Fieldstone Memory Care of Puyallup.

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 05/16/2025 BFG Puyallup MC Propco LLC Fieldstone Memory Care of Puyallup 2121 S Meridian Puyallup, WA 98371 RE: Fieldstone Memory Care of Puyallup # 2561 Dear Administrator: This letter addresses Compliance Determination 59566 (05/16/2025). The Department completed a full inspection of your Assisted Living Facility on 05/16/2025 and found no deficiencies. The Department staff who did the inspection: Susan Carmichael, Nursing Consultant Institutional Kathy Heinz, Long Term Care Surveyor Cory Myers, NCI ALF Licensor If you have any questions, please contact me at (253)442-3013. Sincerely, Manfay Chan, Allied Health Field Manager Region 3, Unit D .

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: Fieldstone Memory Care of Provider Type: Assisted Living Facility Puyallup License/Cert.#: 2561 Intake ID: 131071 Compliance Determination #: 43404 Region/Unit #: RCS Region 3 / Unit D Investigator: Carol Gijima Investigation Date(s): 06/28/2024 through 09/24/2024 Complainant Contact Date(s): 09/24/2024 Allegation(s): 1. Resident had multiple wounds on his body 2. Antibiotic wasn't stopped per doctor's orders 3. Resident not given antibiotics as ordered 4. Facility did not provide resident records per request 5. Facility not feeding resident Investigation Methods: Sample: Total residents: Resident sample size: Closed records sample size: 3 Observations: General environment Residents in common areas Staff-to-resident interactions Interviews: Resident representative Collateral contacts Staff Record Reviews: Resident Characteristic Roster List of discharged residents Resident assessments and negotiated service agreements including the records of the named resident Medication administration records (MAR) Staff records Staff progress notes Medical records (lab reports, H & P summary) Facility P & P - Catheter Care, Medication Pharmacy records Wounds Hospice notes Nurse delegation records Investigation Summary: 1. Per record review, interviews with resident's representative, collateral contacts, . and staff, facility failed to assess and put in place interventions to manage resident's care and skin. The ALF demonstrated failed provider practice as documented in a Statement of Deficiencies dated 09/24/2024. 2.Per record review, interviews with resident's representative, collateral contacts, and staff, facility failed to stop antibiotic administration after it was discontinued. The ALF demonstrated failed provider practice as documented in a Statement of Deficiencies dated 09/24/2024. 3.Per record review, interviews with resident's representative, collateral contacts, and staff, the facility followed procedure. Facility received medications from 2 different pharmacies. No failed practice identified. 4. Per record review, interviews with resident's representative and staff, resident's representative picked up records in person from ALF. No failed facility practice identified. 5. Per record review, interviews with resident's representative, collateral contacts and staff, there was not sufficient information to either support or refute this allegation. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . 10.07.2024 15:10:59 state of Washington 6/18 STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEAL TH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION Statement of Deficiencies License#: 2sa1 · Compliance Determination# 43404 Plan of Correclion Fieldstone Memo,y Care of Puyallup Complelion 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 06/28/2024 and 06/28/2024 of: Fieldstone Memory Care of Puyallup 2121 S Meridian Puyallup, WA 98371 This document references the follol'.ing complaint number(s): 131071, 139213 The following sample was selected for review during the unannounced on-site visit: 0 of 0 current residents and 3 former residents. The department staff that investigated the Assisted Living Facility: Carol Gijima, Community Campain! Investigator (NCI) From: DSHS, Aging and Long-Term Support Administration Lakewood, WA 98496 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. 10/0712024 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. :wo_..::::1 . . . 10.07.2024 15:10:59 State of Washington 9/18 Statement of Deficiencies License#: 2561 Compliance Determination# 43404 Plan of Correction Fieldstone Memory Care of Puyallup Completion Date During an interview on 09/09/2024 at 10:05am, Anonymous Staff E was asked how often residents were to be repositioned. Staff E stated every 2 hours. When asked how they knew how often a resident was to be repositioned, Staff E stated that they had been working there for a while and they knew the routine. During an interview on 09/09/2024 at 10:32am, Anonymous Staff F was asked what interventions were in place to prevent R1's wounds from getting worse and developing other wounds. Staff F stated that there was none. Staff F was asked if they received training on pressure ulcer prevention. Staff F stated "no, I don't recall." During an interview on 09/23/2024 at 2:54pm, Collateral Contact 3 (CC3) stated that R1 was not receiving proper care at the facility. CC3 stated that R1 would not be changed and that they have found R1's brief soiled and bandaged with "green drainage from the wound stuck on the bandage and through the booties." CC3 stated when they asked if R1's wounds had been changed, the ALF staff told them that they were, but no one knew who had changed the wounds. CC3 stated, "it was clearly not changed." CC3 stated that staff didn't know what