Vineyard Park of Puyallup.

Statement of Deficiencies License #: 2553 Compliance Determination # 61426 Plan of Correction Vineyard Park of Puyallup 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-2305 Food sanitation. The assisted living facility must: (1) Manage food, and maintain any on-site food service facilities in compliance with chapter 246-215 WAC, Food service; This requirement was not met as evidenced by: Based on observations and interviews, the Assisted Living Facility (ALF) failed to serve food at a safe temperature in the Memory Care Unit and date marked/labeled food items in the kitchen cold storage refrigerators for 1 of 1 facility kitchen. This failure placed 83 of 83 residents at risk of potential harm for exposure to food-borne illnesses. Findings included… WAC 246-215-03610 Labeling—Food labels (FDA Food Code 3-602.11). (1) food packaged in a food establishment must be labeled as specified in law, including chapters 69.04 and 15.130 RCW; 21 C.F.R. 101 - Food Labeling; and 9 C.F.R. 317 - Labeling, Marking Devices, and Containers. (2) Label information must include: (a) The common name of the food or, absent a common name, an adequately descriptive identity statement WAC 246-215-03526 Temperature and time control—Ready-to-eat, time/temperature control for safety food, date marking (FDA Food Code 3-501.17). (1) Except when packaging food using a reduced oxygen packaging method as specified under WAC 246-215-03540, and except as specified in subsections (5) and (6) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than twenty-four hours must be clearly . Statement of Deficiencies License #: 2553 Compliance Determination # 61426 Plan of Correction Vineyard Park of Puyallup Completion Date marked to indicate the date or day by which the food must be consumed on the premises, sold, or discarded when held at a temperature of 41ºF (5ºC) or less for a maximum of seven days. The day of preparation must be counted as day one. (2) Except as specified in subsections (5) through (7) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant must be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than twenty-four hours, to indicate the date or day by which the food must be consumed on the premises, sold, or discarded, based on the temperature and time requirements specified in subsection (1) of this section and: (a) The day the original container is opened in the food establishment is counted as day one; and (b) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. WAC 246-215-03525 Temperature and time control—Time/temperature control for safety food, hot and cold holding (FDA Food Code 3-501.16). (1) Except during active preparation for up to two hours, cooking, or cooling or when time is used as the public health control as specified under WAC 246-215-03530, and except as specified in subsections (2) and (3) of this section, time/temperature control for safety food must be maintained: (a) At 135°F (57°C) or above, except that roasts cooked to a temperature and for a time specified under WAC 246-215-03400(2) or reheated as specified under WAC 246-215-03440 may be held at a temperature of 130°F (54°C) or above; or (b) At 41°F (5°C) or less. <Hot Foods> An observation on 06/24/2025 at 11:40 AM of the Memory Care dining area showed chicken served at 127.3 degrees, mashed potatoes served at 125.6 degrees and corn served at 118.4 degrees. In an interview on 06/24/2025 at 11:30 AM Staff H, Caregiver, said the food cart is typically not plugged in to the wall socket for food to be kept warm as plates sometimes are too hot to serve. <Cold Foods> An observation on 06/23/2025 at 11:10 AM of the facility’s refrigerator found an opened metal can of tomato sauce with one quarter of the contents remaining and saran wrap over the top. There was no label indicating when the item was opened, stored in the refrigerator and kept in a metal can. An observation on 06/23/2025 at 11:10 AM of the facility’s refrigerator found an opened pitcher of orange liquid, exposed to the air, without saran wrap or a label indicating a description or a date of the liquid’s opening or date of expiration. . Statement of Deficiencies License #: 2553 Compliance Determination # 61426 Plan of Correction Vineyard Park of Puyallup Completion Date An observation on 06/23/2025 at 11:11 AM of the facility’s refrigerator found an opened metal can of pudding containing half full chocolate pudding with saran wrap over the top. There was no label indicating when the item was opened, the date of expiration date or date it was stored in the refrigerator and kept in a metal can. An observation on 06/23/2025 at 11:12 AM of the facility’s refrigerator found a tray containing a meat substance with saran wrap covering. The label stated, “corned beef” and was dated 06/11/2025, indicating the meat substance was one week and six days old and remained in the refrigerator. In an interview on 06/24/2024 at 11:30 AM Staff G, Chef, said they tell staff to store food with the date and label in food containers and toss out old food, but staff do not listen. 