Whispering Willows of Mount Vernon.

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20311 52nd Ave W, Suite 100, Lynnwood, WA 98036 08/11/2025 Whispering Willows of Mount Vernon, LLC Whispering Willows of Mount Vernon 2311 E Division St Mount Vernon, WA 98274 RE: Whispering Willows of Mount Vernon # 2726 Dear Administrator: This letter addresses Compliance Determination 63614 (08/11/2025). The Department completed a full inspection of your Assisted Living Facility on 08/11/2025 and found no deficiencies. The Department staff who did the inspection: Cristina Gonzalez, Nursing Consultant Institutional Allison Nunn, Long Term Care Surveyor Melissa Phillips, Long Term Care Surveyor \f you have any questions, please contact me at (253)312-1446. Jamie Singer, Field Manager Region 2, Unit J Sincerely, ‘BYUSGAM 103907 BY} JO} SAd|AJaS ase jeljUapisay Aq pasedaid sem yuaWNDOp sy,

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: Whispering Willows of MountProvider Type: Assisted Living Facility Vernon License/Cert.#: 2726 Intake ID: 167211 Compliance Determination #: 55460 Region/Unit #: RCS Region 2 / Unit A Investigator: Syng To Investigation Date(s): 02/12/2025 through 03/27/2025 Complainant Contact Date(s): Allegation(s): The Assisted Living Facility (ALF) had a gastrointestinal disease outbreak. Investigation Methods: Sample: Total residents: 49 Resident sample size: 4 Closed records sample size: 0 Observations: Facility Residents Infection Control Interviews: Resident representative Residents Administration Local Health Jurisdiction Record Reviews: Facility Residents Investigation Summary: Based on interviews, observation and record reviews: The ALF failed to initiate, conduct, follow all applicable infection prevention, control guidelines, and policies during the outbreak. Interviews and record reviews showed the communicable disease was not reported to the Local Health Jurisdiction (LHJ). A citation was issued for WAC 388-78A-2610 (2)(f) Infection Control. 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 #: 2726 Compliance Determination # 55460 Plan of Correction Whispering Willows of Mount Vernon 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 02/12/2025 and 03/11/2025 of: Whispering Willows of Mount Vernon 2311 E Division St Mount Vernon, WA 98274 This document references the following complaint number(s): 167285, 167211 The following sample was selected for review during the unannounced on-site visit: 4 of 49 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Syng To, ALF Complaint Investigator From: DSHS, Aging and Long-Term Support Administration 3906-172nd St NE, Suite #100 Arlington, WA 98223 . Statement of Deficiencies License #: 2726 Compliance Determination # 55460 Plan of Correction Whispering Willows of Mount Vernon 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-2610 Infection control. (2) The assisted living facility must: (f) Report communicable diseases in accordance with the requirements in chapter 246-100 WAC. This requirement was not met as evidenced by: Based on interviews and record reviews, the Assisted Living Facility (ALF) failed to report their gastrointestinal outbreak (an infectious disease that causes acute gastroenteritis - inflammation of the stomach and intestines) to the Local Health Jurisdiction (LHJ). This failure resulted in the ALF not receiving current outbreak guidance from the LHJ and the LHJ not having updated community outbreak numbers. Findings included… Review of WAC 246-101-101 Notifiable conditions-Health care providers and health care facilities showed outbreaks and suspected outbreaks was to be reported to the LHJ immediately. Review of the ALF’s "Infection Control 01" Policy dated 09/07/2022, page 1, showed the ALF shall ensure a competent staff member is available with the authority to make infection control decisions regarding resident care and placement, as well as enforce compliance with the Community’s infection control policies. The Director of Health and Wellness will inform the Executive Director of any known or suspected communicable diseases occurring in residents or staff. The ALF must institute appropriate infection control practices to prevent and limit the spread of infections. . Statement of Deficiencies License #: 2726 Compliance Determination # 55460 Plan of Correction Whispering Willows of Mount Vernon Completion Date Review of the ALF’s "Infection Control 28- Reporting of Communicable Diseases" document dated 09/07/2022, page 1, showed the Executive Director or designee is responsible to report to the local health department any known or suspected communicable diseases occurring in the community. The ALF procedure stated the Director of Health and Wellness will inform the Executive Director of any known or suspected communicable diseases occurring in residents or staff. Communicable diseases include but are limited to reportable diseases as identified by the Centers for Disease Control and Prevention (CDC) or state health department. On 03/11/2025 at 12:45 PM, Staff A, Executive Director, stated that the LHJ was not notified for the gastrointestinal illness that occurred at the ALF on 02/10/2025. On 03/11/2025 at 12:54 PM, Staff B, Health Services Director, stated that the ALF had four residents who displayed gastrointestinal symptoms including diarrhea and vomiting as of 02/12/2025. On 03/25/2024 at 12:06 PM Collateral contact (CC), Local Health Jurisdiction, stated that the gastrointestinal outbreak event that included four residents having signs and symptoms of gastrointestinal illness at the ALF was determined as an outbreak. They did not receive any information from the ALF about the outbreak. 