they were supposed to do and "avoided him, He yelled, and it was easier for them not to deal with him." During an interview on 09/24/2024 at 9:42am, Anonymous Staff K stated that when they came on shift, R1 was in bed and staff would tell him that R1 didn't eat. Staff K stated that they had multiple conversation with R 1' s family who expressed concerns that R 1 was not being taken care of, that he was left in bed and not fed. Staff K stated that previous shift staff would state that R 1 had not been fed. Staff K stated that when they arrived on shift, most of the times R 1 would still be in bed and that day shift "would forget that he was in the room." When asked if the negotiated service agreement required R1 to be fed, repositioned or gotten out of bed and by who, Staff K stated that they didn't remember. Plan/Attestation Statement I hereby certify that I have reviewed tt1is report and have taken or will take active me1;1sures to correct this deficiency. By taking this action, Fieldstone Memory Care of Puyallup is or will be in compliance with this law and/ or regulation on 11 /IS/ -=l4 . (Date) In addition, I will implement a system to monitor and ensure continued compliance with this requirement ~ ~ ""ok ~ cJc: e, ~trator (or Representative) :wo.1.::::1 . . . 10.07.2024 15:10:59 State of Washington 12/18 Statement of Deficiencies License#: 2561 Compliance Determination# 43404 Plan of Correction Fieldstone Memory Care of Puyallup Completion Date yelled, and it was easier for them not to deal with him." During an interview on 09124/2024 at 9:42am, Anonymous Staff K stated that when they came on shift R1 was in bed and staff would tell him that R1 didn't eat Staff K stated that they had multiple conversation with Rfs family who expressed concerns that R1 was not being taken care of, that he was left in bed and not fed Staff K stated that previous shift staff would state that R 1 had not been fed. Staff K stated that when they arrived on shift, most of the times R 1 would still be in bed and that day shift "would forget that he was in the room.'' When asked if the negotiated service agreement required R1 to be fed, repositioned or gotten out of bed and by who, Staff K stated that they didn't remember. 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, Fieldstone Memory Care of Puyallup is or will be in compliance with this law and I or regulation on 1q,s(.::i'::\ (Date) In addition, I will implement a system to monitor and ensure continued compliance with this requirement ~C½~£b~ .... ,,., f()jitt,J~~- Administrator (or Representative) Date WAC 388-78A-2100 On-going assessments. The ass.isted living facility must: (2) Complete an assessment specifically focused on a resident's identified problems and related issues: (a) Consistent with the resident's change of condition as specified in WAC 388-78A-2120; (c) \Nhen the resident has an injury requiring the intervention of a practitioner. This requirement was not met as evidenced by: Based on records review and interviews, the Assisted Living Facility (ALF) failed to complete an assessment when a resident had a change in physical condition and worsening wounds for 1 of 1 sampled resident (Resident 1) . This failure resulted in R 1 not receiving care timely, family facilitating outside providers to provide wound care, and hospitalization. Findings included ...

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written . N/A . Investigation Summary Report Provider/Facility: Fieldstone Memory Care of Provider Type: Assisted Living Facility Puyallup License/Cert.#: 2561 Intake ID: 88029 Compliance Determination #: 26092 Region/Unit #: RCS Region 3 / Unit D Investigator: Carol Gijima Investigation Date(s): 06/30/2023 through 10/05/2023 Complainant Contact Date(s): Allegation(s): 1. Staff was holding down residents arms and forcing her to brush her teeth Investigation Methods: Sample: Total residents: Resident sample size: 3 Closed records sample size: Observations: General environment Residents in their rooms Staff-to-resident interactions Resident behaviors Interviews: Resident representatives Staff Record Reviews: Resident Characteristic Roster Resident assessments and negotiated service agreements including the records of the named resident Staff records Staff progress notes Incident log / reports, Facility P & P Abuse/Neglect Investigation Summary: 1. Per record review, observations and interviews with collateral contacts and staff, the facility failed to monitor resident's well being after a staff member held her arms down during care. Failed facility practice identified. See Statement of Deficiency dated 10/05/2023. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written . N/A . Investigation Summary Report Provider/Facility: Fieldstone Memory Care of Provider Type: Assisted Living Facility Puyallup License/Cert.#: 2561 Intake ID: 87996 Compliance Determination #: 26092 Region/Unit #: RCS Region 3 / Unit D Investigator: Carol Gijima Investigation Date(s): 06/30/2023 through 10/05/2023 Complainant Contact Date(s): Allegation(s): 1. Staff slapped resident on the face during care. Investigation Methods: Sample: Total residents: Resident sample size: 3 Closed records sample size: Observations: General environment Residents in their rooms Staff-to-resident interactions Resident behaviors Interviews: Resident representative Staff Record Reviews: Resident Characteristic Roster Resident assessments and negotiated service agreements including the records of the named resident Staff records Staff progress notes Incident log / reports, Facility P & P Abuse/Neglect Investigation Summary: 1. Per record review, observations and interviews with collateral contacts and staff, the facility failed to monitor resident's well being after a staff member hit resident in the face. Failed facility practice identified. See Statement of Deficiency dated 10/05/2023. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . . Statement of Deficiencies License #: 2561 Compliance Determination # 26092 Plan of Correction Fieldstone Memory Care of Puyallup Completion Date Administrator (or Representative) Date WAC 388-78A-2120 Monitoring residents' well-being. The assisted living facility must: (3) Evaluate, in order to determine if there is a need for further action: (b) Each resident when an accident or incident that is likely to adversely affect the resident's well- being, is observed by or reported to staff persons. This requirement was not met as evidenced by: Based on record reviews, observations and interviews, the Assisted Living Facility (ALF) failed to monitor residents’ psychosocial and mental wellbeing after incidents involving a staff member for 3 of 3 sampled residents (Residents 1, 2 & 3). This failure placed all 3 residents at risk for emotional distress and not receiving appropriate care in a timely manner. Findings Included… Record review of Resident 1’s (R1) face sheet on 06/30/2023 showed that R1 was admitted to the ALF with diagnoses to include Review of facility incident reports showed that on 06/30/2023 a staff member held down R1’s wrist while assisting R1 with brushing her teeth. Further review of R1’s progress notes showed no documentation that R1 was monitored for emotional harm or latent injuries. Record review of Resident 2’s (R2) face sheet on 06/30/2023 showed that R2 was admitted to the ALF with diagnoses to include Review of facility incident reports showed that on 06/28/2023, a staff member grabbed R2’s wrist tightly to where the resident responded with an expletive. Further review of R2’s progress notes showed no documentation that R2 was monitored for emotional harm or for latent injuries. Record review of Resident 3’s (R3) face sheet on 06/30/2023 showed that R3 was admitted to the ALF with diagnoses to include Review of facility incident reports showed that on 06/03/2023, a staff member struck R3 on her face. Further review of R3’s progress notes showed no documentation that R3 was monitored for emotional harm or latent injuries. An observation on 06/30/2023 at 9:40am noted bruises to R1's bilateral arms. During an interview on 06/30/2023 at 9:45am, Staff C, Caregiver was asked if any resident . Statement of Deficiencies License #: 2561 Compliance Determination # 26092 Plan of Correction Fieldstone Memory Care of Puyallup Completion Date was being monitored for emotional harm or latent injuries. Staff C stated he was not aware of anyone on alert. When asked how R1 had sustained bruises to her arms, Staff C stated he did not know what happened. Staff C was asked if they received any report about staff being aggressive with or hitting residents, or any incident that occurred involving residents and staff. Staff C stated he was not aware of any incident involving staff and residents. During an interview on 06/30/2023 at 9:50am, Staff D, Caregiver stated that she was not aware of how R1 sustained bruises. When asked if any residents were on alert, Staff D stated she was not aware of anyone being on alert. Staff D was asked if staff received a report on residents that were in a staff related incident or those who had any incidents. Staff D stated that nothing was mentioned in report. Staff D stated she was not aware of any incidents involving a staff member and residents. During an interview on 06/30/2023 at 10:30am, Staff E, Medication Technician stated that they were not aware of staff incidents with R2 or R3. Staff E stated that they heard about R1's incident from another staff member. When asked if all three residents should had been placed on alert, Staff E stated that they should and did not know why they were not. When asked if there was a temporary care plan to address potential harm or latent injuries, Staff E stated there was not. During an interview on 06/30/2023 at 10:30am, Staff B, Assistant Director for Nursing stated that when there was a resident incident, it would be investigated, and resident would be placed on alert. Staff B stated that it would be documented in progress notes. When asked how R1 sustained bruises to arms, Staff B stated, “I don’t have anything, she scratches herself.” When reminded that skin issues were not scratches but bruises, Staff B did not provide an answer. Staff B was asked if all three residents were placed on alert for emotional harm and latent injuries. Staff B stated they were not. Staff B stated she should have placed them on alert and had no reason why she didn’t. During an interview on 06/30/2023 at 10:50am, Staff A, Administrator stated that an investigation should be conducted whenever there was a resident incident. Staff A stated that residents would be placed on alert, and it would be documented. When asked if R1, R2, and R3 should have been placed on alert after a staff member held down R1’s and R2's hands, and one staff member hitting R3 on her face, Staff A stated that they “probably should.” When asked why residents were not monitored after those incidents for emotional harm, Staff A stated nursing should have placed them on alert. Staff A stated she did not know why residents were not being monitored for emotional and physical harm. Plan/Attestation Statement . . . . .