Tri-cities Assisted Living.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A .

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.

Findings included… Record review of the Washington State Patrol Fire Protection Bureau report, dated 12/04/2024, showed that facility failed their initial inspection. The follow-up inspection on 03/17/2025, showed that facility continued to violate the following requirements: • Resident room door failed to close and latch. • Fire sprinkler escutcheon ring was missing. • Single station smoke alarms greater than 10 years old were observed in a resident room. • The heat detector was missing the cover. • The facility could not provide documentation of annual service on the emergency generator. . Statement of Deficiencies License #: 2549 Compliance Determination # 57958 Plan of Correction Tri-Cities Assisted Living Completion Date In an interview on 04/15/2025 at 10:20 AM, Staff A, Administrator, acknowledged that the facility was out of compliance with the Life Safety Code Inspection and requirements. This is an uncorrected deficiency previously cited on 12/04/2024. 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, Tri-Cities Assisted Living 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. No failed practice identified. 7. Identified resident stated they currently had their phone charger and a wheelchair. Interview with administrator showed that upon hearing about the missing items, the facility followed their policy, investigated and offered to replace missing item if not found. Observations showed the resident had their phone charger and no longer had concerns with missing items. Observations of resident’s apartments showed that they had access to locked draws in their apartments. No 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: Tri-Cities Assisted Living Provider Type: Assisted Living Facility License/Cert.#: 2549 Intake ID: 156806 Compliance Determination #: 50634 Region/Unit #: RCS Region 1 / Unit G Investigator: Melissa Milanez Investigation Date(s): 11/21/2024 through 01/13/2025 Complainant Contact Date(s): 01/14/2025 Allegation(s): 1. Unknown staff refuse to help named resident with cares. 2. Family not able to get in touch with the facility staff. 3. Facility administering wrong medication dose. Investigation Methods: Sample: Total residents: 85 Resident sample size: 6 Closed records sample size: Observations: Identified resident Residents Dining Resident rooms Staff to resident interactions Resident to resident interactions Medication administration Interviews: Identified resident Identified staff Nursing staff Residents Family members Record Reviews: Medical records Hospital records State reporting log Incident investigation Facility policies Staff patterns Medications Administration Records Physician Orders Investigation Summary: 1. Interviews and record review showed that the identified resident required assistance with Activities of Daily Living (ADL’s) and staff were to assist as needed. . The identified resident stated that staff had refused to assist them with cares. Interview with facility staff showed that they were told by other staff not to assist with cares and that the identified resident needed to do things on their own. The Administrator stated that there was a failure in communicating the needs of the resident, and that they provided staff education on following the Negotiated Service Agreement. Failed practice identified under WAC 388-78a- 2160. 2. Observations showed that the front desk receptionist was answering the phones during the onsite visit. Interviews showed that care staff are responsible for carrying a cordless phone after hours. The Administrator stated that phone calls not answered after business hours would be re-directed to the Administrator or the Director of Nursing. No failed practices identified. 