the On Site verification: Jodi Condyles, ALF Licensor If you have any questions, please contact me at (360)651-6846. Sincerely,~dn, ~ Kimberley Ripley, Field tanagef Region 2, Unit 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 #: 2149 Compliance Determination # 52572 Plan of Correction THE COTTAGES AT 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 and complaint investigation on 01/06/2025, 01/07/2025 and 01/08/2025 of: THE COTTAGES AT MARYSVILLE 1216 GROVE STREET MARYSVILLE, WA 98270 This document references the following complaint numbers: 160462, 161283, 161232. The following sample was selected for review during the unannounced on-site visit: 6 of 39 current residents and 1 former residents. The department staff that inspected the Assisted Living Facility: Cristina Gonzalez, ALF Licensor Melissa Phillips, Long Term Care Surveyor Jodi Condyles, ALF Licensor 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. . Statement of Deficiencies License #: 2149 Compliance Determination # 52572 Plan of Correction THE COTTAGES AT MARYSVILLE Completion 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-3100 Safe storage of supplies and equipment. The assisted living facility must secure potentially hazardous supplies and equipment commensurate with the assessed needs of residents and their functional and cognitive abilities. In determining what supplies and equipment may be accessible to residents, the assisted living facility must consider at a minimum: (1) The residents' characteristics and needs; (2) The degree of hazardousness or toxicity posed by the supplies or equipment; This requirement was not met as evidenced by: Based on observation, record review, and interview, the Assisted Living Facility (ALF) failed to ensure potentially harmful items were safely stored away in 3 of 4 cottages (Dogwood, Cedar, and Alder). This failure resulted in high-risk items being accessible to all 39 memory care residents and placed these residents at risk of harm from exposure to hazardous materials. Findings included… The ALF is a secured memory care unit consisting of four cottages: Dogwood, Cedar, Birch, and Alder. Review of the Resident Characteristics Roster dated 01/06/2025 showed all 39 residents had a diagnosis of . Dogwood Cottage On 01/06/2025 at 10:15 AM, a 222 milliliter (ml) (a unit of measurement) bottle of perineal cleanser was observed in the communal bathroom. The label on the bottle showed “Caution: may cause eye irritation. Avoid contact with eyes. Keep out of reach of children”. . Statement of Deficiencies License #: 2149 Compliance Determination # 52572 Plan of Correction THE COTTAGES AT MARYSVILLE Completion Date On 01/06/2025 at 10:28 AM, an 8.8 fluid ounce (fl oz) (a unit of measurement) bottle of air freshener was observed in an unlocked cabinet in the living room. The label read “Deliberately concentrating and inhaling the contents can be harmful or fatal. Do not spray toward face. If eye contact occurs, rinse well with water. If irritation persists, get medical attention.” Cedar Cottage On 01/06/2025 at 10:34 AM, a 6 fl oz bottle of nail polish remover was observed in an unlocked cabinet in the living area. The label read “Irritating to eyes and mucus membranes. Harmful if inhaled or ingested. In case of accidental ingestion, consult a doctor immediately.” Alder Cottage On 01/06/2025 at 10:57 AM, a 24 fl oz bottle of urine odor eliminator/stain remover was observed in an unlocked cabinet in the living area. The label showed “May cause eye irritation. Avoid all contact with eyes. Do not take internally. Do not ingest. Do not get in eyes, on skin or on clothing. Harmful if swallowed. Avoid contamination of food. If swallowed, drink large amounts of water or milk. See physician. If on skin, wash with water. If in eyes, flush with large amounts of flowing water for at least 15 minutes. See physician.” On 01/06/2025 at 10:58 AM, a one-pound bottle of disinfecting wipes was observed in an unlocked cabinet in the living area. The label showed “HAZARDOUS TO HUMAN AND DOMESTIC ANIMALS. CAUTION: Causes moderate eye irritation. Avoid contact with eyes or clothing. Wash thoroughly with soap and water after handling. FIRST AID: Call a poison control center for treatment advice. Have the product container or label with you when calling a poison control center or doctor or going for treatment.” On 01/06/2025 at 10:59 AM, a 5 fl oz bottle of vanilla universal fragrance oil was observed in an unlocked cabinet above the microwave. The label read “WARNING: Not for use on skin, avoid contact with eyes. Keep out of the reach of children and pets.” On 01/06/2025 at 10:42 AM, Staff I, Maintenance Director, stated that the chemicals found throughout the tour should be kept in the locked supply closet located in each cottage where it is not accessible to the residents. Plan/Attestation Statement . Statement of Deficiencies License #: 2149 Compliance Determination # 52572 Plan of Correction THE COTTAGES AT MARYSVILLE 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, THE COTTAGES AT MARYSVILLE 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; (d) Cardiopulmonary resuscitation and first aid; and This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure staff completed a 70-hour Basic training course prior to providing unsupervised direct care to residents for 1 of 4 staff (Staff C) and Cardiopulmonary Resuscitation (CPR) and first aid training for 2 of 6 staff (Staff B and C). This failure resulted in Staff B and C not having the necessary training related to their job duties and expectations and placed all 39 residents at risk for compromised care and safety. Findings included… Basic Training Review of the ALF’s employee files showed Staff C, Caregiver, was hired on 08/20/2024. Staff C’s file showed no record of a completed 70-hour Basic training course within 120 days of hire. On 01/07/2025 at 1:12 PM, Staff K, Business Office Manager, stated that they have care staff use a specific training center across the street from the ALF.

