Summer Wood Alzheimer's Special Care Center.

Statement of Deficiencies License #: 2514 Compliance Determination # 67616 Plan of Correction Summer Wood Alzheimer's Special Care Center 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 10/23/2025 of: Summer Wood Alzheimer's Special Care Center 830 NW Sunburst Ct Moses Lake, WA 98837 This document references the following SOD dated: 10/23/2025 The following sample was selected for review during the unannounced on-site visit: 5 of 55 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Carla Rose, NCI Community Licensor From: DSHS, Aging and Long-Term Support Administration 8517 E Trent Ave, Ste 102 Spokane Valley, WA 99212 . Statement of Deficiencies License #: 2514 Compliance Determination # 67616 Plan of Correction Summer Wood Alzheimer's Special Care Center 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-2600 Policies and procedures. (1) The assisted living facility must develop and implement policies and procedures in support of services that are provided and are necessary to: (a) Maintain or enhance the quality of life for residents including resident decision-making rights; (b) Provide the necessary care and services for residents, including those with special needs; This requirement was not met as evidenced by: Based on interview and record review, the facility failed to implement their bowel monitoring policy for 1 of 3 residents (Resident 6) sampled for monitoring. This failed practice resulted in the absence of bowel monitoring and placed Resident 6 at risk of health complications. Findings included… Review of the facility’s policy titled, “Bowel Monitoring,” dated 06/20/2024, showed “under the direction of the LN [License Nurse] or state approved evaluator, monitor the bowel pattern of residents on hospice [end of life care] or who have significant dementia [cognitive decline] if warranted.” The policy showed that it included instructions that the LN or approved evaluator would initiate the monitoring, the caregiver/medication technician would track the bowel pattern in the electronic record, the medication record would include bowel records to be checked daily, if no bowel movement (BM) in four days to follow bowel regimen, and to report to the resident care coordinator or LN if it had been four days without a BM or per doctors orders. . Statement of Deficiencies License #: 2514 Compliance Determination # 67616 Plan of Correction Summer Wood Alzheimer's Special Care Center Completion Date Review of Resident 6’s Individual Service Plan (ISP, the facility’s titled negotiated service agreement), dated 08/01/2025, showed the resident had a diagnosis of and . The ISP showed that the resident received medication administration assistance from staff. Further review showed Resident 6's communication was “word salad” (speech that is a jumbled mix of words and phrases that lack coherent meaning). Review of Resident 6’s assessment, dated 08/01/2025, showed that the resident was “not able to effectively express their selves and/or make their needs/wishes known due to physical or cognitive impairment.” Review of Resident 6’s October 2025 Medication Administration Record (MAR), showed orders for daily and PRN (as needed) medications to relieve constipation. The MAR showed the resident was prescribed the following bowel medications: -polyethylene glycol (for constipation) to be administered daily -bisacodyl (for constipation) suppository as needed if no BM after eight hours -milk of magnesium (for constipation) daily as needed if no BM in three days -polyethylene glycol as needed if no BM after six shifts -Senna laxative (for constipation) as needed if no BM after seven shifts -Saline/sodium phosphate enema (for constipation) as needed if no BM after nine shifts. Further review of the October 2025 MAR showed there were no PRN bowel medications administered to Resident 6. In an interview on 10/23/2025 at 11:55 AM, Staff I, Medication Technician, stated that caregivers were responsible for tracking resident bowel movements. Staff I stated they did not give PRN bowel medications unless a caregiver told them the resident had not had a bowel movement (BM) in two days. Staff I then showed the department the electronic bowel monitoring tracking system on their computer. Staff I was unable to locate any bowel tracking for Resident 6. In an interview on 10/23/2025 at 12:30 PM, Resident 6 was asked basic questions about who they were, how their day was, what they ate, where they lived, and who took care of them. Resident 6 was able to state who they were but was unable to answer other questions and only gave answers that were nonsensical and disorganized (lack of logical and linear thought, resulting in communication that is jumbled, incoherent, or irrelevant). In an interview on 10/23/2025 at 12:35 PM, Staff J, Caregiver, stated they had worked at the facility for two months. Staff J was asked if they had worked directly with Resident 6 during that time and Staff J confirmed they did. Staff J was asked if Resident 6 had the ability to accurately answer questions such as what they had for breakfast or when their . Statement of Deficiencies License #: 2514 Compliance Determination # 67616 Plan of Correction Summer Wood Alzheimer's Special Care Center Completion Date last bowel movement (BM) was. Staff J stated “no” and went on to say that Resident 6 would not be able to remember anything that had happened more than an hour ago. In an interview on 10/23/2025 at 2:45 PM, Staff A, Executive Director, confirmed that their BM monitoring policy had not changed since the full inspection. Staff A then stated that they only monitored BMs for residents on hospice and those that could not express pain. Staff A further stated that they did not monitor Resident 6’s bowel movements because they could express pain. When asked how they would know how many days it had been since Resident 6 had a BM, Staff A was unable to provide an answer. When the department discussed their policy and that it specifically stated they monitored BMs of “residents with severe dementia”, Staff A stated, “if that’s the case then everyone would have to be monitored.” This is an uncorrected deficiency previously cited on 08/28/2025. 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, Summer Wood Alzheimer's Special Care Center 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 . STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 8517 E Trent Ave, Ste 102, Spokane Valley, WA 99212 Statement of Deficiencies License #: 2514 Compliance Determination # 64686 Plan of Correction Summer Wood Alzheimer's Special Care Center 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 08/19/2025, 08/20/2025, 08/21/2025, 08/22/2025 and 08/25/2025 of: Summer Wood Alzheimer's Special Care Center 830 NW Sunburst Ct Moses Lake, WA 98837 This document references the following complaint numbers: 192186. The following sample was selected for review during the unannounced on-site visit: 10 of 49 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Patricia Eddy, Community Licensor Veronica Jackson, Assisted Living Facility Licensor From: DSHS, Aging and Long-Term Support Administration 8517 E Trent Ave, Ste 102 Spokane Valley, WA 99212 . Statement of Deficiencies License #: 2514 Compliance Determination # 64686 Plan of Correction Summer Wood Alzheimer's Special Care Center 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.