3. Record review of the residents after visit summary showed that there was a new order to increase the medication dosage per the physician’s orders. Interview with staff showed that they were aware of the new dosage changes but acknowledged that they had not administered the new dose. Review of the Medication Administration Record failed to show new medication dosage. Failed practice identified under WAC 388-78a-2210. Medication services. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . . . 02/24/2025 MON 14, 05 FAX 50~5472532 TCRI (i]J004/015 01.28.2025 l7d5:47 state of llashin9ton 61 Sfoterne11t of De/,c.:fonCi<ls Lr:.e-r:se: #: 2549 ,j9(npHtant~ D~M~'mlr1;J:tfon #5U634 P1a!'! of Ca,~~etic>,, Tti-Chiu Aotl~t-:i Ll,i119 C~rnp~.t,o~ bait Pai)~ :2 ,,1 i2 u,~f'-i~eei: i~tt~~ia~1$ r1i11~r~GJ9Grn~nt "''"''"·'"· LLC 01:/13/20~6 As a resuit ofth+.1 ,m-sit<:l visit(s), \:he depart1m,m found ttrnty.,u !Ire net in r.ximpli,mce with !he !l•~trn1:ing iaws and re1Julalio11s as stated in thii: dt~d delic.iem:i~s in the sm:losed rap~rt. 01/28/2025 Date i ,mder&and that ttl maintain an Assfsted Liv 0o:lc.Mv \!tense. trw. f.icl!lty m1i.st !l<!i in i:ompli!ll'lt:~ wll.ll all !i'ie lken1llng laws ,m < ~gtJiatiomi !It .iii times. RCW 70_129 .. 140 Qua.lity of lif• •• Righti. (l) Th,; f.a,~ihty mm,rt pn:,mol;;: ,;:imi fo; resid~ms in ,, maru1er and in <!n ~nvimnment !hat rn<1int,1ins or l'lnh01Kes ead'i i-es1denfs: di(l')ity !lM respect in fu!I reec,gni!l1.m ,,f his 01' Mf i!1divi!ju0,it:y·. (5) A residimt h,11.1 the, righ! to. (a) Residi ;ind recaiv" se1vl1:es ii, thll' f:ldhty with rs,.isonmb!<!! ac,:-0mmodaifon ohndividu;il n,;-,,,fa anrl pr,1!,;,r<111c~11:, 11:xcept wlwn the he,;.lft1 or !IJ;;1f11iY ,1fth<1 im:lMrJual 11r other reskh1nts 1NtlLIM be endtmi;ieri!Ht imd WAC 388-76A-2660 Resident rtehu, Tht H Silted llvlng facility llHt11t (1) Comi:i111 wi!l'I d1,1t1tl')i rn. t ~s Rev; Long-term ;;im, remd~nt M;ihts; w~m (2) Ersur~ o~l staft pJ!:its::ms pr1v~d~ (:are- i:tt"i:d se,v~eec tf) ea 1 :::t1 resident c.m1s~sti?.nt c~~~pter 70. 129 RCV\t: 811~ed Ml dJSBfv~tiai\ int~t\/1>cw and •~,:ord ri;vi&w. lhl> t'udlity· !aile·d to e,m,ure that t1\~icle•its vv~re tte.-~ted ~Nit.h 1·$~pel".:t and dignit}1 ri:':l~it~d t(: J'SS1$t;11r, rr:sid,~n~ wtth care :a~d s~~tvt,~~$ M~d ~1'!:sv~1et~n?, t:;:,1,11~ ll~ht r~spons~s fe,r 1 of ~s ~rl1n·:p~e rttldi.i'l'ltt {Resident!). This f;1u!ure r~~'l.~ltt~ct i11 w11:.h9r:lh-d€ ~trJ:ff rf;sp-ons~s to Res1di-;nt ·~ an.d ::~Qnttlbut~d t~ d~.dr.r~/~d c.Mi:.-s and servir;:;s ?(if .\l :'\~ij\de!1t ~<\11:o v,a~ ~iYpi::ritin:.ing p~m ard :tH:te.;.:n,i~~i h~~,it.h i1&ut~~- 1 F~~-1ievv of rtl'!l ALF"$ j.ti)il~}· :;F~:fS•:1:'1,U~ i\1g~m.i' dS't:?.d 08/'! iJi"'2iJ21 SIWW$d th~.t ti11fr f;.o,.:!l!ty l":"k;t.t / pnJ.1111-:it~· c:art '.Jf t~1i:~~rrts !r~ i:..'l: !'!"'l~:tine:- ;]nd in r.m ..~ :l'1vir1j1•1r~•1ent thZJt rn~i,ritijn~ ,')·'· . . . . 02/24/2025 MON 14, 08 FAX 50~5472532 TCRI (i]J009/015 01.28.2025 17,16,47 State of llashington II/ St,Mrrhll1l Qf OQ/i~ittl(.i~i, Ucen$~ #: 2549 Gut,!PMni:il Dateirnrnat1,an #5()6::!4 J!li~f'l ol c~rncti<1f'l Tti-Cmo, As,lillt& ll~ing Compl&tiort D~I• Pag;; 1 M 12 01/131:'.!0.'.:!5 On 121'131"2024 at 11:5! /IM Staff A, Slilt~d that they de not h,we a policy Oh cmll lightru:p(H'\\'W: times; but they strive to ~et them l'lrll'JW~red withm fifteen minutell. They stated that aft.It' revie111M1g the c:~11 light respi:mM times,, tl1~y ackMWectg,id mat they c:oulli b~ bett&r arul wtiuli:! be prn11idfng an in-service to llt<1>4' on call light respons,;: tirn%. On 12/Hll2024 11t t 1 :155 AM, Staff C, He<1lt!l and Willh1ess 01r<11:tor, stated aci<:nawledged obs11rving; other rt,icient!ii as>iitsting Reside·nt 1 ,,,,.;th wheel!:hllir roobi(ity. On OJ/'1 ~/20'JS .it :3:62 PM, St111ff A, litatcld thattho>y believe the st~fl Wiffe misinformed by .; i:JeJegated ai1l regarding to not :.ssis.t Resident 1. They stated that therai ti.id been a note tram a physical thernpi!'