Regency Pullman.

Statement of Deficiencies License #: 2060 Compliance Determination # 66662 Plan of Correction Regency Pullman 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 09/30/2025, 10/01/2025, 10/02/2025 and 10/03/2025 of: Regency Pullman 1285 SW Center St Pullman, WA 99163 This document references the following complaint numbers: 196192. The following sample was selected for review during the unannounced on-site visit: 7 of 54 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Patricia Eddy, Community Licensor Veronica Jackson, Assisted Living Facility Licensor Joy Pipgras, LTC Surveyor From: DSHS, Aging and Long-Term Support Administration 8517 E Trent Ave, Ste 102 Spokane Valley, WA 99212 . Statement of Deficiencies License #: 2060 Compliance Determination # 66662 Plan of Correction Regency Pullman 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-2140 Negotiated service agreement contents. The assisted living facility must develop, and document in the resident's record, the agreed upon plan to address and support each resident's assessed capabilities, needs and preferences, including the following: (1) The care and services necessary to meet the resident's needs, including: (a) The plan to monitor the resident and address interventions for current risks to the resident's health and safety that were identified in one or more of the following: (ii) The resident's full assessments; This requirement was not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure skin integrity monitoring was included in the resident's record for 1 of 7 residents (Resident 1) with a known and observable skin condition. This failure placed the resident at risk for harm and unmet care needs. Findings included… Review of Resident 1’s Face Sheet showed that the resident was admitted to the facility on /2025 and was diagnosed with . Further review showed a photo taken of Resident 1 upon admission to the facility, with a dark colored skin irregularity on their nose. Observation on 10/01/2025 at 11:34 AM showed that Resident 1 had a one inch by one-inch dark lesion (abnormal skin tissue) that resembled a scab on their nose. . . Statement of Deficiencies License #: 2060 Compliance Determination # 66662 Plan of Correction Regency Pullman Completion Date Review of Resident 1’s Care Evaluation, dated 07/23/2025, showed no documentation related to skin cancer. Further review showed that Resident 1 had no ongoing issues with wounds. Review of Resident 1’s Service Plan, dated 07/29/2025, showed no documentation related to skin cancer. In an interview on 10/02/2025 at 9:55 AM, Staff G, Assistant Director of Nursing, stated that Resident 1 admitted to the facility with the scab and that they had heard that the resident had skin cancer. In an interview on 10/02/2025 at 9:58 AM Staff C, Medication Aide, stated that they were not aware that Resident 1 had skin cancer and thought that the scab on their nose was from a fall. In an interview on 10/02/2025 at 3:30 PM, Staff H, Regional Director of Nursing, stated that they received confirmation that day that Resident 1’s skin irregularity on their nose was cancer and was unaware if the resident had been seen by a physician specifically for the cancerous lesion since admission. This is a reoccurring deficiency previously cited on 03/21/2024 for subsections (1)(a)(iii)(iii)(5). 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, Regency Pullman 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 WAC 388-78A-2160 Implementation of negotiated service agreement. The assisted living facility must provide the care and services as agreed upon in the negotiated service agreement to each resident unless a deviation from . Statement of Deficiencies License #: 2060 Compliance Determination # 66662 Plan of Correction Regency Pullman Completion Date the negotiated service agreement is mutually agreed upon between the assisted living facility and the resident or the resident's representative at the time the care or services are scheduled. This requirement was not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure care needs identified in the negotiated service agreement, were completed for 1 of 7 residents (Resident 1). This failure resulted in a lack of weight monitoring and placed the resident at risk for harm and continued weight loss. Findings included… Review of Resident 1’s Face Sheet showed that the resident was admitted to the facility on /2025. Review of Resident 1’s Service Plan (the facility’s titled negotiated service agreement), dated 07/29/2025, showed that the resident received a regular diet and required monthly weight monitoring. Further review showed that licensed nursing staff were to monitor and assess the resident’s weight as needed. Review of the 2025 through October 2025 Medication Administration Records (MARs) showed an order to have monthly weights obtained for Resident 1. Review of Resident 1’s MARs since their admission on /2025, showed the following weights: - 2025 MARs: 121 pounds (lbs) on admission -July 2025 MARs: No weight documented -August 2025 MARs: No weight documented -September 2025 MARs: 116 lbs -October 2025 MARs: 111 lbs In an interview on 10/01/2025 at 3:50 PM, Staff B, Wellness Director, stated that Resident 1’s weights were not measured due to the staff’s lack of documenting and not re-attempting to take weights when necessary. In an interview on 10/02/2025 at 9:58 AM, Staff C, Medication Aide, stated that staff had trouble getting monthly weights for residents. In an interview on 10/02/2025 at 9:55 AM, Staff G, Assistant Director of Nursing, stated that they were not aware that Resident 1 had lost eleven pounds since admission. . . Statement of Deficiencies License #: 2060 Compliance Determination # 66662 Plan of Correction Regency Pullman Completion Date In an interview on 10/02/2025 at 10:10 AM, Staff H, Regional Director of Nursing, stated that staff had not followed the facility's policy regarding weight monitoring. 