Garden Courte Alzheimer Community.

This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written . D N/A . Investigation Summary Report Provider/Facility: GARDEN COURTE Provider Type: Assisted Living Facility ALZHEIMER COMMUNITY License/Cert.#: 1111 Intake ID: 154893 Compliance Determination #: 51110 Region/Unit #: RCS Region 3 / Unit E Investigator: Paul Aube Investigation Date(s): 12/03/2024 through 12/04/2024 Complainant Contact Date(s): Allegation(s): Quality of Care/Treatment: Facility report of a resident fall with injury in the community. Investigation Methods: Sample: Total residents: 83 Resident sample size: 6 Closed records sample size: 0 Observations: Identified resident Residents Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Identified resident Residents Nursing staff Management Record Reviews: Facility policies Incident investigation Resident Service Plans Progress Notes Investigation Summary: Quality of Care/Treatment: Facility made appropriate notifications to all parties and monitored resident per policy. Facility failed to identify and document preventative interventions on the Temporary Service Plans, and notify floor staff so they may be implemented. Failed practice identified. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written . D N/A . Investigation Summary Report Provider/Facility: GARDEN COURTE Provider Type: Assisted Living Facility ALZHEIMER COMMUNITY License/Cert.#: 1111 Intake ID: 156825 Compliance Determination #: 51110 Region/Unit #: RCS Region 3 / Unit E Investigator: Paul Aube Investigation Date(s): 12/03/2024 through 12/04/2024 Complainant Contact Date(s): Allegation(s): Injury of Unknown Origin: Facility report of a resident injury of unknown origin in the community. Investigation Methods: Sample: Total residents: 83 Resident sample size: 6 Closed records sample size: 0 Observations: Identified resident Residents Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Identified resident Residents Nursing staff Management Record Reviews: Facility policies Incident investigation Resident Service Plans Progress Notes Investigation Summary: Injury of Unknown Origin: Facility made appropriate notifications to all parties. Facility failed to conduct a complete a thorough investigation as to how the injury may have been sustained, or if potential abuse was suspected or ruled out, and also failed to document those investigative findings. Failed practice identified. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written . D N/A . Investigation Summary Report Provider/Facility: GARDEN COURTE Provider Type: Assisted Living Facility ALZHEIMER COMMUNITY License/Cert.#: 1111 Intake ID: 154910 Compliance Determination #: 51110 Region/Unit #: RCS Region 3 / Unit E Investigator: Paul Aube Investigation Date(s): 12/03/2024 through 12/04/2024 Complainant Contact Date(s): Allegation(s): Quality of Care/Treatment: Facility report of a resident injury of unknown origin in the community. Investigation Methods: Sample: Total residents: 83 Resident sample size: 6 Closed records sample size: 0 Observations: Identified resident Residents Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Identified resident Residents Nursing staff Management Record Reviews: Facility policies Incident investigation Resident Service Plans Progress Notes Investigation Summary: Quality of Care/Treatment: Facility made appropriate notifications to all parties. Facility failed to conduct a complete a thorough investigation as to how the injury may have been sustained, or if potential abuse was suspected or ruled out, and also failed to document those investigative findings. Failed practice identified. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written . D N/A . Investigation Summary Report Provider/Facility: GARDEN COURTE Provider Type: Assisted Living Facility ALZHEIMER COMMUNITY License/Cert.#: 1111 Intake ID: 154437 Compliance Determination #: 51110 Region/Unit #: RCS Region 3 / Unit E Investigator: Paul Aube Investigation Date(s): 12/03/2024 through 12/04/2024 Complainant Contact Date(s): Allegation(s): Quality of Care/Treatment: Facility report of a resident fall with injury in the community. Investigation Methods: Sample: Total residents: 83 Resident sample size: 6 Closed records sample size: 0 Observations: Identified resident Residents Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Identified resident Residents Nursing staff Management Record Reviews: Facility policies Incident investigation Resident Service Plans Progress Notes Investigation Summary: Quality of Care/Treatment: Facility made appropriate notifications to all parties and monitored resident per policy. Facility failed to identify and document preventative interventions on the Temporary Service Plans, and notify floor staff so they may be implemented. Failed practice identified. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written . D N/A . Investigation Summary Report Provider/Facility: GARDEN COURTE Provider Type: Assisted Living Facility ALZHEIMER COMMUNITY License/Cert.#: 1111 Intake ID: 154080 Compliance Determination #: 51110 Region/Unit #: RCS Region 3 / Unit E Investigator: Paul Aube Investigation Date(s): 12/03/2024 through 12/04/2024 Complainant Contact Date(s): Allegation(s): Quality of Care/Treatment: Facility report of a resident fall with injury in the community. Investigation Methods: Sample: Total residents: 83 Resident sample size: 6 Closed records sample size: 0 Observations: Identified resident Residents Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Identified resident Residents Nursing staff Management Record Reviews: Facility policies Incident investigation Resident Service Plans Progress Notes Investigation Summary: Quality of Care/Treatment: Facility made appropriate notifications to all parties and monitored resident per policy. Facility failed to identify and document preventative interventions on the Temporary Service Plans, and notify floor staff so they may be implemented. Failed practice identified. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written . D N/A . ST ATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEAL TH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 800 NE 136th Ave Ste 200, Vancouver, WA 98684 Statement of Deficiencies License #: 1111 Compliance Determination # 5111 O Plan of Correction GARDEN COURTE ALZHEIMER COMMUNITY 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 12/03/2024 and 12/03/2024 of: GARDEN COURTE ALZHEIMER COMMUNITY 626 LILLY RD NE OLYMPIA, WA 98506 This document references the following complaint number(s): 154080, 154437, 156825, 154910, 154893, 157404 The following sample was selected for review during the unannounced on-site visit: 6 of 83 current residents and O former residents. The department staff that investigated the Assisted Living Facility: Paul Aube, ALF NCI From: DSHS, Aging and Long-Term Support Administration 800 NE 136th Ave Ste 200 Vancouver, WA 98684 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. Cu ~~ 12/16/2024 Residentao/ 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. . 12.17.2024 09:23:44 State of Washington 4/13 Statement of Deficiencies License#: 1111 Compliance Determination #5111 0 Plan of Correction GARDEN COURTE ALZHEIMER COMMUN.ITV Completion Date Page.,2 of10 Licensee: Olympia Special Care LLC 12104/2024 Administrator or Representative) Date WAC 388-78A-2120 Monitoring residents' well-being. The assisted living facility must: (3) Evaluate, in order lo determine 1f there is a need for further action: (ii) The changes identified in the resident per subsecti.on (2) of this section; and (b) E.ach resident when an accident or ·Incident that Is likely to adversely affect the re&ident's well being, is observed by orreported to staff persons. (4) Take appropriate action in response to each resident's changing needs. This requirement was not met as evidenced by: Based on interview and record review, the memory care Assisted Living Facility (ALF) failed to evaluate and implement new preventative Interventions after falls occurred in the community which resulted 1n injuries, for 4 of 4 residents reviewed (Resident 1 [R1], and Resident 2 [R2], Resident 3 [R3], and Resident 4 (R4]). This failure placed R1, R2, R3, R4, and other residents in the facility who are high fall risks at risk for.repeated falls and injury. Findings included ... In an undated facility policy titled, "Reporting Incidences" under the section titled, "Prqcedure," it stated, "Incident Report-An incident report will be prepared for any incident or accident involving a resident to determine the circumstances of the event and to determine appropriate measures to prevent similar future situations. Thl:l following information will be gathered: .. . n.. lntervention.s to prevent reoccurrence." Under the section titled, "Documentation" it stated, "The staff will document on the Incident report the actions related to the incident. The service plan may be amended to include preventative measures to assure safety.

allegations were made, but failed to make a report to the Department. Failed practice identified. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written . Failed Provider Practice Not Identified / No Citation Written N/A . . . .

Allegations of physical and phycological abuse towards residents. Investigation Methods: Sample: Total residents: 80 Resident sample size: 4 Closed records sample size: 1 Observations: Residents Resident rooms Staff to resident interactions Resident to resident interactions Identified resident Interviews: Identified staff Nursing staff Residents Family members Record Reviews: Medical records Grievance log State reporting log Incident investigation Facility policies Personnel files Staff training records Staff patterns Investigation Summary: Based on record review and interview the facility failed to follow stated and facility policy and procedures for suspected and alleged abuse. The facility failed to verify staff references prior to employment. The facility failed to ensure required training for staff working in a dementia care unit. The facility failed to ensure resident right to be free from abuse. Failed practice identified. . Conclusion/ Action: ~ Failed Provider Practice Identified/ Citation(s) Written D Failed Provider Practice Not Identified / No Citation Written □ N/A . Investigation Summary Report Provider/Facility: GARDEN COURTE Provider Type: Assisted Living Facility ALZHEIMER COMMUNITY License/Cert.#: 1111 Intake ID: 101823 Compliance Determination#: 31252 Region/Unit#: RCS Region 3 J Unit E Investigator: Maria Salas Investigation Date(s ): 10/18/2023 through O1 /05/2024 Complainant Contact Date(s): Allegation(s): Allegations of physical and phycological abuse towards residents. Investigation Methods: Sample: Total residents: 80 Resident sample size: 4 Closed records sample size: 1 Observations: Residents Resident rooms Staff to resident interactions Resident to resident interactions Identified resident Interviews: Identified staff Nursing staff Residents Family members Record Reviews: Medical records Grievance log State reporting log Incident investigation Facility policies Personnel files Staff training records Staff patterns Investigation Summary: Based on record review and interview the facility failed to follow stated and facility policy and procedures for suspected and alleged abuse. The facility failed to verify staff references prior to employment. The facility failed to ensure required training for staff working in a dementia care unit. The facility failed to ensure resident right to be free from abuse. Failed practice identified. . Conclusion/ Action: ~ Failed Provider Practice Identified/ Citation(s) Written D Failed Provider Practice Not Identified / No Citation Written □ N/A . Investigation Summary Report Provider/Facility: GARDEN COURTE Provider Type: Assisted Living Facility ALZHEIMER COMMUNITY License/Cert.