.t th:at showl!!d !he rel!l1de11t was encouraged to walk with rest breaks if able .. They slatf:d that d.uring the,r investi9!1!1Jon. the Bm,iness Office Mana~er (SOM) repatted overhearing a caregiver (OM ll'l,it only wor1<s at the fadl!ly part.time) instru~ another !l'la! Resident 1 needed to be c«:H'ning down tn me dining r,:iorn by themselves. St!lff A stated \h&Hha BOM told trie caregivers, that that w:is not true, and that staff n•eeded bt hlllph,g the rasldent with earns. S'taff A aill•J statad they pn:ivkled ;u, !r.-service to staff or. the !rripottance ol fo!!owing the residints co1re plans and th11t thty should not: be fordng r-esictentl!i to do an)•1hllly they cannot cto. This is a nwc,.:urring cftation pr~Yit1usly cited or, 12127"2023 far WAC 3f.l!l-71l-a--2-060 (l). Plan/AttHtation t111t•m11mt I I'm re by certify lfi:11t I have reviewed this re:p~rt .ind have taken or will take active measures to c~rrect this daf(ciericy. Gy ta!iing ll1is action, ,!rP.:iti s ssis ,d Living .!.1\ or \ "'111 b~ w1 compi:an,;e With tlw, i,;,w ar.d J ◊1· regulauon on (0"1tsl} _ __:'1'1,,"1 In .additi:!:i,1. I v,m impleme11t a $y.ttem to monitor .,r,r.i ensure coni!nwed coin'1plia11ce V'.'l'th this t'!\~uir;,rn>'ll'I!. WAC 388-'1':!IA1Z210 Medle-atlon !Ulr\lic U- (2} T!H;i ass1ijtrJd 11:ving ri~i:imy rnust ,::nsure Ul:.!· f0lkH·v1ng r,~sid~irl~ re~eivt tht.m mtdkatron-s as pr1:is-cnbe1j. e~t.i:Jtit ag prcv!.deu fiJr !n v'VA..C 38.8-'lBA---1230 and ~~Be .. TSA,-2150 . • 1 {a) E~ct1 r~sidi:!ntlf~•ho r,;quire-B rr~~di('at1on assistimce ~rnd h~s other 11egC'lt~~ted 'Bi,rvii~e. a~1reement indic,~t~S-n1~ ;;H,sii:;;t~d liv1i:-19 tadhl\l ~\·ill pro"nd(:- medi,::atio~~ ~\i$1itanc:e; and . . . 02/24/2025 MON 14, 11 FAX 50~5472532 TCRI (i]J014/015 01.28,2025 17'15,47 State or Washington IG/ Sfal&n:Jel\t of o~licwnciez u~e,, se #: 2549 Cotr,pHMt•~ D*tMnln3'lml1 #506!14 PkHi of C cnt11ci!oo: Tr ~Cl\i~• ..1 1.s,is:t,.«l Living Ctm1p\<>h~n t'JQ!o Pa\)* 12 ~f ·i2 Ut:.1.l~!S@'i.!: Gr*eri!~~~~ M~1i:sig~n'l:~mt LlC Rl':view slf a pmgre~s notij deited 1 'li'l2l2024 at 5:42 1~M .. showed that the resident was !l<:e11 by tl1e phy;,icai th.imp/st ih>tl•~ report.,d en increased bl cod pressure readlng to tha ladli(y <lf ·177194 No tv additional bl~od presstm,s were dooJmented ()I' l'Nltlrt~d the far:i!ity. Revie,v ,1r Resiilent Vs ER visit rep,~rt da!:<'!ct I 112:J/2024, showed mat the re!lldent was taken tc th,;: ER and evaltrnted for complaints Clf lower extremity edema a11d rep,::,its LJf Hyperkalen1a (high pota5':lium) F~.e;:iident 1 com,plaLneo ot t.ilaterni !•Jwer extremity' !t>g pa,n and was miled to have bilater<1l lower ~xtrnmity sw;illing ~nd bilateral 'ilt:limi;;; dern1atiil~ (skin i;1/l;ition in lhe lower l<ijjll caused try fluid buildup). Furthar physical itxam notfiG from tne hospital records 1:,howed !hat the r/i's1de1,t h.id ~ hlnnn rir"'~~im• ,if? ·f ::t/~;'i ilt l? :14 PM. 17;'i/fl?

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: Tri-Cities Assisted Living Provider Type: Assisted Living Facility License/Cert.#: 2549 Intake ID: 137093 Compliance Determination #: 44171 Region/Unit #: RCS Region 1 / Unit G Investigator: Melissa Milanez Investigation Date(s): 07/16/2024 through 07/31/2024 Complainant Contact Date(s): Allegation(s): Fall with injury. Investigation Methods: Sample: Total residents: 86 Resident sample size: 3 Closed records sample size: 2 Observations: Residents Resident care equipment Resident rooms Staff to resident interactions Resident to resident interactions Resident mobility devices Tripping hazards Interviews: Identified staff Nursing staff Residents Family members Business office manager Record Reviews: Medical records Hospital records State reporting log Incident investigation Facility policies Staff training records Staff patterns Investigation Summary: Observations, interviews and record reviews showed that the facility failed to follow their policy and procedures when responding to falls. The facility failed to summon immediate assistance for the identified resident after the fall and failed to notify the responsible party the day of the fall. The identified resident was taken to the hospital the next day and was diagnosed with a . Failed practice . identified. WAC 388-78A-2600. Reference statement of deficiencies dated 07/31/2024. 