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, Whispering Willows of Mount Vernon 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 . Ii □ □ Investigation Summary Report Provider/Facility: Whispering Willows of MountProvider Type: Assisted Living Facility Vernon License/Cert.#: 2726 Intake ID: 159718 Compliance Determination #: 52260 Region/Unit #: RCS Region 2 / Unit A Investigator: Syng To Investigation Date(s): 12/26/2024 through 01/08/2025 Complainant Contact Date(s): 12/16/2024 Allegation(s): The Named Resident (NR) was hospitalized for fever. The NR was neglected and led up to their current health status. The NR’s Guardian was not notified for the NR’s hospitalization. Investigation Methods: Sample: Total residents: 32 Resident sample size: 3 Closed records sample size: 1 Observations: Facility Residents Interviews: Residents Staff Family Record Reviews: Facility Residents Investigation Summary: Based on interviews and record reviews: The NR was cognitively impaired and resided at the ALF’s memory care unit. The ALF staff found the NR was having high body temperature while getting the NR ready for dinner. The ALF staff conducted an assessment, called 911 and sent the NR to emergency room. The ALF staff notified their supervisor on shift and the NR’s primary care provider. Both the ALF Administration and ALF staff stated the NR’s guardian was not notified for NR’s hospitalization. Record reviews showed the guardian’s contact information was listed as the NR’s guardian, family member and emergency contact. A citation was issued for noncompliance with WAC 388 78A-2640(1)(b) Reporting significant change in a resident's condition. 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 #: 2726 Compliance Determination # 52260 Plan of Correction Whispering Willows of Mount Vernon 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 12/26/2024 and 12/26/2024 of: Whispering Willows of Mount Vernon 2311 E Division St Mount Vernon, WA 98274 This document references the following complaint number(s): 159385, 159718 The following sample was selected for review during the unannounced on-site visit: 3 of 32 current residents and 1 former residents. The department staff that investigated the Assisted Living Facility: Syng To, ALF 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 #: 2726 Compliance Determination # 52260 Plan of Correction Whispering Willows of Mount Vernon Completion Date Administrator (or Representative) Date WAC 388-78A-2640 Reporting significant change in a resident's condition. (1) The assisted living facility must consult with the resident's representative, the resident's physician, and other individual(s) designated by the resident as soon as possible whenever: (b) The resident is relocated to a hospital or other health care facility; or This requirement was not met as evidenced by: Based on interviews and record reviews, the Assisted Living Facility (ALF) failed to notify and consult with the resident’s representative for 1 of 3 residents (Resident 1) when Resident 1 had a significant change in health condition and relocated to a hospital. This failure resulted in Resident 1’s Representative being unable to provide medical decisions for Resident 1 while Resident 1 was at the hospital. Findings included… Record review of the ALF’s policy titled, “Clinical 11-Medical Emergency”, dated 12/12/2022, showed the ALF staff were to contact the resident’s responsible party as quickly as possible for medical emergencies and make reasonable efforts to contact the resident’s legal representative where there was a significant change in the resident’s physical, mental or psychosocial status. Resident 1 was admitted to the ALF on /2024 with diagnoses of Resident 1’s face sheet, dated 12/27/2024, showed Collateral Contact 1 (CC1), Legal Guardian, was their guardian, family member and emergency contact. Review progress notes dated /2024 09:30 PM showed Resident 1 was taken to the hospital due to having a fever. Review progress notes dated /2024 through 12/27/2024, showed no indication any contact was initiated towards CC1. . Statement of Deficiencies License #: 2726 Compliance Determination # 52260 Plan of Correction Whispering Willows of Mount Vernon Completion Date On 12/26/2024, at 09:30 AM, CC1 stated that Resident 1 was relocated to the hospital on /2024 and they were not notified by the ALF when Resident 1 was sent to the hospital. On 12/26/2024, 01:29 PM, Staff A, Executive Director, stated that Resident 1 was sent to hospital due to change in condition on /2024 8:30 PM, and CC1 was not notified before or after Resident 1’s hospitalization. Staff B, Medication Technician, was supposed to notify CC1, but they did not get to it. They were not aware of any other facility staff that may have called or attempted to make any kind of contact to notify CC1 regarding Resident 1’s change in condition and hospitalization. On 12/26/2024, 02:00 PM, Staff B, stated that on /2024, they called 911 and sent Resident 1 to the hospital around 08:30 PM. They did not notify CC1 for Resident 1’s change in condition and hospitalization. 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, Whispering Willows of Mount Vernon 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 .