This document was prepared by Residential Care Services for the Locator website. STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 8517 E Trent Ave, Ste 102, Spokane Valley, WA 99212 Statement of Deficiencies License #: 2514 Compliance Determination # 67616 Plan of Correction Summer Wood Alzheimer's Special Care Center Completion Date Page 1 of 4 Licensee: Summer Wood OpCo LLC 10/23/2025 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 10/23/2025 of: Summer Wood Alzheimer's Special Care Center 830 NW Sunburst Ct Moses Lake, WA 98837 This document references the following SOD dated: 10/23/2025 The following sample was selected for review during the unannounced on-site visit: 5 of 55 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Carla Rose, NCI Community Licensor From: DSHS, Aging and Long-Term Support Administration Residential Care Services, Region 1 , Unit B 8517 E Trent Ave, Ste 102 Spokane Valley, WA 99212 This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2514 Compliance Determination # 67616 Plan of Correction Summer Wood Alzheimer's Special Care Center Completion Date Page 2 of 4 Licensee: Summer Wood OpCo LLC 10/23/2025 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. Residential Care Services 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-2600 Policies and procedures. (1) The assisted living facility must develop and implement policies and procedures in support of services that are provided and are necessary to: (a) Maintain or enhance the quality of life for residents including resident decision-making rights; (b) Provide the necessary care and services for residents, including those with special needs; This requirement was not met as evidenced by: Based on interview and record review, the facility failed to implement their bowel monitoring policy for 1 of 3 residents (Resident 6) sampled for monitoring. This failed practice resulted in the absence of bowel monitoring and placed Resident 6 at risk of health complications. Findings included… Review of the facility’s policy titled, “Bowel Monitoring,” dated 06/20/2024, showed “under the direction of the LN [License Nurse] or state approved evaluator, monitor the bowel pattern of residents on hospice [end of life care] or who have significant dementia [cognitive decline] if warranted.” The policy showed that it included instructions that the LN or approved evaluator would initiate the monitoring, the caregiver/medication technician would track the bowel pattern in the electronic record, the medication record would include bowel records to be checked daily, if no bowel movement (BM) in four days to follow bowel regimen, and to report to the resident care coordinator or LN if it had been four days without a BM or per doctors orders. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2514 Compliance Determination # 67616 Plan of Correction Summer Wood Alzheimer's Special Care Center Completion Date Page 3 of 4 Licensee: Summer Wood OpCo LLC 10/23/2025 Review of Resident 6’s Individual Service Plan (ISP, the facility’s titled negotiated service agreement), dated 08/01/2025, showed the resident had a diagnosis of and . The ISP showed that the resident received medication administration assistance from staff. Further review showed Resident 6's communication was “word salad” (speech that is a jumbled mix of words and phrases that lack coherent meaning). Review of Resident 6’s assessment, dated 08/01/2025, showed that the resident was “not able to effectively express their selves and/or make their needs/wishes known due to physical or cognitive impairment.” Review of Resident 6’s October 2025 Medication Administration Record (MAR), showed orders for daily and PRN (as needed) medications to relieve constipation. The MAR showed the resident was prescribed the following bowel medications: -polyethylene glycol (for constipation) to be administered daily -bisacodyl (for constipation) suppository as needed if no BM after eight hours -milk of magnesium (for constipation) daily as needed if no BM in three days -polyethylene glycol as needed if no BM after six shifts -Senna laxative (for constipation) as needed if no BM after seven shifts -Saline/sodium phosphate enema (for constipation) as needed if no BM after nine shifts. Further review of the October 2025 MAR showed there were no PRN bowel medications administered to Resident 6. In an interview on 10/23/2025 at 11:55 AM, Staff I, Medication Technician, stated that caregivers were responsible for tracking resident bowel movements. Staff I stated they did not give PRN bowel medications unless a caregiver told them the resident had not had a bowel movement (BM) in two days. Staff I then showed the department the electronic bowel monitoring tracking system on their computer. Staff I was unable to locate any bowel tracking for Resident 6. In an interview on 10/23/2025 at 12:30 PM, Resident 6 was asked basic questions about who they were, how their day was, what they ate, where they lived, and who took care of them. Resident 6 was able to state who they were but was unable to answer other questions and only gave answers that were nonsensical and disorganized (lack of logical and linear thought, resulting in communication that is jumbled, incoherent, or irrelevant). In an interview on 10/23/2025 at 12:35 PM, Staff J, Caregiver, stated they had worked at the facility for two months. Staff J was asked if they had worked directly with Resident 6 during that time and Staff J confirmed they did. Staff J was asked if Resident 6 had the ability to accurately answer questions such as what they had for breakfast or when their This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2514 Compliance Determination # 67616 Plan of Correction Summer Wood Alzheimer's Special Care Center Completion Date Page 4 of 4 Licensee: Summer Wood OpCo LLC 10/23/2025 last bowel movement (BM) was. Staff J stated “no” and went on to say that Resident 6 would not be able to remember anything that had happened more than an hour ago. In an interview on 10/23/2025 at 2:45 PM, Staff A, Executive Director, confirmed that their BM monitoring policy had not changed since the full inspection. Staff A then stated that they only monitored BMs for residents on hospice and those that could not express pain. Staff A further stated that they did not monitor Resident 6’s bowel movements because they could express pain. When asked how they would know how many days it had been since Resident 6 had a BM, Staff A was unable to provide an answer. When the department discussed their policy and that it specifically stated they monitored BMs of “residents with severe dementia”, Staff A stated, “if that’s the case then everyone would have to be monitored.” This is an uncorrected deficiency previously cited on 08/28/2025. 