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 (SOD) dated 09/14/2023. 4. Interview and record review showed that the named resident had a history of refusals of care which included getting out of bed, and did not always call for help to ambulate as per their Negotiated Service Agreement (NSA). No failed provider practice identified. 5. Interview and record review showed that the facility made notifications when necessary, no significant change in condition was noted in the resident's record, nor did they require an overnight stay at the hospital. No failed provider practice identified. 6. Interview and record review showed that the ALF requested therapy as asked by the named resident's representative, however the resident had recently been discharged from therapy and was not a candidate for additional services. No failed provider 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: Tri-Cities Assisted Living Provider Type: Assisted Living Facility License/Cert.#: 2549 Intake ID: 93232 Compliance Determination #: 27925 Region/Unit #: RCS Region 1 / Unit G Investigator: Tracy Ramirez Investigation Date(s): 08/23/2023 through 09/14/2023 Complainant Contact Date(s): Allegation(s): Two named staff members abused the named resident. Investigation Methods: Sample: Total residents: 91 Resident sample size: 9 Closed records sample size: 0 Observations: The facility’s common areas, kitchen, meal serve out, resident apartments, resident care, resident to resident and resident to staff interactions were observed. Interviews: Sampled residents, facility staff, and others not associated with the facility. Record Reviews: Resident characteristic roster, resident records (assessments, care plans, temporary service plans, medication administration records, and progress notes), incident investigations, facility policy and procedures, disclosure of services, resident handbook, resident agreements, resident activity schedule, menus, staff roster and work schedules, and activities the budget. Investigation Summary: Interviews with facility staff and the named residents representative showed the facility did not report and thoroughly investigate the allegation between resident and staff. Record review showed the facility did not report or investigation the allegation. Determined failed practice WAC 388-78A-2630 Reporting and WAC 388-78A-2371 Investigations. Statement of Deficiency (SOD) 09/14/2023. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written . N/A . Investigation Summary Report Provider/Facility: Tri-Cities Assisted Living Provider Type: Assisted Living Facility License/Cert.#: 2549 Intake ID: 93108 Compliance Determination #: 27925 Region/Unit #: RCS Region 1 / Unit G Investigator: Tracy Ramirez Investigation Date(s): 08/23/2023 through 09/14/2023 Complainant Contact Date(s): Allegation(s): 1. Facility staff found the named resident with bruises to arms, back, and small bruises to breast area. 2. The named resident also had redness to their genital area and had been recently treated for a urinary tract infection. Investigation Methods: Sample: Total residents: 91 Resident sample size: 9 Closed records sample size: 0 Observations: The facility’s common areas, kitchen, meal serve out, resident apartments, resident care, resident to resident and resident to staff interactions were observed. Interviews: Sampled residents, facility staff, and others not associated with the facility. Record