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, Regency Pullman 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 WAC 388-78A-2290 Family assistance with medications and treatments. (1) An assisted living facility may permit a resident's family member to administer medications or treatments or to provide medication or treatment assistance, including obtaining medications or treatment supplies, to the resident. (3) If the assisted living facility allows family assistance with or administration of medications and treatments, and the resident and a family member(s) agree a family member will provide medication or treatment assistance, or medication or treatment administration to the resident, the assisted living facility must request that the family member submit to the assisted living facility a written plan for such assistance or administration that includes at a minimum: (a) By name, the family member who will provide the medication or treatment assistance or administration; (b) A description of the medication or treatment assistance or administration that the family member will provide, to be referred to as the primary plan; (c) An alternate plan if the family member is unable to fulfill his or her duties as specified in the primary plan; (4) The plan for family assistance with medications or treatments must be signed and dated by: (a) The resident, if able; (b) The resident's representative, if any; (c) The resident's family member responsible for implementing the plan; and (d) A representative of the assisted living facility authorized by the assisted living .

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 . . STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 8517 E Trent Ave, Ste 102, Spokane Valley, WA 99212 Statement of Deficiencies License #: 2060 Compliance Determination # 51861 Plan of Correction Regency Pullman 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 12/17/2024, 12/09/2024 and 12/17/2024 of: Regency Pullman 1285 SW Center St Pullman, WA 99163 This document references the following complaint number(s): 158105 The following sample was selected for review during the unannounced on-site visit: 3 of 56 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Sandra Fast, Community Complaint Investigator From: DSHS, Aging and Long-Term Support Administration 8517 E Trent Ave, Ste 102 Spokane Valley, WA 99212 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 #: 2060 Compliance Determination # 51861 Plan of Correction Regency Pullman Completion Date Administrator (or Representative) Date WAC 388-78A-2462 Background checks Who is required to have. (2) The assisted living facility must ensure that the administrator and all caregivers employed directly or by contract after January 7, 2012 have the following background checks: (a) A Washington state name and date of birth background check; and (b) A national fingerprint background check. This requirement was not met as evidenced by: Based on record review and interview, the facility failed to ensure that 1 of 3 staff (Staff B), hired after 01/07/2012, had a national fingerprint background check done. This placed vulnerable residents residing at the facility at risk to be accessed by someone who was not qualified to have access to vulnerable adults. Findings include… A record review on 01/03/2024, showed that Staff B was hired as a caregiver on 03/27/2024. Per review, a name and date of birth background check was completed on 03/27/2024. Staff B’s records showed that a fingerprint background check was not attempted until 10/18/2024, 6 months and 21 days after their date of hire. Staff B’s fingerprint background check came back showing that, “The applicant’s fingerprint check cannot be completed by the Federal Bureau of Investigation.” In an interview on 12/31/24 at 4:17 PM, Staff A, Executive Director stated that they were unsure why Staff B did not have a valid fingerprint background check on file. An email communication from Staff A, received on 01/03/25 and reviewed at 1:31 PM showed that Staff A was unable to locate any records showing that Staff B had prior attempts to have a background fingerprint check done. In an email from Staff A, received on 01/03/2024 and reviewed at 1:31 PM, Staff A wrote that the facility’s process for background checks needed review and reestablishment of a new process for better tracking of employee background checks. Plan/Attestation Statement . . Statement of Deficiencies License #: 2060 Compliance Determination # 51861 Plan of Correction Regency Pullman Completion Date 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, Regency Pullman is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date .