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 #: 2149 Compliance Determination # 47534 Plan of Correction THE COTTAGES AT 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 an unannounced on-site complaint investigation on 09/20/2024 and 09/20/2024 of: THE COTTAGES AT MARYSVILLE 1216 GROVE STREET MARYSVILLE, WA 98270 This document references the following complaint number(s): 144122, 144576, 147045 The following sample was selected for review during the unannounced on-site visit: 0 of 42 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Karen Glover, 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 #: 2149 Compliance Determination # 47534 Plan of Correction THE COTTAGES AT MARYSVILLE Completion Date Administrator (or Representative) Date WAC 388-78A-24701 Background checks Employment Nondisqualifying information. (1) If the background check results show that an employee or prospective employee has a criminal conviction or pending charge for a crime that is not a disqualifying crime under chapter 388-113 WAC, then the assisted living facility must determine whether the person has the character, competence and suitability to work with vulnerable adults in long-term care. This requirement was not met as evidenced by: Based on interview and record review the Assisted Living Facility (ALF) failed to ensure a staff member with reported information on a fingerprint background check had a Character, Competence and Suitability review completed. The failure resulted in a staff member being hired, with no review being completed to identify if the staff member was suitable to work with vulnerable adults. Findings included… Record review of a Final Fingerprint Background Check Result dated 08/20/2022 showed Staff C, Caregiver, had "information reported by one or more background check sources that requires a Character, Competence and Suitability review." On 09/23/2024 at 2:39 PM, Staff A, Executive Director, stated that they did not complete a Character, Competence and Suitability review form for Staff C. Staff A stated the background check came back with no records attached to review. On 11/05/2024 at 08:47 AM, in an email from the Background Check Central Unit (BCCU), they stated the reason there was no record to review was because it was a Federal Bureau of Investigation (FBI) record, and that information needed to be provided to the ALF by the applicant. Plan/Attestation Statement . Statement of Deficiencies License #: 2149 Compliance Determination # 47534 Plan of Correction THE COTTAGES AT MARYSVILLE 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, THE COTTAGES AT MARYSVILLE 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 . . Statement of Deficiencies License #: 2149 Compliance Determination # 26558 Plan of Correction THE COTTAGES AT MARYSVILLE Completion Date Administrator (or Representative) Date WAC 388-78A-2610 Infection control. (1) The assisted living facility must institute appropriate infection control practices in the assisted living facility to prevent and limit the spread of infections. This requirement was not met as evidenced by: Based on record review and interview the Assisted Living Facility (ALF) failed to follow required infection control measures to prevent infectious respiratory disease by ensuring all staff were current on their fit testing for N-95 respirators. This failure placed all residents, staff, and visitors at risk of contracting a respiratory infection. Findings included… Review of Washington Administrative Code 296-842-15005 (2)(a)(b) showed the ALF will provide fit testing (a fit test tests the seal between the respirator facepiece and the wearer’s face) before employees are assigned duties that may require the use of respirators and at least every twelve months after the initial testing. Record review of the ALF’s Respiratory Protection Program policy dated 05/01/2023 showed: Medical Evaluation Employees who are required to wear respirators must complete a medical evaluation check sheet and meet the criteria prior to being approved to wear a respirator. Any employee refusing the medical evaluation will not be allowed to work in an area requiring respirator use. Fit Testing Employees who are required to wear tight fitting air purifying respirators will be fit tested: *prior to being allowed to wear any respirator with a tight-fitting face piece*annually, or when there are changes in the employee’s physical condition that could affect fit e.g., obvious change in body weight, facial scarring, etc.). Employees will be fit tested with the make, model, and size of respirator that they will actually wear. Employees will be provided with several models and sizes of respirators so that they may find an optimal fit. NOTE: This may not be feasible during times of respirator shortages, such as during a pandemic. In those cases, Facility will follow OSHA and CDC interim guidelines for fit testing. Facility Administrator or designee will conduct fit tests in accordance with the OSHA . Statement of Deficiencies License #: 2149 Compliance Determination # 26558 Plan of Correction THE COTTAGES AT MARYSVILLE Completion Date Respiratory Protection Standard. N95 respirators will be fit tested with a qualitative fit test protocol using an aerosol solution or either saccharin or Bitrex®. Documentation and Recordkeeping A written copy of this program and the OSHA Respiratory Protection Standard shall be kept in the Program Administrator’s office and made available to all employees who wish to review it. Copies of training and fit test records shall be maintained by the Program Administrator or designee. These records will be updated as new employees are trained, as existing employees receive refresher training, and as new fit tests are conducted. For employees covered under the Respiratory Protection Program, the Program Administrator shall maintain copies of the medical evaluation for employee’s ability to wear a respirator. The completed medical questionnaires and evaluations will remain confidential in the employee’s records. Record review of the ALF’s staff list dated 07/13/2023 showed 28 current staff members. In an interview on 07/13/2023 at 10:15 AM, Staff A, Executive Director stated that the current staff have not been fit tested. Staff A just completed the online training and Staff A and Staff B would receive the remainder of the training in August. Staff A stated that they were not aware they needed to have the staff fit tested until it was brought to their attention by a staff member. 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, THE COTTAGES AT MARYSVILLE 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 . . . .