Vineyard Park at Mountlake Terrace.

Statement of Deficiencies License #: 2335 Compliance Determination # 62661 Plan of Correction Vineyard Park at Mountlake Terrace Completion Date You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for the unannounced on-site full inspection on 07/22/2025 and 07/25/2025 of: Vineyard Park at Mountlake Terrace 23008 56th Ave W Mountlake Terrace, WA 98043 The following sample was selected for review during the unannounced on-site visit: 10 of 81 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Faith Le, NCI Erin Steinbrenner, Nursing Consultant Institutional From: DSHS, Aging and Long-Term Support Administration 20311 52nd Ave W, Suite 100 Lynnwood, WA 98036 . . 08.07.2025 16:53:20 State of Washington 6/ Statement of Deficiencies License #: 233.5 Compliance Determination# 62661 Plan of Correction Vineyard Park at Mountlake Terrace Completion Date As a result of the on-site visit(s), the department found that you are not in compliance with the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. Date I understand that to maintain an Assisted Living Facility license. the facility must be in compliance with all the licensing laws and regulations at all times. .2r ~I 11 / 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 observations, interviews and record review, the Assisted Living Facility (ALF) failed to ensure personal care supplies were safely secured in 4 of 5 bathrooms in the secured memory care unit (MCU) and failed to ensure hazardous supplies were safely secured in the first-floor hair salon. These failures placed 28 of 28 dementia care residents and 45 of 53 assisted living residents diagnosed with or at risk of harm or poisoning. Findings included ... The ALF consisted of four floors; the fourth floor had a secure MCU. Record review of a Resident Characteristic Roster (RCR) showed 45 residents living on the ALF's first, second, third and fourth floors were identified with a diagnosis of or with mental health, behavior or psychosocial concerns. Record review of the RCR showed the fourth-floor MCU ~,ad 28 residents with a diagnosis of . Statement of Deficiencies License #: 2335 Compliance Determination # 62661 Plan of Correction Vineyard Park at Mountlake Terrace 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-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 observations, interviews and record review, the Assisted Living Facility (ALF) failed to ensure personal care supplies were safely secured in 4 of 5 bathrooms in the secured memory care unit (MCU) and failed to ensure hazardous supplies were safely secured in the first-floor hair salon. These failures placed 28 of 28 dementia care residents and 45 of 53 assisted living residents diagnosed with or at risk of harm or poisoning. Findings included… The ALF consisted of four floors; the fourth floor had a secure MCU. Record review of a Resident Characteristic Roster (RCR) showed 45 residents living on the ALF’s first, second, third and fourth floors were identified with a diagnosis of r with mental health, behavior or psychosocial concerns. Record review of the RCR showed the fourth-floor MCU had 28 residents with a diagnosis of . . Statement of Deficiencies License #: 2335 Compliance Determination # 62661 Plan of Correction Vineyard Park at Mountlake Terrace Completion Date Observation, on 07/22/2025 at 11:09 AM, during an initial tour of the ALF with Staff G (Maintenance Director), showed a first-floor hair salon to be unlocked and accessible to residents, staff or visitors. Observation of the hair salon showed an unlocked cupboard to contain the following chemicals: Barbicide disinfectant solution, cleaner with bleach spray bottle, Windex, all-purpose cleaner and degreaser spray bottle, multiple shampoos, color care conditioners, hair care products and an unlabeled spray bottle to contain clear liquid. Further observation showed an unlocked upper cupboard with a biohazard sticker on the outside of the door to contain tubes of hair dye. All items had precautionary statements to include, “keep out of reach of children and avoid contact with eyes and skin.” In an interview, on 07/22/2025 at 11:14 AM, Staff G stated, “the hair salon should be locked, I’m not sure why it isn’t.” Observation, on 07/24/2025 at 12:21 PM, of a common bathroom located next to room 415 in the MCU, showed unlocked cupboards to contain tubes of dimethicone (silicone-based skin protectant) cream and antifungal cream with precautionary statements to include “do not use on children, avoid eye contact, contact- external use only.” Observation, on 07/24/2025 at 12:22 PM, of the left side common bathroom located next to room 429 in the MCU, showed unlocked cupboards to contain Renew skin protectant, Remedy zinc oxide skin protectant, Sparkle mouth wash, with a “do not swallow” precautionary statement, and barrier moisture cream with precautionary statements to include “avoid eye contact, contact- external use only.” Observation, on 07/24/2025 at 12:24 PM, of the right-side common bathroom located next to room 429 in the MCU, showed unlocked cupboards to contain hair gel, aquafoam (hair styling product), face cream moisturizer and a refill bag of liquid hand soap with precautionary statements to include “external use only and avoid contact with eyes.” Observation, on 07/24/2025 at 12:27 PM, of a common bathroom across the hall from room 411 in the MCU, showed an unlocked upper cupboard to contain Remedy foam cleanser and anti- perspirant spray bottle with precautionary statements to include “external use only, keep away from face and mouth and avoid inhaling.” Observation of an unlocked lower cupboard showed multiple shampoos and remedy skin protectant. Observation at 12:29 PM of an unlocked upper cupboard showed an unlabeled pink spray bottle with unknown liquid contents. Observations on 07/22/2025 at 10:35 AM, 07/23/2025 at 8:00 AM and 07/24/2025 at 12:30 PM in the MCU showed residents walked throughout the hallways and entered the unstaffed common bathrooms without staff supervision. In an interview and observation, on 07/24/2025 at 12:34 PM, of all four bathrooms, Staff F (Memory Care Coordinator) stated, “Yes, residents use these bathrooms, it's . . 08.07.2025 16:53:20 State of Washington 8/ Statement of Deficiencies License#: 2335 Compliance Determination # 62661 Plan of Correction Vineyard Park at Mountlake Terrace Completion Date [bathroom cupboard] supposed to be locked. I don't have a key for this." Staff F fuither clarified the dimethicone and anti-fungal creams should be kept in the medication cart as residents need a physician order for treatment and resident names should be written on each product. 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, Vineyard Park at Mountlake Terrace is or will be in compliance with this law and/ or regulation on q- 7 - r- . (Date') I 2 In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date WAC 388-78A-2410 Content of resident records. The assisted living facility must organize and maintain resident records in a format that the assisted living facility determines to be useful and functional to enable the effective provision of care and services to each resident.

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 . .