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, Summer Wood Alzheimer's Special Care Center is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date This document was prepared by Residential Care Services for the Locator website. STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 8517 E Trent Ave, Ste 102, Spokane Valley, WA 99212 Statement of Deficiencies License #: 2514 Compliance Determination # 64686 Plan of Correction Summer Wood Alzheimer's Special Care Center Completion Date Page 1 of 15 Licensee: Summer Wood OpCo LLC 08/28/2025 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 08/19/2025, 08/20/2025, 08/21/2025, 08/22/2025 and 08/25/2025 of: Summer Wood Alzheimer's Special Care Center 830 NW Sunburst Ct Moses Lake, WA 98837 This document references the following complaint numbers: 192186. The following sample was selected for review during the unannounced on-site visit: 10 of 49 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Patricia Eddy, Community Licensor Veronica Jackson, Assisted Living Facility Licensor From: DSHS, Aging and Long-Term Support Administration Residential Care Services, Region 1 , Unit B 8517 E Trent Ave, Ste 102 Spokane Valley, WA 99212 This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2514 Compliance Determination # 64686 Plan of Correction Summer Wood Alzheimer's Special Care Center Completion Date Page 2 of 15 Licensee: Summer Wood OpCo LLC 08/28/2025 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. Residential Care Services 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-2600 Policies and procedures. (1) The assisted living facility must develop and implement policies and procedures in support of services that are provided and are necessary to: (a) Maintain or enhance the quality of life for residents including resident decision-making rights; (b) Provide the necessary care and services for residents, including those with special needs; This requirement was not met as evidenced by: Based on interview and record review, the facility failed to implement their policy to provide bowel monitoring for residents with significant dementia for 3 of 7 residents (Resident 3, 4, and 6). This failure placed the residents at risk of discomfort, pain and health complications. Findings included…. Review of the facility’s policy titled, “Bowel Monitoring,” dated 06/20/2024, showed that it stated the purpose of the policy was to provide residents with significant dementia (memory loss) or who were on hospice (end of life care) a method of tracking their bowel pattern. The policy stated, under the direction of the LN (Licensed Nurse) or state approved evaluator, to monitor the bowel pattern of residents on hospice or who have significant dementia, if warranted. Further review showed instructions to follow the procedure of monitoring, including reporting to the RCC (Resident Care Coordinator) or LN when the resident is unable to move their bowels within four days or per their MD (Medical Doctor) ordered bowel protocol. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2514 Compliance Determination # 64686 Plan of Correction Summer Wood Alzheimer's Special Care Center Completion Date Page 3 of 15 Licensee: Summer Wood OpCo LLC 08/28/2025 In an interview on 08/20/2025 at 8:30 AM, Staff A, Executive Director, stated that they only monitored bowel movements for residents who were on hospice care or for residents who had received medications given as needed for constipation to evaluate effectiveness. Staff A confirmed there were many residents who would be unable to state when their last bowel movement was due to cognitive deficits and if they were not on bowel monitoring. Staff A further stated that the facility would only know residents were constipated if they displayed signs of abdominal pain and abdominal distention. <Resident 3> Review of Resident 3’s Nurse Delegation Visit form, dated 06/04/2025 and completed by the facility’s Registered Nurse Delegator (RND), showed that the resident required medication administration by facility staff under RND supervision related to Alzheimer's (disease that causes memory loss, difficulty thinking and loss of body functions). Review of Resident 3’s Individualized Service Plan (ISP, the facility’s titled negotiated service agreement), dated 08/15/2025, showed that the resident had a diagnosis of , was wheelchair and bed bound, and required two staff and a mechanical lift for all transfers. The ISP showed that staff would notify the LN if the resident did not have a bowel movement in three or more days or if the resident had “few” bowel movements, straining to go, hard or small stools or a sense that everything did not come out or saw belly bloating. Review of Resident 3’s Medication Administration Records (MARs), dated May 2025, June 2025, July 2025, and August 2025, showed an order to give milk of magnesium, beginning on 07/24/2024, daily as needed for constipation. Further review showed the order had not been given once in the months reviewed. In an interview on 08/21/2025 at 4:05 PM, Staff A stated that Resident 3 had significant dementia. Review of Resident 3's undated facility record showed no bowel monitoring as required by the facility's policy. <Resident 4> Review of Resident 4’s Nurse Delegation Visit form, dated 06/04/2025 and completed by the facility’s RND, showed that the resident required medication administration by facility staff under RND supervision related to dementia. Review of Resident 4’s ISP, dated 07/07/2025, showed that the resident had a diagnosis of and , was non-ambulatory using a wheelchair, required staff assistance for all transfers, and required medication administration from staff. Further review showed that the resident required assistance from staff with all hygiene needs and was mostly unable to communicate. The ISP showed that staff would notify the LN if the resident did not have a bowel movement in three or more days or if the resident had “few” bowel movements, straining to go, hard or small stools or a sense that This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2514 Compliance Determination # 64686 Plan of Correction Summer Wood Alzheimer's Special Care Center Completion Date Page 4 of 15 Licensee: Summer Wood OpCo LLC 08/28/2025 everything did not come out or saw belly bloating. Review of Resident 4’s MARs, dated May 2025, June 2025, July 2025, and August 2025, showed orders for milk of magnesium, beginning on 07/24/2024, and polyethylene glycol (laxative), beginning on 03/07/2025, daily as needed for constipation. Further review showed neither medication had been given in the months reviewed. In an interview on 08/21/2025 at 2:19 PM, Staff D, Medication Technician, stated that they did not recall when Resident 4’s last bowel movement was and that their bowel movements were not monitored. Review of Resident 4's undated facility record showed no bowel monitoring as required by the facility's policy. <Resident 6> Review of Resident 6’s ISP, dated 07/04/2025, showed that the resident had a diagnosis of and , required two staff for all transfers, and required medication administration from staff. Further review showed that the resident required assistance from staff with all hygiene needs and that their speech was nonsensical at times. Review of Resident 6’s MARs, dated June 2025, July 2025, and August 2025, showed orders beginning on 06/27/2025 for milk of magnesium daily as needed for constipation, bisacodyl as needed for constipation if no bowel movement after eight hours, polyethylene glycol as needed for constipation if no bowel movement after six shifts, Senna laxative as needed for constipation if no bowel movement after seven shifts, and a saline/sodium phosphate enema as needed for constipation if no bowel movement after nine shifts. Further review showed none had been given once in the months reviewed. Review of Resident 6’s Nurse Delegation Visit form, dated 07/21/2025 and completed by the facility’s RND, showed that the resident required medication administration by facility staff under RND supervision due to functional and/or cognitive impairment. In an interview on 08/21/2025 at 2:19 PM, Staff D, stated that they did not recall when the resident 6’s last bowel movement was and that their bowel movements were not monitored. Review of Resident 6's undated facility record showed no bowel monitoring as required by the facility's policy. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2514 Compliance Determination # 64686 Plan of Correction Summer Wood Alzheimer's Special Care Center Completion Date Page 5 of 15 Licensee: Summer Wood OpCo LLC 08/28/2025 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, Summer Wood Alzheimer's Special Care Center 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-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 (b) Respond appropriately when there are observable or reported changes in the resident's physical, mental, or emotional functioning. This requirement was not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure health care services were coordinated for foot and wound care for 3 of 3 residents (Resident 1, 2, and 3). This failure resulted in Resident 1 and Resident 3 not receiving podiatry care and Resident 2 not receiving home health treatment and placed the residents at risk for infection and health complications from not receiving treatment as ordered. Findings included… <Resident 1> Review of Resident 1’s Individualized Service Plan (ISP, the facility’s titled negotiated service agreement), dated 06/10/2025, showed that the resident had diagnoses of and . Further review showed that the resident ambulated independently with a walker and required staff assistance with coordinating transportation and/or appointments. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2514 Compliance Determination # 64686 Plan of Correction Summer Wood Alzheimer's Special Care Center Completion Date Page 6 of 15 Licensee: Summer Wood OpCo LLC 08/28/2025 Review of Resident 1’s Physician’s Progress Notes, dated 03/08/2025 and written by the podiatrist (foot doctor) that provided podiatry (foot) care in the facility, showed that Resident 1 was seen that day for foot care due to increased risk status, had callouses to both heels, onychomycosis (a fungal infection to nails), required debridement (thinning of nails to decrease pressure on the nail), and suggested a follow up in two to three months. Observation on 08/21/2025 at 9:50 AM, showed Resident 1’s left foot toenails were yellow and thick and that the great toe and third toenails were approximately a half inch longer than the toenail beds. Review of Resident 1’s record did not show any further documentation of coordinated podiatrist visits or follow-up visits after the 03/08/2025 physician's progress note. <Resident 3> Review of Resident 3’s ISP, dated 08/15/2025, showed that the resident had a diagnosis of , required assistance with all care, and that the facility staff were to set up all appointments and coordinate the resident’s transportation. Review of Resident 3’s After Visit Summary of Podiatry Care, dated 03/04/2025, showed that the resident was seen for at risk foot care, had absent pulses on both feet due to peripheral vascular disease (decreased circulation in arms and legs), hammertoes (deformed toe joint) on two toes on each foot, had thickened elongated toenails on both feet that required debridement, and recommended a follow up visit in two to three months. Review of Resident 3’s record did not show any further documentation of a coordinated follow-up for podiatry care. In an interview on 08/21/2025 at 4:00 PM, Staff A, Executive Director, stated that the facility’s podiatrist had stopped coming a couple of months previously and they had not been able to arrange for another provider that would come to the facility to treat the residents. <Resident 2> Review of Resident 2’s shower logs, dated 05/29/2025, 06/02/2025, 06/05/2025, 06/09/2025, 06/12/2025, 06/16/2025, 06/19/2025, 06/23/2025, 06/26/2025, 06/30/2025, 07/03/2025, and 07/07/2025, showed that a blister was observed on the resident’s right heel. Further review showed that the Licensed Nurse (LN) was notified on every log. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2514 Compliance Determination # 64686 Plan of Correction Summer Wood Alzheimer's Special Care Center Completion Date Page 7 of 15 Licensee: Summer Wood OpCo LLC 08/28/2025 Review of Resident 2’s Wound/Skin Observation Log note, dated 06/08/2025, showed Staff A assessed the blister, notified the resident’s provider, and requested a home health referral. Review of Resident 2’s After Visit Summary of Primary Care, dated 06/13/2025, showed that the resident's health care provider submitted a referral for home health treatment. Review of fax and phone communication with the home health provider showed that the referral was originally faxed on 06/20/2025. The fax showed the home health provider told the facility they were unable to staff the referral on 06/27/2025. In an interview on 08/25/2025 at 10:43 AM, Staff B, Resident Care Coordinator, stated that they could not provide any documentation that the resident’s provider was contacted about the home health provider not being able to provide home health treatment. Staff B stated the home health provider was not contacted prior to 06/20/2025 or after 06/27/2025. In an interview on 08/25/2025 at 11:30 AM, Staff A stated they could not provide any documentation that they had contacted the resident’s provider to inform them that they were treating the wound or update them on the status. Staff A stated the process for skin checks was for the caregiver to document on the shower log and put the log in the resident care coordinator’s mailbox for review. The resident care coordinator was to then notify Staff A. Staff A stated they had no explanation as to why they were not aware of the wound until ten days after it was first documented, other than it had occurred right before a holiday weekend. Review of Resident 2’s ISP, dated 06/28/2025, showed that the resident had diagnoses of and . The ISP showed no documentation of any guidance or interventions for skin checks. The ISP did not include any information regarding the need for home health treatment. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2514 Compliance Determination # 64686 Plan of Correction Summer Wood Alzheimer's Special Care Center Completion Date Page 8 of 15 Licensee: Summer Wood OpCo LLC 08/28/2025 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, Summer Wood Alzheimer's Special Care Center 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-2130 Service agreement planning. The assisted living facility must: (3) Review and update each resident's negotiated service agreement consistent with WAC 388-78A- 2120 : (a) Within a reasonable time consistent with the needs of the resident following any change in the resident's physical, mental, or emotional functioning; and (b) Whenever the negotiated service agreement no longer adequately addresses the resident's current assessed needs and preferences. This requirement was not met as evidenced by: Based on observation, interview and record review, the facility failed to update negotiated service agreements for 2 of 7 residents (Resident 1 and 4). This failure placed residents at risk of not receiving adequate care and services. Findings included…. <Resident 1> Review of Resident 1’s Physician’s Progress Notes, dated 03/08/2025 and written by the resident's podiatrist (food doctor), showed that Resident 1 was seen that day for foot care due to increased risk status, had callouses to both heels, onychomycosis (a fungal infection to nails), required debridement (thinning of nails to decrease pressure on the nail), and suggested a follow up in two to three months. Review of Resident 1’s Medication Administration Records (MARs), dated May 2025, June 2025, July 2025, August 2025 showed an order for routine oxygen to be applied every night at 8:00 PM after checking oxygen saturation levels (measurement of oxygen in the blood) and to recheck at 2:00 AM to adjust oxygen liters as necessary. Further review showed the oxygen treatment started on 03/04/2025. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2514 Compliance Determination # 64686 Plan of Correction Summer Wood Alzheimer's Special Care Center Completion Date Page 9 of 15 Licensee: Summer Wood OpCo LLC 08/28/2025 Observation on 08/20/2025 at 12:02 PM, showed an oxygen concentrator with a nasal cannula attached, next to Resident 1’s bed in their room. In an interview on 08/21/2025 at 10:50 AM, Staff A, Executive Director, stated that they were not aware that Resident 1 required oxygen at night. In an interview on 08/21/2025 at 11:05 AM, Staff B, Resident Care Coordinator, stated that they did not see that Resident 1 required oxygen on their quarterly service plan. In an interview on 08/21/2025 at 3:00 PM, Staff D, Medication Technician, stated that Resident 1 had an order to check oxygen saturation levels every night at bedtime and that the resident required oxygen based on those saturation levels every night. Staff D further stated that they did apply oxygen to Resident 1 nightly when they worked and were assigned to Resident 1. Review of Resident 1’s Individualized Service Plan (ISP, the facility’s titled negotiated service agreement), dated 06/10/2025, showed no documentation of the resident’s need for podiatry care (foot care) or instructions for staff to assist with oxygen treatment. <Resident 4> Review of Resident 4’s Nurse Delegation Visit form, dated 12/17/2024, showed the resident required two staff assistance with a gait belt for transfers and two staff assistance with toileting. Review of Resident 4’s Nurse Delegation Visit form, dated 06/04/2025, showed that the resident required medication administration by facility staff under Registered Nurse Delegator (RND) supervision due to dementia (memory loss), hypertension (high blood pressure), and pacemaker (a small, implantable medical device that helps regulate the heart's rhythm). In an interview on 08/21/2025 at 2:19 PM, Staff D, Medication Technician, stated Resident 4 required two staff assistance for transfers and toileting. Review of Resident 4’s ISP, dated 07/07/2025, showed that the resident had a diagnosis of and had a pacemaker. The ISP showed no documentation of the need for assistance by two facility staff with a gait belt for transfers and toileting. This ISP showed no documentation of any guidance or interventions for a pacemaker. The ISP further showed contradicting documentation in the pacemaker section of the ISP, showing the resident did not have a pacemaker. The ISP did not include any information regarding the need for nurse delegation. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2514 Compliance Determination # 64686 Plan of Correction Summer Wood Alzheimer's Special Care Center Completion Date Page 10 of 15 Licensee: Summer Wood OpCo LLC 08/28/2025 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, Summer Wood Alzheimer's Special Care Center 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-2461 Background checks General. (1) Background checks conducted by the department and required in this chapter include: (a) Washington state name and date of birth background checks; and (b) After January 7, 2012, a national fingerprint background check in accordance with RCW 74.39A.056 . This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure that staff had a Washington state name and date of birth background check completed upon hire and a fingerprint back round check within 120 days, for 1 of 5 staff (Staff A). This failure placed residents at risk of receiving unsupervised care and services from a potentially disqualified staff. Findings included…. Review of Staff A’s, Executive Director, personnel file showed that they were hired on 11/20/2024. Further review showed that a Washington state name and date of birth background check was completed on 05/27/2025. Further review showed that a fingerprint background check was completed on 08/25/2025. In an interview on 08/25/2025 at 12:01 PM, Staff H, Business Office Manager, confirmed Staff A’s initial background check was not completed until 5/27/2025. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2514 Compliance Determination # 64686 Plan of Correction Summer Wood Alzheimer's Special Care Center Completion Date Page 11 of 15 Licensee: Summer Wood OpCo LLC 08/28/2025 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, Summer Wood Alzheimer's Special Care Center 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-2466 Background checks Washington state name and date of birth background check Valid for two years National fingerprint background check Valid indefinitely. (1) A Washington state name and date of birth background check is valid for two years from the initial date it is conducted. The assisted living facility must ensure: (a) A new DSHS background authorization form is submitted to the department's background check central unit every two years for all administrators, caregivers, staff persons, volunteers and students; and This requirement was not met as evidenced by: Based interview and record review, the facility failed to ensure that a Washington state name and date of birth background check was completed every two years for 1 of 2 staff (Staff E). This failure placed all residents at risk of by receiving care and services from a potentially disqualified staff. Findings included…. Review of Staff E’s, Caregiver, personnel file showed that the most recent Washington state name and date of birth background check was completed on 05/30/2025 and the prior background check was completed on 06/22/2022. In an interview on 08/25/2025 at 2:00 PM, Staff A, Executive Director, confirmed that Staff E’s background checks had not been completed every two years as required. This is a recurring citation previously cited on 05/16/2023. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2514 Compliance Determination # 64686 Plan of Correction Summer Wood Alzheimer's Special Care Center Completion Date Page 12 of 15 Licensee: Summer Wood OpCo LLC 08/28/2025 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, Summer Wood Alzheimer's Special Care Center 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-2930 Communication system. (1) The assisted living facility must: (a) Provide residents and staff persons with the means to summon on-duty staff assistance from all resident-accessible areas including: (ii) Resident living rooms and resident sleeping rooms; and (iii) Corridors, as well as common and outdoor areas accessible to residents. (b) Provide the resident with personal wireless communication devices, such as pendants or wristbands, when a communication device is not installed in the resident's sleeping room, and when wireless communications are used: (i) The system must be designed and installed consistent with industry standards and perform reliably throughout the facility; and This requirement was not met as evidenced by: Based on observation and interview, the facility failed to ensure there was a communication system available to request assistance for 4 of 4 residents (Resident 8, 9, 10 and 30) sampled for communication systems and 5 of 5 facility hallways (Hallway 1, 2, 3, 4, and 5). This failure placed residents at risk for falls and decreased quality of life by not being able to request staff assistance when needed. Findings included…. In an interview on 08/20/2025 at 9:45 AM, Resident 8 stated that they did not have a call light in their room or a pendant to call for staff assistance. Resident 8 further stated that they needed to use their personal phone to call for help when they need assistance. Observation on 08/20/2025 at 2:00 PM, showed no communication system in Resident 10’s bedroom. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2514 Compliance Determination # 64686 Plan of Correction Summer Wood Alzheimer's Special Care Center Completion Date Page 13 of 15 Licensee: Summer Wood OpCo LLC 08/28/2025 Observation on 08/21/2025 at 2:07 PM, showed no communication system in Resident 30’s room. Observation on 08/22/2025 at 11:05 AM, showed no communication system in Resident 8’s room. In an interview at that time, Staff B, Resident Care Coordinator, confirmed that other resident rooms did not have call lights or pull cords and that the facility did not use a pendant system for residents to request assistance from staff when in their rooms. In an interview on 08/22/2025 at 1:30 PM, Staff G, Medication Technician, stated that for as long as they had worked at the facility (since 2013), there had not been a call light system or pendant system for residents to summon staff assistance. In an interview on 08/20/2025 at 3:00 PM, Resident 9 stated that they did not have a call light or pendant to request help when needed and that they have “yelled” for help when they needed assistance from staff. Observation on 08/22/2025 at 11:15 AM, during an environmental inspection of the facility’s five hallways (Hall 1, 2, 3, 4, and 5) showed residents walked through the five hallways. Further observation showed no communication system for residents to request assistance from staff. In an interview on 08/22/2025 at 11:48 AM, Resident 10 stated that they had no call light in their room and had to whistle or yell for staff assistance. 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, Summer Wood Alzheimer's Special Care Center 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-3090 Maintenance and housekeeping. (1) The assisted living facility must: This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2514 Compliance Determination # 64686 Plan of Correction Summer Wood Alzheimer's Special Care Center Completion Date Page 14 of 15 Licensee: Summer Wood OpCo LLC 08/28/2025 (c) Keep facilities, equipment and furnishings clean and in good repair; and This requirement was not met as evidenced by: Based on observation and interview, the facility failed to ensure resident furniture was clean and in good repair in 4 of 4 resident common areas (Common Area 1, 2, 3, and 4) and 2 of 5 hallways (Hallway 2 and 3). This failure placed residents at risk of decreased quality of life due to not having homelike and well-maintained furniture to view and utilize. Findings included…. <Common Area 1> Observation on 08/22/2025 at 11:15 AM, showed two dining room type chairs with frayed and ripped/torn fabric. <Common Area 2> Observation on 08/22/2025 at 11:20 AM, showed that 13 dining room chairs had ripped and torn chair backs with white fuzzy fraying and cushions that were visibly stained. <Hallway 2> Observation on 08/22/2025 at 11:24 AM, showed a red lounge/bench with small tears to the arm and seat cushion. <Common Area 3> Observation on 08/22/2025 at 11:24 AM, showed a large tan colored three cushioned couch with a tear in each seat cushion that measured approximately one to three inches. <Common Area 4> Observation on 08/22/2025 at 11:25 AM, showed 15 dining room chairs with ripped fabric on the back sections and multiple visible large stains on the fabric like seat cushions. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2514 Compliance Determination # 64686 Plan of Correction Summer Wood Alzheimer's Special Care Center Completion Date Page 15 of 15 Licensee: Summer Wood OpCo LLC 08/28/2025 <Hallway 3> Observation on 08/22/2025 at 11:27 AM, showed a brown recliner with a torn seat cushion and missing the handle to recline the legs on the chair. Next to that chair was a brown round side table that showed the top was warped, the wood like laminate peeled back, and the surface appeared porous and could not be sanitized. Further down that hallway there was a red backed lounge/bench with one seat cushion visibly ripped and approximately one inch. In an interview on 08/22/2025 at 11:30 AM, Staff A, Executive Director, stated they were aware of the furniture conditions but that they had not been able to replace the furniture mentioned. When asked about the six recliners not having handles, Staff A stated that they only had one handle that they used for all of the recliner chairs and they were not sure where it was located at that time. 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, Summer Wood Alzheimer's Special Care Center is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date This document was prepared by Residential Care Services for the Locator website. STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 8517 E Trent Ave, Ste 102, Spokane Valley, WA 99212 Summer Wood OpCo LLC Summer Wood Alzheimer's Special Care Center 830 NW Sunburst Ct Moses Lake, WA 98837 RE: Summer Wood Alzheimer's Special Care Center # 2514 Dear Administrator: This document references the following complaint numbers 192186. The Department completed a full inspection and complaint investigation of your Assisted Living Facility on 08/28/2025 and found that your facility does not meet the Assisted Living Facility requirements. The Department: • Wrote the enclosed report; and • May take licensing enforcement action based on many deficiency listed on the enclosed report; and • May inspect your program to determine if you have corrected all deficiencies; and • Expects all deficiencies to be corrected within the timeframe accepted by the department. You Must: • Begin the process of correcting the deficiency or deficiencies immediately; • Contact the Field Manager for clarifications related to the Statement of Deficiencies (SOD); • Within 10 calendar days after you receive this letter, complete and return the enclosed 'Plan/Attestation Statement'; o Sign and date the enclosed report; o For each deficiency, indicate the date you have or will correct each deficiency; o Return the Plan/Attestation Statement and report with signatures to: Stephanie Jenks, Community Field Manager Residential Care Services This document was prepared by Residential Care Services for the Locator website. Summer Wood Alzheimer's Special Care Center # 2514 08/28/2025 Page 2 of 3 Region 1, Unit B Preferred methods: eFax: (509) 921-2426 Email: rcsregion1email@dshs.wa.gov Optional method: 8517 E Trent Ave, Ste 102 Spokane Valley, WA 99212 • Complete correction(s) within 45 days, or sooner if directed by the Department, after review of your proposed correction dates. • Have your plan approved by the Department. Consultation(s): In addition, the Department provided consultation on the following deficiency or deficiencies not listed on the enclosed report. WAC 388-78A-2950 Water supply. The assisted living facility must: (6) Provide all sinks in resident rooms, toilet rooms and bathrooms, and bathing fixtures used by residents with hot water between 105 F and 120 F at all times; and Based on observation and interview, the facility failed to maintain hot water below 120 degrees during the inspection in one of two common area restrooms and the activities room. The maintenance director immediately turned down the water temperature and by the conclusion of the department's visit, all water temperatures were within required parameters. You Are Not: • Required to submit a plan of correction for the consultation deficiency or deficiencies stated in this letter and not listed on the enclosed report. You May: • Contact me for clarification of the deficiency or deficiencies found. In Addition, You May: • Request an Informal Dispute Resolution (IDR) review within 10 working days after you receive this letter. Your IDR request must include: o What specific deficiency or deficiencies you disagree with; o Why you disagree with each deficiency; and o Whether you want an IDR to occur in-person, by telephone or as a paper review. o Send your request to: Email: RCSIDR@dshs.wa.gov; or Fax: (360) 725-3225 This document was prepared by Residential Care Services for the Locator website. Summer Wood Alzheimer's Special Care Center # 2514 08/28/2025 Page 3 of 3 If You Have Any Questions: • Please contact me at (509)993-7821. Sincerely, Stephanie Jenks, Community Field Manager Region 1, Unit B Residential Care Services Enclosure This document was prepared by Residential Care Services for the Locator website.