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, Vineyard Park of Puyallup 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-2466 Background checks Washington state name and date of birth background check Valid for two years National fingerprint background check Valid indefinitely. (1) A Washington state name and date of birth background check is valid for two years from the initial date it is conducted. The assisted living facility must ensure: (a) A new DSHS background authorization form is submitted to the department's background check central unit every two years for all administrators, caregivers, staff persons, volunteers and students; and (b) There is a valid Washington state name and date of birth background check for all administrators, caregivers, staff persons, volunteers and students. This requirement was not met as evidenced by: Based on record review and interview the Assisted Living Facility (ALF) failed to ensure a Washington state name and date of birth background check was completed every two years for 1 of 6 sampled staff (Staff A). This failure placed 83 of 83 residents at risk of having care and services provided by staff with a potentially disqualifying crime. . Statement of Deficiencies License #: 2553 Compliance Determination # 61426 Plan of Correction Vineyard Park of Puyallup Completion Date Findings included… Review of the personnel records for Staff A, Executive Director, showed that Staff A was hired on 03/01/2021. A Washington state name and date of birth background check was last completed on 05/15/2023 per the personnel file for Staff A. There was no record of the Washington state name and date of birth background check required every two years in the personal file for Staff A which was due on 05/15/2025. On 06/26/2025 at 11:15 am during an interview, Staff A stated it was an oversight on her part that she needed to complete the Washington state name and date of birth background check that was due every two years for herself (Staff A) on 05/15/2025. 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, Vineyard Park of Puyallup 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 .

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION PO Box 99250, Lakewood, WA 98496 Puyallup ALC LLC Vineyard Park of Puyallup 1813 S Meridian St Puyallup, WA 98371 RE: Vineyard Park of Puyallup License # 2553 Dear Administrator: This letter addresses Compliance Determination(s) 65553 (Completion Date 09/12/2025) and 61426 (Completion Date 07/24/2025). The Department completed a follow-up inspection of your Assisted Living Facility on 09/12/2025 and found no deficiencies. Your facility meets the Assisted Living Facility licensing requirements. The Department found that deficiencies for the following licensing laws and regulations were corrected: WAC 388-78A-2305, WAC 388-78A-2305-1, WAC 388-78A-2466-1, WAC 388-78A-2466-1-a, WAC 388-78A-2466-1-b, WAC 388-78A-2466 The Department staff who did the on-site verification: Melisa Moran, Assisted Living Facility Nursing Consultant Institutional If you have any questions, please contact me at (253)234-6020. Sincerely, Laurie Anderson, Community Field Manager Region 3, Unit D Residential Care Services This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2553 Compliance Determination # 61426 Plan of Correction Vineyard Park of Puyallup Completion Date Page 2 of 5 Licensee: Puyallup ALC LLC 07/24/2025 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. Residential 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. Administrator (or Representative) Date WAC 388-78A-2305 Food sanitation. The assisted living facility must: (1) Manage food, and maintain any on-site food service facilities in compliance with chapter 246-215 WAC, Food service; This requirement was not met as evidenced by: Based on observations and interviews, the Assisted Living Facility (ALF) failed to serve food at a safe temperature in the Memory Care Unit and date marked/labeled food items in the kitchen cold storage refrigerators for 1 of 1 facility kitchen. This failure placed 83 of 83 residents at risk of potential harm for exposure to food-borne illnesses. Findings included… WAC 246-215-03610 Labeling—Food labels (FDA Food Code 3-602.11). (1) food packaged in a food establishment must be labeled as specified in law, including chapters 69.04 and 15.130 RCW; 21 C.F.R. 101 - Food Labeling; and 9 C.F.R. 317 - Labeling, Marking Devices, and Containers. (2) Label information must include: (a) The common name of the food or, absent a common name, an adequately descriptive identity statement WAC 246-215-03526 Temperature and time control—Ready-to-eat, time/temperature control for safety food, date marking (FDA Food Code 3-501.17). (1) Except when packaging food using a reduced oxygen packaging method as specified under WAC 246-215-03540, and except as specified in subsections (5) and (6) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than twenty-four hours must be clearly This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2553 Compliance Determination # 61426 Plan of Correction Vineyard Park of Puyallup Completion Date Page 3 of 5 Licensee: Puyallup ALC LLC 07/24/2025 marked to indicate the date or day by which the food must be consumed on the premises, sold, or discarded when held at a temperature of 41ºF (5ºC) or less for a maximum of seven days. The day of preparation must be counted as day one. (2) Except as specified in subsections (5) through (7) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant must be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than twenty-four hours, to indicate the date or day by which the food must be consumed on the premises, sold, or discarded, based on the temperature and time requirements specified in subsection (1) of this section and: (a) The day the original container is opened in the food establishment is counted as day one; and (b) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. WAC 246-215-03525 Temperature and time control—Time/temperature control for safety food, hot and cold holding (FDA Food Code 3-501.16). (1) Except during active preparation for up to two hours, cooking, or cooling or when time is used as the public health control as specified under WAC 246-215-03530, and except as specified in subsections (2) and (3) of this section, time/temperature control for safety food must be maintained: (a) At 135°F (57°C) or above, except that roasts cooked to a temperature and for a time specified under WAC 246-215-03400(2) or reheated as specified under WAC 246-215-03440 may be held at a temperature of 130°F (54°C) or above; or (b) At 41°F (5°C) or less. <Hot Foods> An observation on 06/24/2025 at 11:40 AM of the Memory Care dining area showed chicken served at 127.3 degrees, mashed potatoes served at 125.6 degrees and corn served at 118.4 degrees. In an interview on 06/24/2025 at 11:30 AM Staff H, Caregiver, said the food cart is typically not plugged in to the wall socket for food to be kept warm as plates sometimes are too hot to serve. <Cold Foods> An observation on 06/23/2025 at 11:10 AM of the facility’s refrigerator found an opened metal can of tomato sauce with one quarter of the contents remaining and saran wrap over the top. There was no label indicating when the item was opened, stored in the refrigerator and kept in a metal can. An observation on 06/23/2025 at 11:10 AM of the facility’s refrigerator found an opened pitcher of orange liquid, exposed to the air, without saran wrap or a label indicating a description or a date of the liquid’s opening or date of expiration. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2553 Compliance Determination # 61426 Plan of Correction Vineyard Park of Puyallup Completion Date Page 4 of 5 Licensee: Puyallup ALC LLC 07/24/2025 An observation on 06/23/2025 at 11:11 AM of the facility’s refrigerator found an opened metal can of pudding containing half full chocolate pudding with saran wrap over the top. There was no label indicating when the item was opened, the date of expiration date or date it was stored in the refrigerator and kept in a metal can. An observation on 06/23/2025 at 11:12 AM of the facility’s refrigerator found a tray containing a meat substance with saran wrap covering. The label stated, “corned beef” and was dated 06/11/2025, indicating the meat substance was one week and six days old and remained in the refrigerator. In an interview on 06/24/2024 at 11:30 AM Staff G, Chef, said they tell staff to store food with the date and label in food containers and toss out old food, but staff do not listen. 