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: Regency Pullman Provider Type: Assisted Living Facility License/Cert.#: 2060 Compliance Determination #: 36618 Intake ID: 117949 Investigator: Sylvia Shauvin Region/Unit #: RCS Region 1 / Unit B Investigation Date(s): 02/08/2024 through 02/15/2024 Complainant Contact Date(s): 02/01/2024, 02/13/2024 Allegation(s): Nurse instructs staff to give medications to resident that is inebriated Investigation Methods: Sample: Total residents: 57 Resident sample size: 11 Closed records sample size: 3 Observations: Residents' safety and well-being Medication services Staff-to-staff communication Interviews: Twelve residents, including alleged victim (AV) Five resident reps Four caregivers Six Medication Aides/caregivers Resident Care Coordinator Interim facility nurse Administrator Record Reviews: Fourteen sampled residents' Face Sheets, assessments, care plans, Progress Notes, and Medication Administration Records (MARS) Twelve sampled staff's credentials Disclosure of Services Admission Agreement Policy and procedures - Medication services Investigation Summary: During department investigator's observations of staff providing medications to residents, no medications were held. In an interview with AV, they stated they negotiated with facility for their medications to be held if the AV had used alcohol around the time the medications were due. Review of AV's care plan contained instructions for one of the AV's medications to be held if the AV had used alcohol around the time the medication was due. In interviews with three staff, they stated when staff voiced concern to the nurse about providing AV's medications when the . resident had been drinking alcohol, the nurse told staff to provide the medications. The staff was concerned about the AV's safety, so they held all of the medications that were due when the resident had been drinking alcohol. There were no adverse outcomes to the AV therefore, no failed facility practices were found related to the alleged issue. Technical assistance was provided to the facility regarding Washington Administrative Code 388-78a-2210(1)(b) Medication services. This regarded staff's need to consult with prescriber or pharmacy regarding any concerns about safe medication services. During the investigation, failed practice was found related to facility's failure to ensure two Medication Aides received nurse delegation training and/or had the required nursing assistant or Home Care Aide license before administering medications to a resident. The violation was documented in a Statement of Deficiencies under Washington Administrative Code (WAC) 2320(1)(b) Intermittent nursing services systems; reference to WAC 246-840-930(8)(a)(b) Criteria for delegation. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . . Statement of Deficiencies License #: 2060 Compliance Determination # 36618 Plan of Correction Regency Pullman Completion Date Administrator (or Representative) Date WAC 388-78A-2320 Intermittent nursing services systems. (1) When an assisted living facility provides intermittent nursing services to any resident, either directly or indirectly, the assisted living facility must: (b) Ensure the requirements of chapters 18.79 RCW and 246-840 WAC are met. This requirement was not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure medication aides completed nurse delegation training for 1 of 6 sampled staff (Staff C) and were registered or certified as a nursing assistant or home care aide for 2 of 6 sampled staff (Staff C and E) prior to administering medicated eye drops to 1 of 14 sampled residents (Resident 1). These failures placed the resident at risk for improper eye drop administration. Findings included… Washington Administrative Code 246-840-930(8)(a)(b) Criteria for delegation requires nursing assistant or home care aide (HCA) to be currently registered or certified and have completed the core delegation training before performing any delegated task. Review of Resident 1’s move-in record dated, /2022, showed the resident was diagnosed with ( ). Review of Resident 1’s undated Negotiated Service Plan showed Resident 1 had problems with vision, poor judgment, understanding others, and needed staff to administer eye medications. Prescriber’s orders for Resident 1, dated 10/14/2022, that were listed on the January 2024 and February 2024 medication administration records (MARS), included two medicated eye drops. Review of Resident 1’s February 2024 MAR showed Staff C, Medication Aide, administered the eye drops into Resident 1’s eyes six times. Review of the January 2024 MAR showed Staff E, Medication Aide, administered the eye drops into Resident 1’s eyes twice. The February 2024 MAR showed Staff E administered . Statement of Deficiencies License #: 2060 Compliance Determination # 36618 Plan of Correction Regency Pullman Completion Date the eye drops into Resident 1’s eyes one time. On 02/08/2024 at 11:25 AM, Staff C was observed instilling the eye drops into Resident 1’s eyes. In an interview on 02/08/2024 at 11:25 AM, Staff C stated they were not licensed as a nursing assistant or HCA. Review of sampled staff’s credentials showed Staff C had not completed nurse delegation training. In an interview on 02/09/2024 at 10:00 AM, a representative for Resident 1 stated the resident had been unable to independently manage and instill eye drops “for a long time”. In an interview on 02/15/2024 at 10:45 AM, Staff E stated they did not have a nursing assistant or HCA credential. 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, Regency Pullman 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 .

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