Reviews: Resident characteristic roster, resident records (assessments, care plans, temporary service plans, medication administration records, and progress notes), incident investigations, facility policy and procedures, disclosure of services, resident handbook, resident agreements, resident activity schedule, menus, staff roster and work schedules, and activities the budget. Investigation Summary: 1. Record review of the Medication Administration Record showed the named resident was on blood thinning medication. Interview with facility staff stated that the named resident had increased hands on assistance with all physical transfers. Interview with facility staff stated they investigated the bruising and that they believed that abuse was founded. The facility failed to report and thoroughly investigate the incident and failed practice identified WAC 388-78A-2640 Reporting and WAC 388-78A-2371 Investigation. Reference Statement of Deficiencies (SOD) 09/14/2023. 2. Record review of progress note showed the named resident was diagnosed with a . and received treatment. No 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 1200 Alder Street, Union Gap, WA 98903 Statement of Deficiencies License #: 2549 Compliance Determination # 27925 Plan of Correction Tri-Cities Assisted Living 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 08/23/2023, 08/24/2023, 08/25/2023, 08/28/2023, 08/29/2023, 08/30/2023, 08/31/2023 and 09/05/2023 of: Tri-Cities Assisted Living 2000 N 22nd Ave Pasco, WA 99301 This document references the following complaint numbers: 92331, 91558, 93232, 93108, 93439, 92741, 94575, 94493. The following sample was selected for review during the unannounced on-site visit: 9 of 91 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Anna Cairns, ALF Long Term Care Surveyor Robin Rainville, Assisted Living Facility Licensor Tracy Ramirez, Assisted Living Facility Licensor Jessica Clapp, Assisted Living Facility Licensor Elaine Lopez, Licensor Gwin Kaercher, Community Field Manager From: DSHS, Aging and Long-Term Support Administration 1200 Alder Street Union Gap, WA 98903 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. . . . Statement of Deficiencies License #: 2549 Compliance Determination # 27925 Plan of Correction Tri-Cities Assisted Living Completion Date facility staff, and resident's family or other significant persons in meeting the resident's needs and preferences. Except as specified in WAC 388-78A-2290 and 388-78A-2340 (5), if a person other than a caregiver is to be responsible for providing care or services to the resident in the assisted living facility, the assisted living facility must specify in the negotiated service agreement an alternate plan for providing care or service to the resident in the event the necessary services are not provided. The assisted living facility may develop an alternate plan: (a) Exclusively for the individual resident; or (7) The resident's ability to leave the assisted living facility premises unsupervised; and This requirement was not met as evidenced by: Based on observation, interview, and record review, the Assisted Living Facility (ALF) failed to develop in the Negotiated Service Agreement (NSA) the plan to provide care and services which included wound care, the ability to leave unescorted, and accurate evacuation information for 3 of 9 residents (Residents 1, 4, 5) who had assessed needs. This failure placed the residents at risk of unmet needs and unsafe conditions. Findings Included... Resident 1 An interview was attempted with Resident 1 on 08/28/2023 at 1:23 PM in the Memory Care Unit (MCU). Due to the resident’s cognitive deficits, they were unable to track and answer questions about the care and services that were provided to them. Resident 1’s 07/03/2023 assessment and NSA showed that the resident was independent with transportation and was able to leave the