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, Vineyard Park of Puyallup 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-2466 Background checks Washington state name and date of birth background check Valid for two years National fingerprint background check Valid indefinitely. (1) A Washington state name and date of birth background check is valid for two years from the initial date it is conducted. The assisted living facility must ensure: (a) A new DSHS background authorization form is submitted to the department's background check central unit every two years for all administrators, caregivers, staff persons, volunteers and students; and (b) There is a valid Washington state name and date of birth background check for all administrators, caregivers, staff persons, volunteers and students. This requirement was not met as evidenced by: Based on record review and interview the Assisted Living Facility (ALF) failed to ensure a Washington state name and date of birth background check was completed every two years for 1 of 6 sampled staff (Staff A). This failure placed 83 of 83 residents at risk of having care and services provided by staff with a potentially disqualifying crime. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2553 Compliance Determination # 61426 Plan of Correction Vineyard Park of Puyallup Completion Date Page 5 of 5 Licensee: Puyallup ALC LLC 07/24/2025 Findings included… Review of the personnel records for Staff A, Executive Director, showed that Staff A was hired on 03/01/2021. A Washington state name and date of birth background check was last completed on 05/15/2023 per the personnel file for Staff A. There was no record of the Washington state name and date of birth background check required every two years in the personal file for Staff A which was due on 05/15/2025. On 06/26/2025 at 11:15 am during an interview, Staff A stated it was an oversight on her part that she needed to complete the Washington state name and date of birth background check that was due every two years for herself (Staff A) on 05/15/2025. 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, Vineyard Park of Puyallup 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 This document was prepared by Residential Care Services for the Locator website. Vineyard Park of Puyallup # 2553 07/24/2025 Page 2 of 3 eFax: (253) 589-7240 Email: rcsregion3email@dshs.wa.gov Optional method: PO Box 99250 Lakewood, WA 98496 • Complete correction(s) within 45 days, or sooner if directed by the Department, after review of your proposed correction dates. • Have your plan approved by the Department. Consultation(s): In addition, the Department provided consultation on the following deficiency or deficiencies not listed on the enclosed report. WAC 388-78A-2484 Tuberculosis Two step skin testing. Unless the staff person meets the requirement for having no skin testing or only one test, the assisted living facility choosing to do skin testing, must ensure that each staff person has the following two-step skin testing: (1) An initial skin test within three days of employment; and (2) A second test done one to three weeks after the first test. Record review of 1 of 6 staff sampled (Staff E) showed Staff E was hired on 12/01/2022 and was tested for Tuberculosis (TB) on 12/08/2022. The TB test was completed five days beyond the required three days after hire date. The deficiency was corrected prior to survey. You Are Not: • Required to submit a plan of correction for the consultation deficiency or deficiencies stated in this letter and not listed on the enclosed report. You May: • Contact me for clarification of the deficiency or deficiencies found. In Addition, You May: • Request an Informal Dispute Resolution (IDR) review within 10 working days after you receive this letter. Your IDR request must include: o What specific deficiency or deficiencies you disagree with; o Why you disagree with each deficiency; and o Whether you want an IDR to occur in-person, by telephone or as a paper review. o Send your request to: Email: RCSIDR@dshs.wa.gov; or Fax: (360) 725-3225 This document was prepared by Residential Care Services for the Locator website. Vineyard Park of Puyallup # 2553 07/24/2025 Page 3 of 3 If You Have Any Questions: • Please contact me at (253)442-3013. Sincerely, Manfay Chan, Allied Health Field Manager Region 3, Unit D Residential Care Services Enclosure 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 N/A . I&] □ □ STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION Statement of Deficiencies License #: 2553 Compliance Determination # 46496 Plan of Correction Vineyard Park of Puyallup 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 08/30/2024 and 11/01/2024 of: Vineyard Park of Puyallup 1813 S Meridian St Puyallup, WA 98371 This document references the following complaint number(s): 136953, 139086, 139339, 143336 The following sample was selected for review during the unannounced on-site visit: 4 of 0 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Carol Gijima, Community Compaint 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. 