#: 1111 Intake ID: 104783 Compliance Determination#: 31252 Region/Unit#: RCS Region 3 J Unit E Investigator: Maria Salas Investigation Date(s ): 10/18/2023 through O1 /05/2024 Complainant Contact Date(s): Allegation(s): Allegations of physical abuse and restraining of resident. Investigation Methods: Sample: Total residents: 80 Resident sample size: 4 Closed records sample size: 1 Observations: Residents Resident rooms Staff to resident interactions Resident to resident interactions Identified resident Interviews: Identified staff Nursing staff Residents Family members Record Reviews: Medical records Grievance log State reporting log Incident investigation Facility policies Personnel files Staff training records Staff patterns Investigation Summary: Based on record review and interview the facility failed to follow stated and facility policy and procedures for suspected and alleged abuse. The facility failed to verify staff references prior to employment. The facility failed to ensure required training for staff working in a dementia care unit. The facility failed to ensure resident right to be free from abuse. Failed practice identified. . Conclusion/ Action: ~ Failed Provider Practice Identified/ Citation(s) Written D Failed Provider Practice Not Identified / No Citation Written □ N/A . or STATE WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION BOO NE 136th Ave Ste 200, Va11co11ver WA 91684 1 Statement of Deficiencies License.#; 1111 Compl.ian•ce Oe.te.rmit1ation #31252 Plan of Correction GARDEN COURTE ALZHEIMER COMMUNITY Completion Date Page 1 or 13 licensee: Olympia Special Ca.re LLC 0UJ5/2024 be You are required to in compliance at all times with all licensing laws and regulations to maintain your Assisted Living faciUty license. The department completed data collection far an unannounced on-site c.omplaint investigation on to/ 18/2023 and 12.t 13/202.lrof: - - - - - GARDEN COURTE ALZHEIMER COMMUNITY 626 ULLY RD NE OLYMPIA WA 98506 1 This document references the fol.lowing complaint number{s): 101047, 99320, 99595; 101823, 99931, 102395, 104783 The following sampt,e 'INtls selected for review during the unannounced on-site visit 4 otBO cu.rr.eint residents and. 1 former res1dents .. The department staff that investigited the As.sistBd Living Facility: Maria Satas, ALF Compl'aint lnvemigator From: OSHS, Aging and long-Term Support Administration 1 8()0 NE 136th Ave Ste 200 Vam.:ouverr WA 98684 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. 0 ~~ 01/17/2024 Rel.ntial Care Services Date I understand U1at to matntain an .Assisted Living Facrl:ity l1icense the facility must be Jn 1 compliance with all the l.icensJng raws and regulations at all tfmes. STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 800 NE 136th Ave Ste 200, Vancouver, WA 98684 Statement of Deficiencies License #: 1111 Compliance Determination # 31252 Plan of Correction GARDEN COURTE ALZHEIMER COMMUNITY 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 10/18/2023 and 12/13/2023 of: GARDEN COURTE ALZHEIMER COMMUNITY 626 LILLY RD NE OLYMPIA, WA 98506 This document references the following complaint number(s): 101047, 99320, 99595, 101823, 99931, 102395, 104783 The following sample was selected for review during the unannounced on-site visit: 4 of 80 current residents and 1 former residents. The department staff that investigated the Assisted Living Facility: Maria Salas, ALF Complaint Investigator From: DSHS, Aging and Long-Term Support Administration 800 NE 136th Ave Ste 200 Vancouver, WA 98684 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 o.f Deficiencies License#. 1111 Gomplian,ce• Determination #31252 Piao of Correction GARDEN COURTEALZHEIMER COMMUNITY Completion Date Date WAC 388-78A-2600 Policies and procedures. (1) The assisted living facmty must develop and implement policies and p,rm;edurns in support of services that are provided and are necessary to: (a) Maintain or enhance the quality of life for residents lnduding resident decision-making rights; (2)_ The assisted living facility must develop, .implement and traln staff p@rnons on policies and procedures to address what staff persons must do: (a) Related to suspected abandonment, abuse, neglect exp]oitation, or fiinaridal exploitation of any 1 resident; This requirement was not m.et as evidenced by: Based on record review and inte,view, the facility faired to implement f~ci!lity policies and procedures V\ihen suspected abuse was reported for 2 of 2 residents (Resident 2 and Resident 3); These failures contributed to Resident 2 bei:ng placed at risk for on going har.m and placed all 80 of 80 residents at risk of harm due to staff not followlng facUity and state policies \lvhen suspected abus.e had been reported. Findings included ... WAC 388-78A-2020 "DetiniUons. "Abuse" means the willful action or inaction that infllcts injury, unreasonable carifinement, intimidation or punishment an a vulnerable adult In Instances of abuse of a vulnerable adult who is I unable to express or demonstrate physical harm, pain, or menta1I anguJsh, the abuse is presumed ta cause physical harm, pain, o.r mental anguish, Abuse inc:ludes sexual abuse, mental abuse. physical abuse, and personal exploitation of a vulnerable adult, and improper use of restraint against a vulnerable adulL. "f;>;J egl!ect" means: {'I) A pattarn of conduct or fnaction resulting in the failure to provide the goods and services that maintain physical or mental health of a resident, or that fails ta avoid or prevent physical or mental harm or pat.n to a resJdent: or (,2) An act or omis'Slon by a person or entity with a duty of care that demonstrates a serrious disregard of consequences ot such a magnitude as ta constitute a clear and p1·esent danger to the resident's health, welfare, or safety, including but not limited to conduct prohibited under RCW 9A,42J 00,,,11lmproper use of restralnt" means the inappropriate use of chemleail, pl1ysical or mechanicat restraints for convenience or 1 discipline or.." "Physical restraint" means the application of physical force without use of any device for the purpose of restraining the free movement of a vulnerable adult's body.