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Home and Community Living Administration PO Box 45600, Olympia, WA 98504-5600 November 4, 2025 ELECTRONIC-FACSIMILE Administrator Summer Wood Alzheimer's Special Care Center 830 NW Sunburst Ct Moses Lake, WA 98837 Assisted Living Facility License # 2514 Licensee: Summer Wood OpCo LLC IMPOSITION OF CIVIL FINE Dear Administrator: On October 23, 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 a civil fine on the license for your assisted living facility, also known as Summer Wood Alzheimer's Special Care Center, located at 830 NW Sunburst Ct, Moses Lake, 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 fine on the license is based on the following violation of the RCW and/or WAC as described in the attached Statement of Deficiencies (SOD) report dated October 23, 2025. Civil Fine WAC 388-78A-2600 (1)(a)(b) Policies and procedures. $400.00 The licensee failed to implement their bowel monitoring policy for one resident. This failed practice resulted in the absence of bowel monitoring and placed the resident at risk of health complications. This is an uncorrected deficiency previously cited on August 28, 2025. NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Administrator Summer Wood Alzheimer's Special Care Center License # 2514 November 4, 2025 Page 2 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: Stephanie Jenks, Field Manager Region 1, Unit B 8517 E Trent Ave, Suite 102 Spokane Valley, WA 99212-2329 Phone: (509) 993-7821/ Fax: 509-921-2426 rcsregion1email@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. 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 Administrator Summer Wood Alzheimer's Special Care Center License # 2514 November 4, 2025 Page 3 Formal Administrative Hearing You may contest the civil fine by requesting a formal administrative hearing to challenge the deficiency, which resulted in the civil fine. 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 fine is due to the Office of Financial Recovery twenty-eight (28) calendar days after receipt of this letter. Mail a check for $400.00 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 Summer Wood Alzheimer's Special Care Center License # 2514 November 4, 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 Stephanie Jenks, Field Manager, at (509) 993-7821. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 1, Unit B RCS Regional Administrator, Region 1 HCS Regional Administrator, Region 1 DDA Regional Administrator, Region 1 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW HP

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 8517 E Trent Ave, Ste 102, Spokane Valley, WA 99212 Statement of Deficiencies License #: 2514 Compliance Determination # 57032 Plan of Correction Summer Wood Alzheimer's Special Care Center 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 03/26/2025 of: Summer Wood Alzheimer's Special Care Center 830 NW Sunburst Ct Moses Lake, WA 98837 This document references the following complaint number(s): 171535 The following sample was selected for review during the unannounced on-site visit: 46 of 46 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Anne Sinclair, NCI Community Complaint Investigator From: DSHS, Aging and Long-Term Support Administration 8517 E Trent Ave, Ste 102 Spokane Valley, WA 99212 . Statement of Deficiencies License #: 2514 Compliance Determination # 57032 Plan of Correction Summer Wood Alzheimer's Special Care Center 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-2040 Other requirements. (2) The assisted living facility must have its building approved by the Washington state fire marshal in order to be licensed. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure compliance with the Washington State Patrol Office of State Fire Marshal when the facility failed their second Fire and Life Safety Inspection. This failure placed residents', staff and visitors’ safety at risk. Findings included… Review of the Department/s Electronic Working Papers System, on 03/27/2025, showed the ALF was licensed for 56 beds. In an interview on 03/26/2025 at 12:45PM, Staff A, Executive Director, stated there were currently 46 residents in the facility. Review of records from the Washington State Patrol Office of State Fire Marshal (OSFM), showed the facility failed their initial Fire and Life Safety Inspection (LSI) on 10/30/2024, then failed their first OSFM reinspection on 03/10/2025. Review of the most recent failed LSI report, dated 03/10/2025, showed the facility continued to be out of compliance with International Fire Code (IFC) standards in two categories. The Statement of Violation noted the following: . Statement of Deficiencies License #: 2514 Compliance Determination # 57032 Plan of Correction Summer Wood Alzheimer's Special Care Center Completion Date The facility was found to be out of compliance in two of five code requirements, as follows: Testing and Maintenance (IFC 903.5 2021), NFPA 80 Fire Door Inspection and testing (IFC 5.2. 1, 5.2.4.1, 5.2.2.4). In an interview on 03/26/2025 at 12:50PM, Staff A verified the facility had failed their second Fire Marshall inspection on 03/10/2025. 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, Summer Wood Alzheimer's Special Care Center 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 .