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 #: 2553 Compliance Determination # 46496 Plan of Correction Vineyard Park of Puyallup Completion Date 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 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 interviews and record review, the Assisted Living Facility (ALF) failed to provide services as agreed upon for 2 of 4 sample residents (Resident 1 &2). This failure resulted in Resident 1 & 2 not receiving showers. Findings Included... Resident 1 (R1) Records reviewed showed that R1 admitted to ALF on /2023 with diagnoses to include . A negotiated service agreement with a last review date of 08/26/2024 showed that R1 was to receive 2 showers per week (Mondays and Fridays) with staff assistance. Shower records reviewed showed that R1 did not receive 2 showers for the following weeks in September; Week 1- 7, 8-14 and 22-28. During an interview on 08/28/2024 at 8:19am, R1’s representative stated that R1 was supposed to have 2 showers a week with staff assisting her. RR1 stated that R1 had “gone 20 days without a shower”. RR1 stated that they have had 3 different meetings regarding showers, and nothing had changed. Resident 2 (R2) Records reviewed showed that R2 admitted to ALF on /2022 with diagnoses to include . A negotiated service agreement with a review date of 11/25/2023 showed that R2 was to receive 2 showers per week with 1 person staff assistance due to “physical or cognitive limitation”. Shower records reviewed showed that R2 did not receive any showers for the following weeks: July 21-27, July 28-August 3. There were no scheduled showers for entire month of August. R2 received 2 showers (as needed) for entire month of September (16th and 20th). During an interview on 11/01/2024 at 11:10am, R2’s Representative (RR2) stated that R2 was not able to initiate or complete showers on her own. RR2 stated that staff were . Statement of Deficiencies License #: 2553 Compliance Determination # 46496 Plan of Correction Vineyard Park of Puyallup Completion Date responsible for helping R2 with showers at least twice a week. RR2 sated that there have been times that R2’s hair was greasy and looked unkempt. RR2 stated they have complained multiple times and the issue “gets better for a while” then goes back to not having showers. During an interview on 08/30/2024 at 10:16am, Collateral Contact 1 (CC1) stated that residents received at least 2 showers per week. CC1 stated that if residents refused or were not given a shower, the medication technician would be notified. CC1 stated that the medication technician would document in progress notes if a resident did not receive their shower and notify the nurse. During an interview on 08/30/2024 at 10:30am, Collateral Contact 2 (CC2) stated that when residents refused showers, staff would call family members to assist. CC2 stated that showers were documented in the “point of care” system. CC2 stated that the only reason a resident would not receive a shower was when they refused. CC2 stated that when residents refused, they would document the refusal on the computer and notify the medication technician. During an interview on 08/30/2024 at 10:45am, Staff B, Director of Nursing Services stated that they were not aware of any shower complaints. Staff B stated that if residents refused their showers, it would be documented in the point of care system. Staff B stated that there was no reason a resident would not receive their shower as scheduled. When asked how one would now if a resident received their shower if it wasn’t documented, Staff B stated, “if it’s not documented, it didn’t get done”. During an interview on 10/28/2024 at 1:25pm, Administrator was asked if Residents 1 and 2 had received their showers. Administrator stated that R2 had experienced some agitation , that they could not “see anything for showers” on the record. Administrator was asked about R2 not having any shower documentation for the entire month of August. Administrator stated that the wrong documentation may have been attached and would send the August showers. No documentation was received as of the last day of data collection. When asked why R2’s September documentation only showed 2 as needed showers, Administrator stated that they would attempt to pull the record and send by the next day. No documentation was received as of the last day of data collection. 