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 . . .

Statement of Deficiencies Plan of Correc\lon GARD!=N COURTEALZHEIMER COMMUNITY Completitm .Date Page 1 of4 Licensee: Olympia Special Care LLC 07/02/2024 You are required to be in compliance at all limes 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 06/27/2024 and 07/02/2024 of: GARDEN COURTE ALZHEIMER COMMUNITY 626 LILLY RD NE OLYMPIA, WA 98506 This document references the following SOD dated: 07/02/2024 The following sample was selected for review during the unannounced on-site visit: 88 of 88 current residents and O former residents. The department staff that inspected the Assisted Living Facility: Anissa Bearden, Licensor Celeste Vashey, ALF LTC Licensor Emily Boniface, Community Program Nurse Licensor From: DSHS, Aging and Long-Term Support Administration 800 NE 136th Ave Ste 200 Vancouver, WA 98684 As a result of the 011-s;ite viait(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. 07/.15/2024 . Date I understanc:I that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. . 07.16.2024 10:59:02 State of Washington 4/7 Statement of Deficiencies License#: 1111 Compliance .Dete.rmination # 43293 Plan of Correction GARDEN COURTE ALZHEIMER COMMUNITY Completion Date Page2 014 Licensee.: Olympia Special Care LLC 07i02l2024 Date WAC 388-7SA-2040 Other requirements. (1) The assisted living facility must comply with all other applicable federal, state, county and municipal statutes, rules, codes and ordinances, including without limitations those that prohibit discrimination. (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 observation, interview, and record review, the facility failed to ensure fire safety doors were not propped open for 1 of 1 facility reviewed. These failures placed 88 of 88 residents, staff, and visitors' lives and safety at risk in the event of a fire or natural disaster. Findings Included ... 'Code IFC 705.2 2018: Opening protectives in fire-resistance-rated assemblies shall be inspected and maintained in accordance with NFPA 80. Opening protectives in smoke barriers shall be inspected and maintained in accordance with NDPA 80 and NFPA 105. Openings in smoke partitions shall be inspected and maintained in accordance with NFPA 105. Fire doors and smoke and draft control doors shall not be blocked, obstructed, or otherwise made inoperable. Fusible links shall be replaced promptly whenever fused or damaged. Opening protectives and smoke and draft control doors shall not be modified." Record review of the "Department of Social And Health Services" document, Completion date 05/13/2024, showed "As a result of the on-site vlsit(s) the department found that you are not In compliance with the licensing laws and regulations [including WAC 388-78A-2040] 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 ail. the licensing laws and regulations at all times.'' The administrator section showed Staff A, Executive Director, signed the qocument on 05/28/2024. Staff A signed the "Pian/Attestation Statement" for all citations cited that read "I hereby c.ertify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, [the facility] is or will be in compliance with this lew and/or regulation on 06/05/2024." Review of the facility policy, titled, "Fire and Smoke Barrier Doors", undated, showed " ... Fire and smoke barrier doors must be closed at all times, except those that are held . 07.16.2024 10:59:02 State of Washington 5/7 Statement of Deficiencies .License#: 1111 Compliance Determination # 43293 Plan of Correction GARDEN COURTE ALZHEIMER COMMUNITY Completion Date Page3 of4 Licensee.: Olympia Special Care LLC 0710212024 open by an electric built-in magnetic device that will automatically close when the fire alarm system is activat.ed .or power failurE! occurs ... Fire and smoke barrier doors are not lo be blocked at any time or be held open by any means other than the automatic holding device built into the door." Record review of the facility's "Plan of Correction" dated ''05/09/2024 and 05/13/2024", under section titled, "doors propped", showed medication technicians and resident care managers and all staff were aware that d.oors were not to be propped open. Me dicatlon technicians and resident care managers understood that lt)ey were not to prop the doors open to the office and medication room even if they were in the rooms. Record review of the facility's document titled, ''medication techni.cian meeting", dated 04/1712024, showed "we can not prop the medication room, or any doors open. This is per the Fire Marshall. The only time the doors is propped open is if you are putting or taking the cart in the med room. If you need to talk to staff, please step outside of the medication room and speak with them. If you need .Privacy, you are more than welcome to use the resident care manager office or go to a private area. Record review of the facility's document tilled, "medication technician meeting", dated 05/15/2024, showed "reminder, do not prop the medication room or any doors open. This is per the Fire Marshall. The only time the doors is propped open is if you are putting or taking the cart in the med room. If you need. to talk to staff, please step outside of the medication room and speak with them. If you need privacy, please go to the resident care manager office. In an observation on 06/27/2024 at 11:20 AM, the South Side medication