Regency On Whidbey.

Statement of Deficiencies License #: 1738 Compliance Determination # 54461 Plan of Correction REGENCY ON WHIDBEY 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 02/07/2025, 02/10/2025 and 02/11/2025 of: REGENCY ON WHIDBEY 1045 SW KIMBALL DR OAK HARBOR, WA 98277 The following sample was selected for review during the unannounced on-site visit: 7 of 35 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Cristina Gonzalez, ALF Licensor Allison Nunn, Long Term Care Surveyor Steven Kindle, From: DSHS, Aging and Long-Term Support Administration 3906-172nd St NE, Suite #100 Arlington, WA 98223 . Statement of Deficiencies License #: 1738 Compliance Determination # 54461 Plan of Correction REGENCY ON WHIDBEY 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-2474 Training and home care aide certification requirements. (2) The assisted living facility must ensure all assisted living facility administrators, or their designees, and caregivers hired on or after January 7, 2012 meet the long-term care worker training requirements of chapter 388-112A WAC, including but not limited to: (a) Orientation and safety; (b) Basic; (c) Specialty for dementia, mental illness and/or developmental disabilities when serving residents with any of those primary special needs; (d) Cardiopulmonary resuscitation and first aid; and (e) Continuing education. (4) The assisted living facility must ensure all persons listed in subsection (2) of this section, obtain the home-care aide certification. This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure staff completed Orientation and Safety training prior to providing care to residents for 1 of 6 staff (Staff C), 70-hour Basic training within 120 days from their of hire for 3 of 6 staff (Staff C, D, and E), Specialty dementia and mental health training for 1 of 6 staff (Staff C), Cardiopulmonary Resuscitation (CPR) and first aid training for 1 of 6 staff (Staff C), Department of Social and Health Services (DSHS) approved continuing education (CE) for 2 of 2 staff (Staff E and F), and received credentials through the Department of Health (DOH) within 200 days of hire for 2 of 6 staff (Staff C and D). This failure resulted in Staff C, D, E, and F not having the necessary training related to their job duties and expectations and placed all 35 residents at risk for compromised care and safety. . Statement of Deficiencies License #: 1738 Compliance Determination # 54461 Plan of Correction REGENCY ON WHIDBEY Completion Date Findings included… Orientation and Safety Training Review of WAC 388-112A-0200(2)(a) showed all long-term care workers must complete two hours of long-term care worker orientation training before providing care to residents. Review of WAC 388-112A-0220(1) showed all long-term care workers must complete three hours of safety training prior to providing care to a resident. Review of the ALF’s employee files showed the following: Staff C, Caregiver, was hired on 03/13/2024. Staff C’s file showed a completed Orientation and Safety training course dated 06/12/2024, 91 days after their date of hire. On 02/11/2025 at 2:51 PM, Staff H, Human Resources, stated that they weren’t sure why Staff C didn’t complete Orientation and Safety training when they were first hired. Staff H stated that schedules showed that Staff C was on the floor scheduled as a caregiver before completing their training. Basic Training Review of WAC 388-112A-0080(5) showed long-term care workers in assisted living facilities must complete the 70-hour Basic training within one hundred twenty days of their date of hire. Review of the ALF’s employee files showed the following: Staff C was hired on 03/13/2024. Staff C’s file showed no record of a completed 70-hour Basic training course. Staff D, Caregiver, was hired on 05/08/2024. Staff D’s file showed no record of a completed 70-hour Basic training course. Staff E, Caregiver, was hired on 09/07/2023. Staff E’s file showed no record of a completed 70-hour Basic training course. . Statement of Deficiencies License #: 1738 Compliance Determination # 54461 Plan of Correction REGENCY ON WHIDBEY Completion Date On 02/11/2025 at 11:46 AM, Staff H stated that Staff C, D, and E had not completed their Basic training. Staff H stated that staff have 120 days after their date of hire to complete their 70-hour Basic training, so they weren't sure why Staff C, D, and E had not completed it as of yet. On 02/13/2025 at 2:31 PM, Staff H stated that they had spoken with Staff C, D, and E, who all denied completing Basic training. Specialty Training Review of the ALF's Resident Characteristic Roster, dated 02/03/2025, showed 35 residents living in the ALF had a diagnosis. Review of the ALF’s employee files showed the following: Staff C was hired on 03/13/2024. Staff C’s file showed no record of completed dementia or mental health training. On 02/11/2025 at 11:46 AM, Staff H stated that Staff C had not taken any of the dementia or mental health trainings offered by the ALF. On 02/13/2025 at 2:31 PM, Staff H stated that they had spoken with Staff C who denied ever taking dementia or mental health specialty training. CPR and First Aid Training Review of the ALF’s employee files showed the following: Staff C was hired on 03/13/2024. Staff C had no record of a completed CPR and First Aid training. On 02/11/2025 at 11:46 AM, Staff H stated that Staff C had not taken any of the CPR and First Aid training offered in-house by the ALF. On 02/13/2025 at 2:31 PM, Staff H stated that they had spoken with Staff C who denied having a current CPR and First Aid card. Continuing Education (CE) . Statement of Deficiencies License #: 1738 Compliance Determination # 54461 Plan of Correction REGENCY ON WHIDBEY Completion Date Review of WAC 388-112A-0611(1)(a)(i) showed long-term care workers, including certified home care aides, must complete 12 hours of continuing education by their birthday each year. Review of WAC 388-112A-0600 showed DSHS must approve continuing education curricula. Review of DSHS’s Continuing Education Approval Process (https://www.dshs.wa.gov/altsa/faq?field_altsa_topics_value=ce) showed that once DSHS approves a CE, it is assigned a unique DSHS CE approval code and that without a DSHS CE approval code on the certificate or transcript, the CE cannot be used to meet the 12-hour CE requirement. Review of the ALF’s employee files showed the following: Staff E was hired on 09/07/2023. There was no documentation that Staff E completed any CE in the time period between their birthday in 2023 and their birthday in 2024. Staff F, Caregiver, was hired on 01/16/2016. Two of the 12 hours of CE's dated from their birthday in 2024 and their birthday in 2025 were not DSHS approved. On 02/11/2025 at 11:46 AM, Staff H stated that they weren’t aware that CE required an approval code and would work with their team to be sure courses provided to staff have been approved through DSHS. On 02/13/2025 at 2:31 PM, Staff H stated that they had spoken with Staff E and F who stated that they had not completed any other CE’s other than what was in their files. DOH Credentials Review of the ALF’s employee files showed the following: Staff C was hired on 03/13/2024. Staff C’s file showed no record of obtaining certification as a home care aide. Staff D was hired on 05/08/2024. Staff D’s file showed no record of obtaining certification as a home care aide. . Statement of Deficiencies License #: 1738 Compliance Determination # 54461 Plan of Correction REGENCY ON WHIDBEY Completion Date Review the DOH’s Provider Credential Search (https://fortress.wa.gov/doh/providercredentialsearch/) showed that Staff C and D did not have any health care provider credentials in the State of Washington. On 02/11/2025 at 11:46 AM, Staff H stated that Staff C and D had not yet completed their Basic training and therefore weren't yet able to take their test to be certified as a home care aide.