facility unattended. Additionally, Resident 1’s assessment and NSA showed that the resident had difficulty remembering and using information. Under the evacuation section the NSA showed that Resident 1 required supervision, needed to be escorted downstairs, and had a dog. Review of the ALF's Resident Characteristic Roster, dated, 08/28/2023. showed that Resident 1 resided in a first-floor room in the MCU, was an exit seeker and had memory loss. The information from the NSA did not match the information on the characteristic roster. On 08/30/2023 interview with Staff J, Licensed Practical Nurse (LPN)/Executive Director, they stated that the Resident Roster and NSA needed to be corrected. . Statement of Deficiencies License #: 2549 Compliance Determination # 27925 Plan of Correction Tri-Cities Assisted Living Completion Date Resident 4 An interview was attempted with Resident 4 on 08/28/2023 at 12:53 PM in the MCU. Due to the resident’s cognitive deficits, they were unable to state what staff helped them with. Resident 4 stated that they sometimes needed help, referred to their childhood, and that they wanted to go to their room. The resident was observed seated in their manual wheelchair. Review of a 08/08/2023 progress note in Resident 4’s record showed that the resident was moved from the Assisted Living side of the ALF to the secure MCU due to safety concerns.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . I&] □ □ . 08.11.2023 10:02:44 State of lolashington 5 (SHiNGrON DEP.ARTlV1ENT OF SOC! AL AND HEAL TH SERVJCES .A$!NO .<\ND LONG-TERM SUPPORT AD MH\Jl:STRATfON 12.0D Mier Slteet, Union Gap, WA 98903 Statement ◊f Defh:i~ncies CM}¢i.arice Dretec-rmil.atmn # 2lt 76 F'l.an zyf C-c;~ectfon 'fri-Cities .As~i-sts<l Living Cm11pt~forn bah:: Pa9~ l of 3 Ucsnse::: Gr-.enfak~ l\•~,anagemsnt t:'as:::zy. LLC You are required to be in mmpliarn.:-.e at ;;:ll tim,es wRh all licBnsing 1avvs and re9ulafo:ins to maintain y':JL:r Assist!i:.d Uv1ng fa,:/ity ti,:ense. The dep.;rntment :::on1pl.et-ed d~:t:ta CtJU~chon for an unann.atH1ced o-n-site ~:ornp~aint Sr~v.e~~t~gHtfr}n on 07l27i2ll23 ~nd 0712?i2(123 of: Tri-Cities Assisted Uving 2000 N 22nd Ave F' ascn ; vv.a. 9tn O·1 This co,::tJm,ent refernrn::~s the folh::v"~ng con1plaint r,umb~r(s}: 90943, 9054B, 9048·1, 9D4 79, 89834,91122,67741,91120 The fvl10;.'\1ing st.lmple was gelected for {evie~•'.i dw~ng ttie unamwunc::ed en-site vislt 7 af S& cun--::nt ;+::skknts and ·l former t'.:'.sldents. U,urel Knight. C,::rnmunity Cornpla1r1t !n-~··1c:s1i1ptrn Anna C:aims. ALF Long Terrn Care Survey,Jr From: DSHS . .A.qing anct Long-Term !S,.,pport: Arfn'iinistrnt:on Resid~ntia! Care Setvs.cBs, Regian 'l , UnJ G ·1 2DD Aider ~:.'ltreet Union Gap, V\i/._ 98~G3 As a t~su!t of the on-site vis,it{~). the zi>::p,~ftm-ent found that :{GU ,~fe n,,t m ci::m~,lianc;; v-.ith the ~;c..=~nsing ic:~•'/$ and re9ulat~::;ns a'S st::~ted in t~:t? c~ted d;::f1ci~nci~~s ~n ttl".! i=~nclosed r~pcrt, 08/11/2023 STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 1200 Alder Street, Union Gap, WA 98903 Statement of Deficiencies License #: 2549 Compliance Determination # 27176 Plan of Correction Tri-Cities Assisted Living 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 07/27/2023 and 07/27/2023 of: Tri-Cities Assisted Living 2000 N 22nd Ave Pasco, WA 99301 This document references the following complaint number(s): 90943, 90548, 90481, 90479, 89834, 91122, 87741, 91120 The following sample was selected for review during the unannounced on-site visit: 7 of 95 current residents and 1 former residents. The department staff that investigated the Assisted Living Facility: Laurel Knight, Community Complaint Investigator Anna Cairns, ALF Long Term Care Surveyor From: DSHS, Aging and Long-Term Support Administration 1200 Alder Street Union Gap, WA 98903 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. . . 