technician and charting room's door was propped open with a brown rubber stopper that was wedged under the bottom of the door. Staff C, Delegated Medication Tectmician, was observed to be inside of the room. In an interview on 06/27/2024 at 11 :·30 AM, Staff B, Maintenance Assistant, said they had to make daily rounds to ensure facility doors were not propped open throughout the day. In an observation on 06/27/2024 at 11 :44 AM, Resident 1's door was propped open with a wooden wedge witl1 a long handle. In front of the door was the housekeeping cart. Staff D, Housekeeping was observed inside of the. room. In an observation and interview on 06/27/2024 at 12:40 PM, Staff A, E.xecutive Director, office door showed it was propped open with a wooden stopper that was wedged under the bottom oflhe door. Staff A said Maintenance staff collected all door stoppers through out the facility. Staff A said rubber stoppers should have been removed from the medication technician offices. Staff A said housekeeping staff used tall wedges wit11 sticks to prop open resident room doors when they were inside cleaning resident rooms. Staff A said the medication technicians in the facility were in serviced and educated . 07.16.2024 10:59:02 State of Washington 617 Statement of Deficiencies License #: 1111 Compliance Determination # 43293 Plan of Correction GARDEN COURTE ALZHEIMER COMMUNITY Completion Date Page4 of4 Licensee: Olympia Special care LLC 07/0212024 about not using rubber stoppers and keeping all facility doors closed. This is an uncorrected and recurring deficiency previously cited on 05/13/2024, 03/20/2024, 0111112024, and 03/22/2022, for S\Jpsection 388-78a-2040(1). Plan/Attestation Statement I hereby certify that I have reviewed !his report and have taken or will take active measures to correct this deficiency. By taking this acilon, GARDEN COURTE ALZHEIMER COMMUNITY is or will be in compliance with this law and I or regulation on ·7\Sw\ SL\ . . (Date) \ \ In addition, i will implement a system to monitor and ensure continued compliance with this requirement. ............... 71~/e>,U Date . 05.23.2024 15:53:26 State of Washington 3/14 ST1\TE OF WASHiNGTON DEPARTMENT OF SOCIAL AND HEAL TH SERVICES AG!NG AND LONG-T~RM SUPPORT .A,DMINISTRATION 800 NE 136th Ave Ste 200, Vancouver, WA 98684 sfate.riieii.t. of befide.iicies ................................... . License#: 1111 ...............C 6ri1i.)Uaii.Ce··nete:rrriiri8tl0ri.~f4fdfd" Pl~n of Coirection GARDEN COURTE ALZHEIMER COMMUNITY Cotnpletlon Date Page1 of11 Licensee: Olympia Special Care LLC 05/13/2024 You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license.

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 December 17, 2024 ELECTRONIC-FACSIMILE Administrator GARDEN COURTE ALZHEIMER COMMUNITY 626 LILLY RD NE OLYMPIA, WA 98506 Assisted Living Facility License # 1111 Licensee: Olympia Special Care LLC IMPOSITION OF CIVIL FINE Dear Administrator: On December 4, 2024, the Department of Social and Health Services (DSHS), Residential Care Services completed a Complaint Investigation at your facility. This letter constitutes formal notice of a civil fine on the license for your assisted living facility, also known as GARDEN COURTE ALZHEIMER COMMUNITY, located at 626 LILLY RD NE OLYMPIA, 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 December 4, 2024. Civil Fine WAC 388-78A-2371(1)(2)(3) Investigations. $500.00 The licensee failed to document and determine the investigative findings to rule out the possibility of abuse or neglect, and failed to document preventative measures to prevent recurrence, for two residents. These failures placed both residents and other residents in the facility who experienced injuries of unknown origin at risk for ongoing or unidentified abuse or neglect. This is a recurring deficiency previously cited on August 4, 2023, and June 14, 2022. NOTE: These are the violations, which resulted in the fines; see the attached Statement of Deficiencies for any additional violations. Administrator GARDEN COURTE ALZHEIMER COMMUNITY License # 1111 December 17, 2024 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: Cory Cisneros, Field Manager Region 3, Unit E 6639 Capitol Blvd SW Point Plaza West Tumwater, WA 98501 Phone: (253) 254-3190 / Fax: (360) 664-8451 rcsregion3email@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. Send your written request to: Informal Dispute Resolution Program Manager Residential Care Services PO Box 45600 Olympia, Washington 98504-5600 Administrator GARDEN COURTE ALZHEIMER COMMUNITY License # 1111 December 17, 2024 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 $500.00 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 GARDEN COURTE ALZHEIMER COMMUNITY License # 1111 December 17, 2024 Page 4 If you have any questions, please contact Cory Cisneros, Field Manager, at (253) 254-3190. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 3, Unit E RCS Regional Administrator, Region 3 HCS Regional Administrator, Region 3 DDA Regional Administrator, Region 3 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW HP

Allegations of physical and phycological abuse towards residents. Investigation Methods: Sample: Total residents: 80 Resident sample size: 4 Closed records sample size: 1 Observations: Residents Resident rooms Staff to resident interactions Resident to resident interactions Identified resident Interviews: Identified staff Nursing staff Residents Family members Record Reviews: Medical records Grievance log State reporting log Incident investigation Facility policies Personnel files Staff training records Staff patterns Investigation Summary: Based on record review and interview the facility failed to follow stated and facility policy and procedures for suspected and alleged abuse. The facility failed to verify staff references prior to employment. The facility failed to ensure required training for staff working in a dementia care unit. The facility failed to ensure resident right to be free from abuse. Failed practice identified. . Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: GARDEN COURTE Provider Type: Assisted Living Facility ALZHEIMER COMMUNITY License/Cert.#: 1111 Intake ID: 101823 Compliance Determination #: 31252 Region/Unit #: RCS Region 3 / Unit E Investigator: Maria Salas Investigation Date(s): 10/18/2023 through 01/05/2024 Complainant Contact Date(s): Allegation(s): Allegations of physical and phycological abuse towards residents. Investigation Methods: Sample: Total residents: 80 Resident sample size: 4 Closed records sample size: 1 Observations: Residents Resident rooms Staff to resident interactions Resident to resident interactions Identified resident Interviews: Identified staff Nursing staff Residents Family members Record Reviews: Medical records Grievance log State reporting log Incident investigation Facility policies Personnel files Staff training records Staff patterns Investigation Summary: Based on record review and interview the facility failed to follow stated and facility policy and procedures for suspected and alleged abuse. The facility failed to verify staff references prior to employment. The facility failed to ensure required training for staff working in a dementia care unit. The facility failed to ensure resident right to be free from abuse. Failed practice identified. . Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: GARDEN COURTE Provider Type: Assisted Living Facility ALZHEIMER COMMUNITY License/Cert.#: 1111 Intake ID: 104783 Compliance Determination #: 31252 Region/Unit #: RCS Region 3 / Unit E Investigator: Maria Salas Investigation Date(s): 10/18/2023 through 01/05/2024 Complainant Contact Date(s): Allegation(s): Allegations of physical abuse and restraining of resident. Investigation Methods: Sample: Total residents: 80 Resident sample size: 4 Closed records sample size: 1 Observations: Residents Resident rooms Staff to resident interactions Resident to resident interactions Identified resident Interviews: Identified staff Nursing staff Residents Family members Record Reviews: Medical records Grievance log State reporting log Incident investigation Facility policies Personnel files Staff training records Staff patterns Investigation Summary: Based on record review and interview the facility failed to follow stated and facility policy and procedures for suspected and alleged abuse. The facility failed to verify staff references prior to employment. The facility failed to ensure required training for staff working in a dementia care unit. The facility failed to ensure resident right to be free from abuse. Failed practice identified. . 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 800 NE 136th Ave Ste 200, Vancouver, WA 98684 Statement of Deficiencies License #: 1111 Compliance Determination # 31252 Plan of Correction GARDEN COURTE ALZHEIMER COMMUNITY 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 10/18/2023 and 12/13/2023 of: GARDEN COURTE ALZHEIMER COMMUNITY 626 LILLY RD NE OLYMPIA, WA 98506 This document references the following complaint number(s): 101047, 99320, 99595, 101823, 99931, 102395, 104783 The following sample was selected for review during the unannounced on-site visit: 4 of 80 current residents and 1 former residents. The department staff that investigated the Assisted Living Facility: Maria Salas, ALF Complaint Investigator From: DSHS, Aging and Long-Term Support Administration 800 NE 136th Ave Ste 200 Vancouver, WA 98684 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 #: 1111 Compliance Determination # 31252 Plan of Correction GARDEN COURTE ALZHEIMER COMMUNITY Completion Date 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; (2) The assisted living facility must develop, implement and train staff persons on policies and procedures to address what staff persons must do: (a) Related to suspected abandonment, abuse, neglect, exploitation, or financial exploitation of any resident; This requirement was not met as evidenced by: Based on record review and interview, the facility failed to implement facility policies and procedures when suspected abuse was reported for 2 of 2 residents (Resident 2 and Resident 3). These failures contributed to Resident 2 being placed at risk for on going harm and placed all 80 of 80 residents at risk of harm due to staff not following facility and state policies when suspected abuse had been reported. Findings included… WAC 388-78A-2020 “Definitions. "Abuse" means the willful action or inaction that inflicts injury, unreasonable confinement, intimidation, or punishment on a vulnerable adult. In instances of abuse of a vulnerable adult who is unable to express or demonstrate physical harm, pain, or mental anguish, the abuse is presumed to cause physical harm, pain, or mental anguish. Abuse includes sexual abuse, mental abuse, physical abuse, and personal exploitation of a vulnerable adult, and improper use of restraint against a vulnerable adult… "Neglect" means: (1) A pattern of conduct or inaction resulting in the failure to provide the goods and services that maintain physical or mental health of a resident, or that fails to avoid or prevent physical or mental harm or pain to a resident; or (2) An act or omission by a person or entity with a duty of care that demonstrates a serious disregard of consequences of such a magnitude as to constitute a clear and present danger to the resident's health, welfare, or safety, including but not limited to conduct prohibited under RCW 9A.42.100..."Improper use of restraint" means the inappropriate use of chemical, physical, or mechanical restraints for convenience or discipline or... ”Physical restraint" means the application of physical force without use of any device for the purpose of restraining the free movement of a vulnerable adult's body..." . Statement of Deficiencies License #: 1111 Compliance Determination # 31252 Plan of Correction GARDEN COURTE ALZHEIMER COMMUNITY Completion Date Record review of the facility’s Abuse Policy and Procedure, undated, showed that the purpose of the Abuse Policy and Procedure was to ensure that all residents were treated with respect, dignity and lived in a community that was free of verbal, sexual or physical abuse. To establish a procedure for investigating and documenting suspected or alleged abuse. To delineate state specific definitions and reporting requirements for alleged or suspected abuse. The policy stated that all allegations of abuse would be treated as serious and would be investigated, documented and reported per the standards set forth in the policy and procedure or per State or Federal regulations. Physical Abuse as defined in the Abuse Policy and Procedure was any physical injury to a resident caused by other than an accident. Physical injuries included injuries that a reasonable and prudent person would be able to prevent such as hitting, pinching or striking, or injuries resulting from rough handling or corporal punishment. Verbal or Emotional Abuse as defined in the Abuse Policy and Procedure was any oral, written or gestures communicated to a resident or to a visitor or staff about a resident within that resident’s presence, that described that resident in a disparaging or derogatory terms, humiliation, harassment threats of punishment or deprivation directed towards the resident.

Conclusion / Action: I&] Failed Provider Practice Identified / Citation(s) Written □ Failed Provider Practice Not Identified / No Citation Written □ N/A . Investigation Summary Report Provider/Facility: GARDEN COURTE Provider Type: Assisted Living Facility ALZHEIMER COMMUNITY License/Cert.#: 1111 Intake ID: 67618 Compliance Determination #: 20265 Region/Unit #: RCS Region 3 / Unit E Investigator: Cory Cisneros Investigation Date(s): 02/22/2023 through 04/11/2023 Complainant Contact Date(s): Allegation(s): 1) resident had a fall from their wheelchair with the wheelchair landing on them and enduring facial injuries. Investigation Methods: Sample: Total residents: 85 Resident sample size: 5 Closed records sample size: 2 Observations: Activities Dining Resident care equipment Resident rooms Staff to resident interactions Resident to resident interactions Residents Interviews: Identified staff Nursing staff Residents Management staff Family members Record Reviews: Facility policies Incident investigation State reporting log Medical records Investigation Summary: 1) after interview and record review the facility failed to follow their own policy and procedure for supportive devices. the facility failed to assess the appropriateness of the device for the resident and obtain consent and review the risks and benefits with the responsible party. The facility failed to document the assessment or that the consent was obtained in the residents record. the facility's failure to assess the supportive device contributed in the resident to have multiple falls. Those falls caused the resident to endure facial injury when they attempted to get out of the supportive . device. Conclusion / Action: Ii Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written □ N/A □ . MAY/03/2023/WED 10:45 AM Garden Courte FAX No. 360-491-4372 P. 002 DSHS RCS REG. 3 VANCOWER MAY O3 2023 RECENeo STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 6639 Capitol Blvd SW, Floor 1or 1~ Tumwater, WA 98501 Statement of Deficiencies License#: 1111 Compliance De'termination # 20265 Plan of Correction GARDEN COURTE ALZHEIMER COMMUNITY . Completion Date You are required to be in compliance at all time$ 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 02/22/2023, 0'3/15/2023, 03/20/2023 and 03/20/2023 of: GARDEN COURTE ALZHEIMER COMMUNITY 626 LILLY RD NE OLYMPIA, WA 98506 Thfs document references the following complaint number(s): 67818, 67618 63018 61737, 1 1 61049, 72433 The following sample was selected for review during the unannounced on-site visit: 5 of 85 current residents and 2 former residents. The depqrtment st~ff that investigated the Assisted Living Facility: Anissa Bearden, Licensor Cory"Cisneros, Field Manager From: DSHS, Aging and Long-Term Support Administration 6639' Capitol Blvd SW, Floor 1o r 1 Tumwater,. WA 98501 As a result of the on-site visit(s), the department found that you are not in compliance with the licensing laws a·nd regu1ations as stated jn the cited deficiencies in the enclosed report. ~ ~4, 04/24/2023 Residlt;al Care Services Date . MAY/03/2023/WED 10:45 AM Garden Courte FAX No. 360-491-4372 P. 003 Statement of Deficiencies Licflnse #: 11·11 Compliance Determination# 20285 Plan of Correction GARDEN COURTE ALZHEIME~ COMMUNITY Completion Date Page 2 of11 Licensee: Olympia Special Care LLC 04/11/2023 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. lQU WAC 388-78A-2610 lnfectior1 control. 1 (2) The assi~ted living facility must (d) Provide all resident care and services according to current acceptable standards for infection control; This requirement wa~ not met ct~ evi~enoed by: Based on observation, interviews! and record review the facility faiJed to follow infection control practice b_y not washing their hands and changing their gloves after care was proviqed or wer~ visit::>ly soiled. Thi~ failure pli;;1ced 7 of 7 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, and Resident 7) all at risk for cross contamination and infection when care was provided to them by the facility staff. Flndlngs included ... Record review of the Centers for Disease Control and Prevention (CDC) document, titled, 11Hand Hygiene in healthcare Settings Guidance'', dated 01/30/2020, showed health care personnel should use an arcahol-based hand rub or wasti with soap and water for the following clinical inc:tlcations: immediately before touching a patient, before moving from work on a soiled bOdy site to a clean body site on the same patient, after touching a patient or the patients immediate environment, after contact with blood, body fluids, or contaminated surface$, immediately after gl_ove removal., Health care facilities should require healthcare personal to perform hand hygiene in accordance with CDC recommendaUons. Record review of the facility poficy and procedure for 1'Handwashing11 undated, showed the [!purpose , of good handwashing is to be the front-line protection of spread of infections.1 Hand washing was the l single tnost important measure for preventing the spread of lnfection and diseas·e. All staff were· responsible for carrying out the hand washing policy. Staff were to wash their hands after handling spiled laundry or items with body fluids c1.nd housekeeping tasks, before arid after helping resident with personal care task of daily living, whenever staff change from doing a ''dirty" task to ::i 11crean" task, and whenever hands were obviously soiled. The use of gloves did not replace hand washing. In an observation on 03/15/2023 at 4:12 AM, Staff C, Caregiver, applied gloves on her hands. Staff C took Resident 11s (R1) brief 9ttthatwas soiled with urjne. Staff C did not chang~ their gloves. They then placed the new, clean brief under the resident. They then . MAY/03/2023/WED 10:46 AM Garden Courte FAX No. 360-491-4372 P. 004 Statement of Deficiencies License #= 1111 Compliance Determination # 20265 Plan of Correction GARDEN COURTE ALZHEIMER COMMUNITY Completion Date appli~d barrier cream to R1's bLJtt□cks •ijnd coccyx area. Staff C assisted the resident with rolling on their other side with the same gloves. Staff C completed fastening the brief on R1. Staff C covered R1 with their blankets with their soiled gloves on, picked up ths soiled brief with one gloved hand, turned R1rs bedside table lamp off with the other gloved hand, walked out of the room to their linen cart to discard the brief in a bag. Staff C then removed her gloves. Staff C then applied a new pair of ·g loves from her linen cart. Staff C did not use soap and water or an alcohol-based hand rub prior to applying new gloves. In an observation on 03/15/2023 at 4:19 AM, Staff Casked Resident 2 (R2) to toilet. Staff C assisted R2 to the bathroom. Staff C"removed R2's urine soiled brief and discarded it. Staff C then assisted R2 to put on and pull up the new brief. Staff C assisted R.2 to bed, covered R2 with their blankets, turned the bed alarm on with the same gloves on. Staff C picked the trash bag up from the bathroom1 turned ·the light off and exited the room. Sta.ff C's gloves were removed at the linen cart at 4:24 AM after exiting R2's room. Staff C was not observed to use any alcohal-paseg hand rub or washed their hands with soap and water during the entire observation. Staff C1s gloves were not changed during the entire observation of cara. In an observation on 03/15/2023 at 4:26 AM, Staff C applied new gloves to their hands. Staff C did not use soap and water or an alcohol-based hand rub prior to applying new gloves. Staff C, touched Resident 31s (R3) shoulder. Staff C asksd R3 if they needed to use the bathroom. R3 stated that they didn't think they needed to b.e changed. R3 gave permission for Staff C to check their brief to ensure they didn1t need to be provided care. Staff Chad touched R31s brief tq ensure they were dry. Staff C then adjusted R3js pillow and pulled their blankets up. Staff C went to the other side of the room to R31s roommate, Resident 4 (R4). Staff C touched R4's arm to wake them while still wearing the same gloves she enterecl the room with. Staff C ·asked R4 if they needed to ·use the bathroom and R4 declined. Staff Cleft the room. Staff C then went to the·linen cart, removed their gloves and· discarded them in the trash. No observed.