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, Vineyard Park of Puyallup 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. . Statement of Deficiencies License #: 2553 Compliance Determination # 46496 Plan of Correction Vineyard Park of Puyallup Completion Date Administrator (or Representative) Date WAC 388-78A-2150 Signing negotiated service agreement. The assisted living facility must ensure that the negotiated service agreement is agreed to and signed at least annually by: (1) The resident, or the resident's representative if the resident has one and is unable to sign or chooses not to sign; (2) A representative of the assisted living facility duly authorized by the assisted living facility to sign on its behalf; and (3) Any public or private case manager for the resident, if available. This requirement was not met as evidenced by: Based on record review and interviews, the Assisted Living Facility (ALF) failed to ensure that negotiated service agreements were agreed upon and signed as required for 3 of 4 sample residents (Residents 2,3, & 4). This failure placed all 3 residents at risk for not receiving the care and services they needed. Findings Included: Resident 2 (R2) Records reviewed showed that Resident 2 admitted to ALF on /2022 with diagnoses to include . A negotiated service agreement with a review date of 11/25/2023 was not signed. During an interview on 11/01/2024 at 11:10am, R2’s Representative (RR2) stated that R2 has memory loss and unable to agree or sign any of her documents. RR2 stated they were responsible for signing the negotiated service plan for R2. When asked if they signed R2’s negotiated service agreement, RR2 stated they had not signed one. . Statement of Deficiencies License #: 2553 Compliance Determination # 46496 Plan of Correction Vineyard Park of Puyallup Completion Date Resident 3 (R3) Records reviewed showed that R3 admitted to ALF on /2024 with diagnoses to include . A negotiated service agreement with a review date of 05/14/2024 was not signed.

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 License #: 2553 Compliance Determination # 23425 Plan of Correction Vineyard Park of Puyallup Completion Date Administrator (or Representative) Date RCW 70.129.110 Disclosure, transfer, and discharge requirements. (3) Before a long-term care facility transfers or discharges a resident, the facility must: (a) First attempt through reasonable accommodations to avoid the transfer or discharge, unless agreed to by the resident; (b) Notify the resident and representative and make a reasonable effort to notify, if known, an interested family member of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; (c) Record the reasons in the resident's record; and (d) Include in the notice the items described in subsection (5) of this section. (6) A facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This requirement was not met as evidenced by: Based on record reviews and interviews, the Assisted Living Facility (ALF) failed to properly discharge a resident and give them a written notice prior to the discharge for 1 of 1 sampled resident (Resident 1, R1). This resulted in resident not receiving an orderly transfer and placed her at risk for emotional distress. Findings Included… Record review on 05/03/2023 of R1’s assessment and negotiated care plan showed that R1 was admitted to the facility on /2020 with diagnoses to include and where she needed a staff member to provide total assist with transfers. Review of facility documents on 05/03/2023 showed no documentation showing communication with the resident’s representative regarding discharges or transfers to a different facility. A progress note dated /2021 at 7:04pm stated that R1 had been discharged and transferred to another community with her belongings and was transported by her husband. An incident investigation note dated 03/10/2021 at 12:13pm stated that R1 had an emergency discharge to another community for resident safety after a 03/07/2021 incident where R1 had aggressive behaviors towards staff. Per progress note dated /2021 at 6:22pm, the progress note stated that R1 was transferred to another . Statement of Deficiencies License #: 2553 Compliance Determination # 23425 Plan of Correction Vineyard Park of Puyallup Completion Date community and was not at the facility. At 6:27pm, a progress note dated /2021 stated that R1 was transferred to another community and at 7:43pm that R1 was discharged to another community. Record review of facility records on 05/03/2023 showed a discharge notice written on /2021 with an effective date of /2021. It was not signed by R1’s representative. There were no records indicating that reasonable accommodations had been attempted to avoid the transfer. The facility did not have any record of notifying the resident’s representative of the reasons for the transfer or what the urgent medical needs that necessitated the transfer. During an interview on 04/26/2023 at 4:04pm, R1’s representative (RR1) stated that he received a call from the facility on /2021 stating he needed to pick up R1 because physical therapy had decided she was a two-person transfer. RR1 stated that he was told that R1 had to leave the facility as they did not have the staff to assist her. RR1 stated that he was told R1 had to be out of the facility on that day. When RR1 stated that it was late and a Friday, the facility stated they would keep her until Monday, /2021, to give him time to find a place for R1. RR1 stated he never received advance written notice about the reasons for discharging R1. During an interview on 08/22/2023 at 10:30am, Staff A, Administrator stated that R1 was discharged on a Friday afternoon after an appointment with physical therapy. When asked what the reason for the transfer was, Staff A stated because therapy had written an order that R1 was a two-person transfer, and they did not have the staff to provide the two-person assist care. During an interview on 08/23/2023 at 12:09pm, Staff E, Marketing Director, was asked what the reasons for R1’s discharge. Staff E stated that Staff B, Former Administrator, told her that R1 was “smacking and throwing feces at staff.” During an interview on 08/25/2023 at 10:51am, Staff B stated that residents were given a 30-day written notice prior to discharge. When asked about R1, Staff B stated she didn’t remember if she had been given a 30-day discharge notice. When asked if she had any urgent medical needs that could not be met at the facility, Staff B stated that she did not think so. During an interview on 09/05/2023 at 1:14pm, Staff A was asked why R1 was not given a proper discharge notice. Staff A stated that she had urgent medical needs that the facility could not provide. When asked what the urgent medical needs where, Staff A stated that they did not have staff to provide a two-person transfer. Staff A was asked how that was an emergency when R1 had been receiving two person transfers since 02/25/2021. Staff A stated she was not aware of R1 being transferred by two staff, and that it was before her time. Staff A stated that staff could have been documenting as a way of providing feedback about R1’s needs. . Statement of Deficiencies License #: 2553 Compliance Determination # 23425 Plan of Correction Vineyard Park of Puyallup Completion Date During an interview on 09/05/2023 at 1:45pm, Staff F, Rehab Manager, was asked if R1’s therapy notes or orders meant R1 needed 1:1 care. Staff F stated that resident was not able to perform tasks on her own or be able to return home as she needed assistance with activities such as transfers and toileting. Staff F stated that resident would need someone to assist with her care and that she did not need 1:1 private care. 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, Vineyard Park of Puyallup 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-2640 Reporting significant change in a resident's condition. (1) The assisted living facility must consult with the resident's representative, the resident's physician, and other individual(s) designated by the resident as soon as possible whenever: (a) There is a significant change in the resident's condition; (3) Whenever the conditions in subsection (1) or (2) of this section occur, the assisted living facility must document in the resident's records: (a) The date and time each individual was contacted; and (b) The individual's relationship to the resident. This requirement was not met as evidenced by: Based on record reviews and interviews, the Assisted Living Facility (ALF) failed to consult with a resident’s representative when there was a significant change in condition for 1 of 1 sampled resident (Resident 1, R1). This failure placed R1 at risk for not timely receiving needed services and poor quality of life. Findings Included… Record review on 05/03/2023 showed that R1 was admitted to the facility on /2020 with diagnoses to include and R1’s assessment dated /2020 and care plan dated 02/03/2021 showed that R1 needed a one staff member total assist with transfers, physical assist with wheelchair, and maximum staff assist with personal hygiene. . Statement of Deficiencies License #: 2553 Compliance Determination # 23425 Plan of Correction Vineyard Park of Puyallup Completion Date Progress notes showed that R1 had a significant deterioration in physical and mental status where she had difficulties with transfers, had confusion and aggression starting 02/24/2021.Progress notes showed that at times R1 required two person transfers. Progress notes were as follows: 02/24/2021 at 9:50pm - resident was weak and hard to transfer, and it took over an hour and a half to assist her. 02/25/2021 at 10:58pm - resident was weak during transfer and staff provided two-person assistance. 02/26/2021 at 6:48am - resident complained about right knee not being strong enough to stand up. 02/26/2021 at 10:56pm-resident was not able to support herself on the right side and was difficult to transfer. 02/27/2021 at 9:58pm -resident was having trouble with transfers.