08.11.2023 10:02:44 State of Washington 6 ts Smt!?m.::rnt ~f O~frd;mcies L-c~ns~ fr. 2&4S C-o~~liar.<{;& Oet~mlina1~n # 271 Plan of C ;;mection 'fri-Cities Assisieci li<ting Com~)/stio~ Date Piigs 2 of 3 ~ underst~nd tr·~at to maintain .an Assist1:;1:d L~v·~rig F~!ci§~ty· ~;cense~t t1~ fac.inty rnust be !n ,:omp\iancc v,~th aH the licensing l<YNs and regt,l&tions at an t irrn:s. WAC 38:8~78A-301O Resident units. Th• assisted living tacmty r&sident units mu$t hav• the foUowing: (4) 8,,throcms: A<::c~1ss to trnthing/tGi!eting foc.,tiiies \Nithin th~ msidB-nt Lmit tr~st ncit be t~irnt,<Jh ~1 reskiN,t steeping rncirn or ~then,'Vlse cornprornis•.: tr~siden.t dignri.-y r:ir privacy. (\.) Th~, pri1,tate apartrnent inducii:.:s a r~sid1=nt sl:e~ping rn<:m\ a resident Hving room, and a private bathrncm; (iii} There are no morn th.an tv1m residents li\iiniJ in the a.-p,1rtrn~nt Gr (0 V\.1ndow sills at or s1bove Jr;<id~. v•ith grade e:--<tending horizontal\' tefl or more foet frorn n"le bui\dlng; and (d} An individual tovvel ~nd v'lashcbth rad,. or equi·._i·ai~nt. e:<:,::ept ~-vtwn there is a pnv~t~) bat~!m::,rn attac.nf~d to the resident sleeping or liYing n:;0,!\ th~ individm1l tcv,rd Bmi washclotn rack rmiy he ,f, located the atta,::hed rri'._iate irnthrnom: (e) A. Joch;ble drav,,er. cupbn&n-i ;)r other secl.lre space measurin9 a /~;3st cne-h8tf tutik: foot vvith ;~ n:inirnum dimenslon nf four 1,1,:hes.: (f} ~3epar8te storage f~~iht~es fi}f ea,:h r:::sident in .:)r }rnrn;:-:diate!:~l adja~:ent t~:) that res~dents sl~:!~p;ng rcom k1 adequ>:tttly stori; :a r-~~-s..:matle qw:1ntil:i-' or c:h::i.tiin;;l m,d personal p,:i3-:.ess10ns: .mJ This requirement was not met as evid~nc-ed by: Bas~~j -on 1 )b·s-ervati-Jn: 1nte1v~evv. and n:-.c:::rU rev·~=\-\/ the Ass~sted Li"·~n9 f'1ciHty·. (Alf:.} f:}iled :t~} t nst::·t:' th~~t ea:::h re-sfdent t·i:3cl rc1(HT1 a.:::c-orn:rn()dat~an~ th~it r11-et n~(:e-ss;~ry s:pac~ t:.~:~d aineniti=s rt~quiri:rnt~nts f::.;r :3: or 3 sarnpr:~..H 1 resid2"nts {Res~dents -~, 2 c-n·~-1 :~L v'i~1G e\'.i{:h ~h21rtd ;:t on9-bt~dror}rn ;;:p~rttr1e:nti:;,\;~th anc-ther r,-:--~tdi?-t'it ;!ind t:·:,~ ron:T1<.; \!~!~ti=..: on\-' ~i(:~.ns:ecl Statement of Deficiencies License #: 2549 Compliance Determination # 27176 Plan of Correction Tri-Cities Assisted Living Completion 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-3010 Resident units. The assisted living facility resident units must have the following: (1) General characteristics: (b) Residents may not enter their rooms through another resident unit or resident bedroom; (4) Bathrooms: Access to bathing/toileting facilities within the resident unit must not be through a resident sleeping room or otherwise compromise resident dignity or privacy. (5) Sleeping rooms size: (c) When a resident sleeping room is located within a private apartment: (i) The private apartment includes a resident sleeping room, a resident living room, and a private bathroom; (iii) There are no more than two residents living in the apartment; or (8) Miscellaneous: Each sleeping room must have: (a) One or more outside windows with: (i) Window sills at or above grade, with grade extending horizontally ten or more feet from the building; and (ii) Adjustable curtains, shades, blinds, or equivalent for visual privacy. (d) An individual towel and washcloth rack or equivalent, except when there is a private bathroom attached to the resident sleeping or living room, the individual towel and washcloth rack may be located in the attached private bathroom; (e) A lockable drawer, cupboard or other secure space measuring a least one-half cubic foot with a minimum dimension of four inches; (f) Separate storage facilities for each resident in or immediately adjacent to that residents sleeping room to adequately store a reasonable quantity of clothing and personal possessions; and This requirement was not met as evidenced by: Based on observation, interview, and record review the Assisted Living facility, (ALF) failed to ensure that each resident had room accommodations that met necessary space and amenities requirements for 3 of 3 sampled residents (Residents 1, 2 and 3), who each shared a one-bedroom apartment with another resident and the rooms were only licensed . . 