allegations and the named caregivers were suspended during the investigation and removed from service shortly after the investigation concluded. No failed facility practice was identified. 5. The facility conducted education for staff on the facility's code of conduct, reporting of abuse and neglect and the WACs that applied. The facility staff stated that when the two named caregivers were together, they would "loaf off" and spend long periods of time in resident rooms. The caregiver staff also stated that they had seen the named caregivers on their cell phones occasionally. The facility removed the caregivers from the schedule while an investigation was conducted. Shortly after the investigation the named caregivers were removed from service. One of the named caregivers had not completed their HCA training within the allotted timeframe and had an expired license. A citation was issued for WAC 388-78A (2474) (4). Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Ii □ □ . 04.25.2024 15:31:37 State of ~ashi119ton .1\:GiNG .t.ND LONG-TERM SUPPORT ADMH·tSTRATlON 8$1'1 f freMAve. Ste 1M, Spot-..-..~ne Valley, WA 992.12 St~tffrn~nt Defid,~ndes {}f Plan ◊f CGirndi!m ~{umrnr:-r VVOu<l .Alz.hi}in1e(s ~;p~ti~li Care c~n~er F'ntN 1 o!2 l~c~~nsetr Surnt{1t~r \i~lt)9d ,)p(!v LLC 04l23l2Ct24 ~y··Gu an~ requ:lred ta be in {~~1rnpn~~nce .fit. c~U tlrr:e~-vv~th t.~11-Hi.:~:ens!ntJ ~avv:;; and f''t!JUl~~tiGn£ t(~ rntHnt~in your .A.ssjsted Liv·f.~1:f~ F ~ctgty· ~~c~r~se. The d:et1'c~itn-ient t)}mp!drrd d.ati,1 <:<:iHectkn for ,im an,~t'.mnunc-€d <:>:'H~ltfr ,::ompl.:1int fr~ve5,;t\pfa:in (:fl o~~t08/20-'24; G4/0t~t2024 and l1ill08l2024 (lf: S:urnmerVVnoJ .4,\:zheimer's: Spf.dal C,:1re Cent~r 830 NW Si.mburnt Ct The !'olfowir19 $.Wrnph:.! v\'tl'S sd1:id£:d for revi<::\·'i during the ~.mann-:n..tnc.ed ;Jn-£ite visit: 4 ;Jf: 4 l c:.unent n~sid:ents: and 0 former n:sldents. Fn:wn: DSHS, Aging tmd Long-Tern: SupportAdrnnistraticwt R-estdtn~~bai Care-S~rvic:es.t F~ef~iar~ ·~ . Ltt1~t 8 85 -~ 7 E 1'r~.;r~t i\ve. ~Ste 102 As ~i r>.'sult of the ,;,,n-1:-ite vi:sit(s), the deparunent found ti-Hit ym-l are net in <.:{n-npli~nc.e \·Vitl1 the ~~r.::er1:sing ~a·t~s ~r,1 r~gulat~(t1S as: s.tate~j in tl1e e:1tfr.d d~h(:i€nties ~n the encki.sed rt~po~t. 04/25/2024 l L'inderstand that to rmiint.i:in im Ai~sh:ted Uvitt1 F~ci!ity· h.:-ense, the i't:cility must be jn {:Ot'l',p~iance \rVl!h ~)If the lkcnsm!~ lm,vs t':nd n'!;~~u!~tion':) at >:iH tirne~. . 04.25.2024 15:31:37 State oF Washington 5/6 St~~t~m~nt ,~f Oefici<c:ndes F1lm~, )f C()rr,,Ktion SlHrln~e.r \ 1 \IO(!d 1\J:ttH~irnsr's ~3p~c~a·l t~:tn~ c~~n~{~:· Pags 2 of 2 l.ic-ense~: Sun1n1~r \!\iOad -OpCu-llC WAC 388-78A-2474 Tr-;ti:ning and hom·e c:~re ~ide eertffleat!o-n r(tqukementi. (2} The assisted living (':-KiHv rnust emure ail assisted livino 1:m.:1liiV i,dm,nistnitGrs, or thdr di?.Signee:s, and cari::give'. s hr~~d {,n or· after J~nua1v 7, .'.i:G 12 n~ee.t the bng-timn care \:>,'mi~er trdning rtquirnments ;:,f d1aptsr :rn8-·1 l 2l", W'..t\C, indudhq but nz,t iir'nit~d to. This require:m ent was not met as evtden~ed by: B,Ised Q:n int:ervie.1.N imd record review·. the farYit,-· faH8 d to ensure a t:aregive:r comple-ttd the long t•~rm c~u-e ~~-atxer trnining 11::1:1uk2•m;~nt~ f.or 1 ut'} st;11H {Statf C). Thi$ faiihHf pl~it1,:d r0.sidents. Qt risk ot r,~ceiv1t1g cam and si:ivici::-s frcwn staff \\tho v,;ere· not a~:itquat?.ly trainHL 1 In an fntervii:.v,,i {m 04/'! t~/2D24 at ·i ·\ :·15 ;~M, Staff .A., ,Admini:s-tritc,r, state,d that Stuff C, C~r:en~v{:.r, ~rnd not C{~!~'1p!H,;d ~~ii th~ir t'!-duc,~lki'I hou:rt; ('}I"! fa1"ll;j. R!:"li~w o·f Sli1H C's training tr,ms.-::r1pt sb:,\ive:d Hwt Staff C, vvhu \•Vas hired on 08/21/2.-022. had cnly comp~eted 20 .5 hours of the required 7:0 hours d tr--afnln!~! for fotig-ti::.rm c,:1re worker requirf:ments ;\f\Jhkh \·rnd ,:: due uate ,)f H}J'3'il20:'?:J. bm.wd un th:.ir hin:'. d;:::te\. 1 . ' Revil?.\f\!' of tniT tai::@:y"s stuff '>.l-die(h.ile for the mtinth of i\.'l.cirGt·i 2024 ~1-iowe(i thmt Sf.~if C hid w1Jrk~d a to 4 diy-s ~-ad, w,~ek Plan/Attestation Statement i h!€'eby C!?.ttify thtit I hav~ rev!fr\·\•ed n1is repc,rt tm{i h::.w~ tal~e-:r-1{ 1PNf takiz ci.-::ti've rrn~a~.ures ti:! ci)rrect this de.ficiem:y. By t;,1king t11is action., SumrnE:rV\1i:Kid Alz.hetrn.er\, Special Ctm, t\-::riter· is or v.-m be in {'.t)rnr.,i!iarK:e v1Mh tr1is l~~w and! J,r H?.,:mlatinn on (Date Ljff~+ :J.w...i/ . · -· in ,;~;.M1titi,,. I •·'~1Hi mph~n-~1~nt a s.yst-i:,rn to mmiitm and ensure confamed r:Grnpfonse v\'ith thi5 requ~te~~-~~nt.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: Summer Wood Alzheimer's Provider Type: Assisted Living Facility Special Care Center License/Cert.#: 2514 Intake ID: 117520 Compliance Determination #: 36780 Region/Unit #: RCS Region 1 / Unit B Investigator: Sandra Fast Investigation Date(s): 02/13/2024 through 02/15/2024 Complainant Contact Date(s): Allegation(s): A resident suffered burns after spilling a hot beverage in their lap. Investigation Methods: Sample: Total residents: 43 Resident sample size: 5 Closed records sample size: 0 Observations: Named residents Sample residents Medication aid Medication pass Order processing Lunch service Kitchen and coffee area Common areas, hallways and corridors Resident apartments Interviews: Administrator Health Services Director Medication aids Named residents Sample residents Resident representatives Dietary Director Record Reviews: Disclosure of services Characteristic roster Staff roster Staff background check Staff education Abuse and Neglect policy Medication aid training Alert Charting policy Managing Medications policy Processing Physicians Orders policy Named residents' face sheets . Named residents' negotiated service plans Named residents' individual service plans Named residents' medication orders Named residents' medication administration record Sample residents' face sheets Investigation Summary: A named resident who had a chronic condition which limited their capability to make safe choices, was given a hot beverage by a facility staff and sustained burns. The facility failed to ensure that the hot beverage was at a safe temperature before it was served to the resident. There was no system in place for monitoring or recording the hot beverage was at a safe temperature before dispensing it to residents. Failed facility practice was identified. A statement of deficiency was issued based on WAC 388-78A-(2170)(1). Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A .

—: WA DSHS report: Inspections (10/2023) —: WA DSHS report: Investigations (10/2023)