08.11.2023 10:02:114 State of Mashington 7 Sta-t-Jm'3.:lt ~f Ot?Jrci;;,n-::fos Ll<:~'mSi3 :#: 2$.49 Plan Qf C ~mictior, Tfi-Cllies Assis/ed Li'iing P .. gs 3 of 3 Licen se-e. Green,:a~;e ~. .f an.iigemen; Pa sc:;;,, lLC for on-e {,ct;~id~.;ni ··rhi3 f~ifure re5utte d in ~--esid.ent2 :sht\ring eJ:purtrnenbs that il~'r;;re not 3pprGv·{~d fol" mc:,re than ont hct::m,i::d sleeping roam and phc.ed tht , ..! sidents at risk for not having pr;vacy and 'dignit/. During an {}bservatk:n nn IJ7t27i2G23 at ·i 1: OJ ,A.tvl, Resident ·l's apartment was observed. Their bed was in it~•.! living E:rea of' tt1e Jµartrnent with a part.iJi cu:rt~in panel ar1:nmci the t1eHd (:f tr!eir bed in the living rn<::i.rn mea of the apart.-.rnent. R•Jsident ·t st~teJ tltey did n(,t have any privacy ~-~hen theif r:::ommate or staff ~~-aiked by to the sleeping mrnn and wanted to m,}ve to ,~ roorn ~,vith .a door. Dudng an nhserv<ltlon en 07/27i2iJ23 at ·\ ~ :30 .Ai\A Resident 2 v,.l.;1s ::ibserved in their bedr<H)rn 1,'\i·hb~ .•,,as shared by ~-.,,fo resident)~fa1 n~sicttnt in the living arna orth~ apartm~nt. Resident 2 statt'id they \¾~re ~oing to be m,1vin:J out be;::ause friey were urn:omfofu'1bl~ with the shar~d livlng m::c,:nnrnodations. The r•:inm dkl net rneet the nec~ssa~,t ::.p:a,:e and amt::r.kties requlremei1ts to indude an art,a to hang tawe!s and washdath or store personal items surh as clothing. There Wm€ ~ n::, secure ltKkiqJ drawet~:'c:abinet ta store items for resident use. Our~r1g an ubs~,v~atioti on 07i27i2023 at 1 ~ :40 .J~~t'/1 R·eside·nt 3 ~vas obse~\f•ed fn tM~ Hving roorn area of :a si1ared one-bedrnom ~~partm&nt. The rncrn. The room did n~-tmeet the neces.s.my space and >.lrnenities r~quirements tc inch.de an are;1 to ha;;g tt1v11·els and \r\',lShdoih er sk,re p~fS{':}rlal item~ sud, as -clothing. Rtsident 3 stated foey were rn:it happy w,m t:ne shared sp-ac-s, tut th~y v,:ilUc-t1 1 - . , : · : » ~ U - < ~ . ~ • • ~. g , - ; : ;, , t r~,:,•1~..,-• .'...• ~ .-> t -.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: Tri-Cities Assisted Living Provider Type: Assisted Living Facility License/Cert.#: 2549 Intake ID: 81037 Compliance Determination #: 23237 Region/Unit #: RCS Region 1 / Unit G Investigator: Melissa Milanez Investigation Date(s): 05/01/2023 through 05/22/2023 Complainant Contact Date(s): 05/22/2023 Allegation(s): 1) The named resident had a fractured arm. Investigation Methods: Sample: Total residents: 101 Resident sample size: 3 Closed records sample size: Observations: Environment, cares, residents, resident apartments, staff to resident interactions, staff availability and response to resident's needs. Interviews: Residents, staff and others not associated with the facility. Record Reviews: Characteristic roster, resident records (assessments, care plans, temporary service plans, behavioral care plans, case manager’s assessments, and doctor orders), resident shower schedules, incident investigations, staff schedules, staff phone list, and facility policies. Investigation Summary: Observations, interviews and record review showed that the named resident required a two- person transfer with the Hoyer lift. Facility staff failed to follow the named residents Negotiated Service Plan for transferring. The resident obtained a closed left humeral fracture and pain was not addressed and monitored appropriately. Failed practice identified. Citation written for WAC 388-78A-2160 and 388-78A- 2120. Reference Statement of Deficiencies dated 05/22/2023. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . .