Overlake Terrace.

This document was prepared by Residential Care Services for the Locator website. STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEAL TH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20425 72nd Avenue S, Suite 400, Kent, WA 98032 HSRE-Stellar II TRS LLC Overlake Terrace 2956 152nd Ave NE Redmond, WA 98052 RE: Overlake Terrace License# 2551 Dear Administrator: This letter addresses Compliance Determination(s) 54447 (Completion Date 02/07/2025) and 51030 (Completion Date 12/11/2024). The Department completed a follow-up inspection of your Assisted Living Facility on 02/07/2025 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-3010-8-e, WAC 388-78A-3100-1, WAC 388-78A-3100-2, WAC 388-78A-2474-2- c, WAC 388-78A-2474-2-d, WAC 388-78A-2474-2-e, WAC 388-78A-2600-1-b, WAC 388-78A- 2100-2-a, WAC 388-78A-3090-1-c The Department staff who did the on-site verification: Jane Hermano, NCI Kathy Young, Licensor If you have any questions, please contact me at (253)234-6020. Sincerely, Laurie Anderson, Community Field Manager Region 2, Unit D Residential Care Services This document was prepared by Residential Care Services for the Locator website. STATE Of WASHINGTON DEPARTMENT OF SOCIAL AND HEALT H SERVICES AGING ANO LONG-TERM SUPPORT ADMINISTRATION .20U~ 72nd Avenue S, Suite 400, ICanr, WA IIOJ2 Staiement of Oef1e1enc1et License #. 255i Compliance Oeterm1nition #61030 Plan of Correction Overlake Terrace Completion Date Page 1 of 10 Licensee: HSRE-Sta/lar II TRS LLC 12/11Q024 You are required to be in compliance at all times vvith all licensing laws and regulations to maintain your Assisted Living Facility license. The department con,:,leted data collection for the unannounced on-site full inspection on 12/02/2024 and 12/05/2024 of: Overlake Terrace 2956 152nd Ave NE Redmond, WA 98052 The following sample was selected for review during the unannounced on-site visit 13 of 63 current residents and Of ormer residents. The department staff that inspected the Assisted Living Facility: Kathy Young, Licensor Jane Hermano, NCI From: DSHS, Aging and Long-Term Support Adrrinistration Residential Care Services, Region 2 , Unit D 20425 72nd Avenue S, Suite 400 Kent, WA 98032 As a result of the on-site visit( s), the department found that you are not in cofl1)1iance ¥.lith the licensing laws and regulations as stated in the cited deficiencies in the enciosed report. ~A~~ 12/20/2024 l"'(esit1enbal Care Services Date I understand that to maintain an Assisted Li\ling Facility license, the facility must be in co"1)liance with all the licensing laws and regulations at all times. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #. 2551 Compliance Determination #51030 Plan of Correction Overlake Terrace Completion Date Page 2 of 10 Licensee: HSRE-SteBar II TRS LLC 12/11Q024 WAC 388-78A-3010 Resident units. Th• assisted llvlng faolllty resident units must have the following: (8) Miscellaneous: Each sleeping room must have: (e) A lockable drawer, cupboard or other secure space measuring a least one-half cubic foot Yllith a minimum dimension of four inches; Thi• requirement was not met II evldeneed by: Based on observation, interview, and record review, the facility failed to provide lockable storage for 3 of 8 assisted living residents (Resident 3, Resident 4, and Resident 10). This failure placed residents at risk of financial Joss, property loss, and a diminished quality of life. Findings included ... Record review of the facility's Resident Characteristic Roster showed Resident 3, Resident 4, and a Resident 1 handled their medications independently. Observation on 1210412024 at 12:37 PM, showed Resident 3 stored their prescription medications in their apartment. No lockable storage was observed. Observation on 12/04/2024 at 1: 38 PM. showed Resident 4 stored their prescription medications in their apartment. No lockable storage was observed. During an interview on 12/04/2024 at 12:37 PM, Resident 3 stated that they had no lockable storage in their apartment. During an interview on 12/0412024 at 1: 38 PM, Resident 4 stated that they had no lockable storage in their apartment. During an interview on 12/05/2024 at 10:00 AM, Resident 10 stated that they had no lockable storage in their apartment. During an interview on 12/0512024 at 11 :32 AM, Staff-G, Maintenance Director. stated that they were aware all assisted living residents djd not have lockable storage in their apartments. This document was prepared by Residential Care Services for the Locator website. Statement of Oeficiencias License #: 2551 Compliance Determination #5-\030 Plan of Correction Overtake Terrace Completion Date Page 3 of 10 liC9nsee: HSRE-Stelar HT RS LLC 12/11/2024 PlantAtte1tation Statentent 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, nrlake Terrace is or will be in ,._.S: . compliance with this law and I or regulation on {Date) , \ "2- j In addition, I will il'Tl)lement a system to monitor and ensure continued co"°"liance mh this requirement. Date · WAC 388-78A~100 Safe storage of 1uppllu and equipment. Th• assisted llvlng faclllty must secure potentially hazardous suppllet and equipment commensurate with th• assessed needs of ,...ldems and their funedonal and cognitive abhltles. In dttenn lnlng what 1uppllu and equipment may be acceI1lbl• to residents, th• assisted living facility must consider at a minimum: (1) The residents' characteristics and needs; (2) The degree of hazardousness or toxicity posed by the supplies or equipment; This requirement was not II et as evidenced by: Based on observation, interview, and record review, the facility failed to ensure 1 of 1 housekeeping utility cart (third-floor cart) with hazardous chemicals was locked while unattended and in resident areas. The facility failed to ensure 1 of 2 memory care resident's (Resident 6} apartment was free of unlocked hazardous chemicats. These failures placed all 64 residents at risk of injury due to skin and eye contact with hazardous chemicals and ingesting hazardous chemicals. Findings induded ... Review of the facility's •Hazardous Material Policy", revised 02/06/2024, showed it was suggested that staff lock housekeeping carts when unattended. Staff were to ensure that each resident's safety needs vvere protected. HOUSEKEEPING CART Observation an 12/02/2024 at 11 :40 AM, showed that the housekeeping cart in the third-floor resident hall was unlocked with the rolltop for the deaning chemicals' compartment in the up position. The housekeeper was not present. The _cleaning chemicals were in view. The chemicals inside contained hazardous warning labels that indicated they were harmful if swallowed, to keep out of reach of children, and could cause skin and eye irritation. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2551 Compliance Determination #51030 Plan of Correction Overtake Terrace Coinptation Date Page 4 of 10 Licensee: HSRE-Stallar II TRS LLC 12/1112024 ' During an interview on 12/02/2024 at 11 :40 AM, Staff G, Maintenance Director, stated that housekeeping staff were trained not to leave the housekeeping carts unlocked and unattended. During an interview on 12/04/2024 at 1: 03 PM, Staff G darified the policy and stated that they tell their staff locking the cart is the best practice which does not mean staff must lock the housekeeping carts. RESIDENTS Observation of Resident 6's apartment in the memory care unit on 12/04/2024 at 9:28 AM, showed an unlocked cabinet. The cabinet contained a liquid laundry detergent and two bottles of hand sanitizer. The products' label read, "Keep out of reach of children.• Review of Resident 6's assessment and care ptan, dated 10/01/2024, showed Resident 6 ambulated with walker independently. The care plan showed Resident 6 wandered throughout the unit. The care plan showed Resident 6 had cognitive impairment. During an interview on 1210412024 at 9:45 AM, Staff 1, Memory Care Director stated that the facility I encouraged best practice and kept potentially harmful substances or sharp objects locked. PlanlAttestatlon Statem ant I hereby certify that I have reviewed this report and have taken or \!Viii take active measures to correct this deficiency. By taking this actio11 Overlakue rrace is or will be in \\'5) ,-.~ compliance with this law and/ or regulation on (Date) In addition, I will irf1)1ement a system to monitor and ensure continued con,,liance with this requirement. WAC 388-78A-247.4 Training and home can aid• cll'tltlcatlon requlre1111nt1. (2) The assisted living facility rrust ensure all assisted Jiving facility administrators, or their designees, and caregivers hired on or after January 7, 2012 meet the long-term care worker training requirements of chapter 388-112A WAC, induding but not lin'ited to: (c) Specialty for dementia, mental iflness and/or developmental disabilities when serving residents with any of those primary special needs; (d) Cardiopulmonary resuscitation and first aid; and This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies Ucen19 #. 2551 Compliance Determination #51030 Plan of Correction Onrlake Terrace Completion Date Page 5 of 10 Licensee: HSRE-SteBar II TRS U.C 12/1112024 (e) Continuing education. WAC 388-18A4800 PollclH and procedur•. (1) The assisted living facility mJst develop and implement policies and procedures in support of services that are provided and are necessary to: (b) Provide the necessaty care and services for residents, including those \l\tth special needs; This r•qulramentwas notmet11 evfdenc•d by: Based on interview and record review the Assisted Living Facility failed to ensure 4 of 4 staff (Staff A, C, D, and E) con,:,leted all required training to perform their job duties and responsibilities. This failure placed all residents at risk of unmet care needs from staff with incofT1)Iete training. Fjndings included ... Review of the facility's undated personnel records showed the facility hired Staff A, Executive Director, on 11/13/2023; Staff C, Memory Care Resident Assistant, on 06128/2023; Staff D, Memory Care Resident Assistant and Medication Technician, on 09105/2023; and Staff E, Assisted Living Resident Assistant and Medication Technician on 02/14/2022. SPECIALTY TRAINING Review of staff A and Staff C's personne1 records showed no dowmentation that Staff A and Staff C completed the required dementia and mentaJ health specialty training. CONTINUING EDUCATION (CE) Review of Staff D's personnel records showed no documentation that Staff D completed 12 hours of □ep·artment approved CE training, between their August 2023 birthday to their August 2024 birthday as required. CPR and FIRST AID Review of Staff E's personnel records showed no documentation that Staff E completed the required cardio-pulmonary resuscitation (CPR) training with hands-on skill development and first aid training. During an interview on 12/04/2024, Staff J, Busi·ness Office Man ager, stated that they were responsible for completion of the staff trainings for •II employees. Staff J stated that they were aware of the staff training and CE requirements. Staff J stated that they were unaware that Staff D's annual CE trainings dated September 2024, did not apply from Staff D's 2023 birthday to their 2024 birthday. PlanlAttestatlon Statement This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #. 2551 Compfrance Determination #51030 Plan of Correction Overlake Terrace Completion Date Page 6 of 10 Licensee: HSRE-Stdar II TRS LLC 12/11Q024 Over 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. Tenace is or will be in compliance with this law and I or regulation on (Date) \\ ">S ""l.,-S: . " In addition, I will il'Tl)lement a system to monitor and ensure continued compliance with this requirement. Ad.i~:£.J:11.:;r•tive) Date WAC 388-78A-21G0 Ongoing assnsmants. (2) The assisted living facility must: (a) Complete a full assessment addressing the elements setforth in WAC 388-78A-2090 for each resident at least annually; This requirement was not met as evld•nc■d by: Based on observations, interviews, and record reviews, the Assisted Living Facility failed to assess 3 of 5 residents (Resident 5, Resident 12, and Resident 13) for safe and proper use of a medical device. This failure placed Resident 6, Resident 12, and Resident 13 at risk of potential entrapment and injury. Findings included ... NOTE: Per WAC 388-78A-2090 Full assessment topics. The assisted living facility m.Jst obtain sufficient information to be able to assess the capabilities, needs, and preferences for each resident, and must complete a full assessment addressing the following, within fourteen days of the resident's move-in date, unless extended by the department for good cause: (6) Significant known behaviors or symptoms of the individual causing concern or requiring special care, including: (e) Other safety considerations that may pose a danger to the individual or others, such as use of medical devices or the individual's ability to smoke unsupervised, if smoking is pemitted in the assisted living facility. Review of the facility's policy titled "Mobmty Enablers Policy HW 101lt. revised 05/01/2024, showed that the facility allowed the use of bedside rails or other such devices (medical device designed to assist resident lllrith repositioning-and movement). The policy stated that the facility's licensed nun;e or physical therapist assessed residents and residents on hospice (a program that provide special care to individual near the end of their life and stopped treatment to cure their diseases) in need of an assistive device. The poticy stated the residents were informed of the risks associated with mobitity devices. The policy stated that the facility ensures the residents assessed with such devices were monitored appropriately for safety as required by state law. This document was prepared by Residential Care Services for the Locator website. statement of Deficiencies Ucannf.2551 Compliance ba,armination #51030 Plan of Corradion Overlake Terrace Complatron Date Page 7 of 10 Licensee: HSRE•SteYar II TRS LLC 12/1112024 Review of the Dear Provider Letter titled ~safety Risk of Medical Devicesn, dated 0511512013, showed the potential risks of using side bed rails included strangulation, suffocation, and bodily injury. The letter showed the importance of evafuating the safety of each resident and recognize the risks of using medical devices, such as side bedrails. RESIDENTS Observation of Resident 5's apartment on 12/04/2024 at 10: 53 AM, showed two half-length side rails attached at the head of the bed, along the right and left side. Each of the bedrails measured approximately 26 inches in length. Observation showed the two rails were fu11y raised with a 3.5-inch gap between the rail supports. Review of Resident 5's records showed that the facility admitted Resident 5 in 2019. Review of the Resident S's assessment and care plan, dated 10110/2024, showed Resident 5 had poor coordination with limted use of right arm and required one-person assistance ~th transfers. Review of the care plan showed no documentation Resrdent 5 used a bedrail. There was no documentation Resident 5 was assessed to safely use the bedrail. During an interview on 12/04/2024 at 10:54 AM, Resident 5 stated that they used the bedside rails to sit up in bed. Resident 5 stated that they started using the bed rail a while ago. Resident 5 was unable to recall if the staff had explained the potential risks of using bed rails. \ RESIDENT 12 Observation of Resident 12's apartment on 12/05/2024 at 9:42 AM, showed quarter-length side rails attached at the head of the bed, along the right side. The bedrail measured approximately 18.5 inches in length. Observation showed the bedrail was fully raised with a 4.5-inch gap between the rail ~upports. Review of Resident 12's records showed that the facility adrmted Resident 12 in 2024. Review of Resident 12's assessment and care plan, dated 10131 /2024, showed Resident 12 diagnosed with . The care plan showed Resident 12 did not require assistance for transfer or mobility and showed no documentation Resident 12 used a bedrail. There was no documentation ~esident 12 was assessed to safely use the bedrail. RESIDENT 13 Observation of Resident 13's apartment on 12/0512024 at 9:42 AM, showed a U•shaped quarter length side rail attached atthe head of the bed, atong the right side. The bedrail measured approximately 11.5 inches in length with a pocl<et storage. Observation showed the bedrail was fully raised with an 11.5-lnch gap. Review of Resident 13's records showed that1he facility admitted Resident 13 in This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #. 2551 Compliance Oeterrmnation #51030 Plan of Correction Overlake Terrace Completron Date Page 8 of 10 Licensee: HSRE-Stdar II TRS LLC 12/11f.Z024 2024. Review of Resident 13's assessment and care plan, dated 10/31/2024, showed Resident 13 diagnosed with . Review of the care plan showed Resident 13 required stand-by assistance for transfers. Review of the care plan showed no documentation Resident 13 used a bedrail. There was no documentation Resident 13 was assessed to safely use the bedrail, as required in the facility's bedrail policy. During an interview on 12/05/2024 at 9:43 AM, Resident 12 and Resident 13's representative stated that the facility never discussed the potential risks when bed rails were used. [)iring an interview on 12/05/2024 at 1: 37 PM, Staff A, Executive Director was unaware there was no documentation to show that Resident 6, Resident 12, and Resident 13 were assessed to safely use the bedrail. Plan/AU.stat on Statement l hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action-_~erlake Terrace is or will be in compliance with this law and I or regulation on (Date} ,\ '1..: :z_...S::: . \ In addition, I will implement a system to monitor and ensure continued co111>f iance !Mth this requirement. bate nd housekNplng. ( t) The assisted living facility must (c) Keep facilities, equipment and furnishings clean and in good repair; and This requtrementwas not111et as evldencacf by: Based on observations, interview, and record reviews. the Assisted Living Facility failed to ensure 2 of 5 residents' (Resident 1 and Resident 11) medical devices were securely and safely installed for use and were aware of the risk of using. This failure placed Resident 1 and Resident 11 at risk of potential entrapment and injury from use of unsafe medical equipment. Findmgs included ... Review of the facility's policy titled "Mobility Enablers Policy HW 101•, revised 05/01/2024, showed that the facility allowed the use of bedside rails or other such This document was prepared by Residential Care Services for the Locator website. Statement of DaficienciH LicenH #: 2551 CompHance Determination #51030 Plan of Correction Ovarlaka Terrace Completion Date Page 9 af 10 Licensee: HSRE-Stelar II TRS LLC 12/11f.2024 devices {medical device designed to assist resident with repositioning and movement). The policy stated that the facility's licensed nurse or physicat therapist assessed residents and residents on hospice (a program that provide special care to individual near the end of their life and stopped treatment to cure their diseases) in need ot an assistive device. The policy stated the residents were informed of the risks associated with mobility devices. The policy stated that the facility ensures the residents assessed with such devices were monitored appropriately for safety as required by state law. Review of the Dear Provider Letter titJed • Safety Risk of Medical Devicesn, dated 05/1512013, showed the potential risks of using side bed rails included strangulation, suffocation, and bodily injury. The letter showed the importance of evaluating the safety of each resident and recognize the risks of using medical devices, such as side bedrails. RESIDENT 1 Obseivation of Resident 1' s apartment on 12/04/2024 at 10:20 AM, showed a half-length side rail attached at the head of the bed, along the left side. The bedrail measured approximately 26 inches in length with a 3.5-inch gap between the rail supports. Observation showed the bed rail was fully raised. Observation showed the side rail was loose and tilted w,en moved with minimal effort which created a gap, greater than four inches, between the mattress and the side rail. Review of Resident 1' s records showed that the facility adrritted Resident 1 in 2023. Review of the Resident 1' s assessment and care pla.n, dated 1D/10/2024, showed Resident 1 had lirrited mobility and required two-person assist with transfers. Review of Resident 1' s mobility device safety assessment showed that Resident 1 used a bedrail as part of the hospit.a1 bed to assist in repositioning. The records shewed no documentation that Resident 1 or their family representative was informed on the risk of bedside rail use, as required in the facility's side rail policy. Review of the care plan showed the staff were to ensure the bedrail was tight and to shake each use for stabiUty. [}Jring an interview on 12/04/2024 at 1D : 26 AM, Resident 1 stated that the side rail was loose and shoutd be tightened. Resident 1 stated that they were unable to lower the rail. Resident 1 stated they were unaware of the potential risk of entrapment from the space between the mattress and the side rail. RESIDENT 11 Observation of Resident 11's memory care apartment on 12/05/2024 at 8:54 AM, showed two half length side rails attached at the head of the bed, along the right and left side. Each of the bedrails measured approximatety 26 inches in length with a 3.5•inch gap between the rail supports. Observation showed the two rails were fully raised. The left bedside rail was loose and not firmly attached to the bed frame. Review of Resident 11's records showed that the facility admitted Resident 11 in 2022. Review of the Resident 11 's assessment and care plan, dated 11/13/2024, showed Resident 11 diagnosed with This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License#. 2551 Compliance Determination #510J[J Plan of Correction Overlake Terrace Comptetion Date Page 10 of 10 Licensee: HSRE-Stellar II TRS LLC 12/11Q024 and . Review of Resident 111s assessment showed that Resident 11 used a bedrail to assist with turning and repositioning in bed. Review of the record showed no documentation that Resident 11 or their family representative was informed an the risk of bedside rail use, as required in the facility's side rail policy. Review of the care plan showed the staff were to ensure the bedrails were tight and had no gaps to decrease the risk of entrapment. PlanfAttHtation 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, OVe ake Terrace is or will be in compliance with this law and/ or regulation on (Date) S- In addition, I vv'ill implement a system to monitor and ensure continued compliance with this requirement. A~ nlalive)==--,_ Date This document was prepared by Residential Care Services for the Locator website. STATE OTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 2NZ5 1l.nd Avenue S, Suite 400, Kent, WA 91032 12/20/2024 HSRE-Stellar II TRS LLC 0/erlake Terrace 2956 152nd Ave NE Redmond, WA 98052 RE: 0Ver1ake Terrace# 2551 Dear Administrator: The Department completed a full inspection of your Assisted Living Facility on 12/11/2024 and found that your factlity does not meet the Assisted Living Facility requirements. The O.p1rtm1nt • Wrote the enclosed report; and • May take licensing enforcement action based on many deficiency listed on the endosed report and • M~ inspect your program to determine if you have corrected all deficiencies; and • Expects all deficiencies to be corrected within the timeframe accepted by the department. Yr,u Must: • Begin the process of correcting the deficiency or deficiencies immediately; • Contact the Field Man ager for clarifications related to the Statement of Deficiencies (SOD}; • Wthin 1O calendar days after you receive this letter, complete and return the enclosed 'Plan/Attestation Statement'; o Sign and date the endosed report; o For each deficiency, indicate the date you have or will correct each deficiency; o Mail the Plan/Attestation statement and report with original signatures to: Laurie Anderson, Field Manager Residential Care Services Region 2, Unit D 20425 72nd Avenue S, Suite 400 This document was prepared by Residential Care Services for the Locator website. Ovenake Terrace #2551 12/11/2024 Page 2 of5 Kent, WA 98032 • 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. Consultatlon(s): In addition, the Department provided consultation on the following deficiency or deficiencies not listed on the enclosed report. WAC 388-78A-230D Food and nutrition services. ( 1) The as siste cl living facility mu st (h) Develop, make known to residents, and ir11Jlement a process for residents to express their views and conment on the food services; and (i) Maintain a dining area or areas approved by the department IMth a seating capacity for fifty percent or more of the residents per meal setting, or ten square feet times the licensed resident bed capacity, whichever is greater. The facility failed to ensure menus were posted in the memory care unit where the residents could see them. During the full inspection, the facility posted menus where the residents could see. WAC 388-71A47G0 Em er9ency and disaster preparednas. (1 ) The assisted living facility must (a) Maintain the premises free of hazards; (b) Maintain any vehicles used for transporting residents in a safe condition; (c) Provide, and tell staff persons of a means of emergency access to resident-occupied bedrooms, toilet rooms, bathing rooms, and other rooms; (d) Provide emergency lighting or flashlights in all areas accessible to residents of the assisted living facility. (e) Make sure first-aid supplies are: (i) Readily available and not locked; (ii) Oear1y marked; (iii) Able to be moved to the location where needed; and The facility failed to ensure first aid kits were clearly marked, readily available, and appropriate for the size of the facility. During the full inspection, the facility made clearly marf<ed first aid kits readily available throughout the facility. This document was prepared by Residential Care Services for the Locator website. Ovarlake Terrace #2551 12111/2024 Page 3 of 5 WAC 388-78A-Z730 Llcen111'1 re1pon1lbllltl11. (2) The licensee must (b) Maintain and post in a size and format that is easily read, in a conspicuous place on the assisted living facility premises: (i) A current assisted living facility license, including any related conditions on the license; (iii) A copy of the report, including the cover letter, and plan of correction of the most recent full inspection conducted by the department. The facility failed to post a copy of the last full inspection report and the current assisted living license in a conspicuous location available to residents and guests. During the inspection, the facility corrected this i_ssue per the regulation. WAC 388-71A-3000 Ventltltlon. Th• a11t1tad llvlng facility ■u1t m• • th• ventllatlon requfr11nant1 ofth• 111echanlcal code as adopted and amended by 111• Washington state bullcllng council; and ( 1} Ventilate rooms to: (a) Prevent excessive odors or moisture; and Toe facility failed to ensure the ventilation system in the common bathrooms and utility dosem with mop sink were exchanging fresh air from the outside to the inside of the facility. During the full inspection, the facility demonstrated that it had a quarterly system in place for reviewing the ventilation system and corrected the issue. WAC 388-78A-3090 Maintenance and houslkeaplng. ( 1) The assisted living facility rrust: (a) Provide a safe, sanitary and well-maintained environment for residents; (b} Keep exterior grounds, assisted living facility structure, and component parts safe, sanitary and in good repair; Toe facility failed to ensure the resident-accessible memory care exterior courtyard was fru of a used paint tray that collected stagnant water. During the full inspection, the facility emptied the water and removed the tray. WAC 318-78A4411 Tubercufosls Tntln9 method Required. The assisted llvlng faclllty must ansurathat all tuberculoslt tHtlng Is done through either: (1) lntradermal (Mantoux) administration with test results read: (a) Within forty-eight to seventy-two hours of the test; and The Assisted Living Facility failed to read the required tuberculosis (TB) testing results for 1 of 6 staff (Staff D} within 48 to 72 hours following the first step of the two-step TB This document was prepared by Residential Care Services for the Locator website. Overlake Terrace #2551 12/11/2024 Page 4 of5 skin test administration. Staff D's two-step TB skjn tests showed negative results. During the inspection, the staff initiated a better tracking process to ensure skin test reaction for all staff were read and the result commJnicated within the required timeframe. WAC 388-78A-Zl20 Pets. If an assisted llvlng faelllty allows pets to llve on the premises, the uslsted llvlng faelllty Ill Ult (2) Ensure animals living on the assisted living facility premises: (a) Have regular examinations and immunizations, appropriate for the species, by a veterinarian licensed in Washington state; (b) Are certified by a veterinarian to be free of diseases transmittable to humans; The facility failed to ensure that 1 of 2 pets (Pet 2) in the assisted living received regular examination and immunizations. The facility obtained current pet records during the time of the full inspection. 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 endosed report. You May: • Contact me for ciarification of the deficiency or deficiencies found. In Addition, You May: • Request an lnfonn al Dispute R11olutlon (IDR) review within 10 working days after you receive this letter. Your !DR request must include: o Wlat specific deficiency or deficiencies you disagree with; o '#ny you disagree with each deficiency; and o Wietheryou want an IDR to occur in-person. by telephone or as a paper review. o Send your request to: IDR Program Manager Department of Social and Health Services Aging and Long-Term Support Administration Residential Care Services PO Box '15600 Olyf11)ia, WA 98504-5600 If You Have Any Questions: • Please contact me at (25 3)234-6020. Sincerely, This document was prepared by Residential Care Services for the Locator website. Ovarlake Terrace #2561 12111/.202-4 Page 5 of5 Laurie Anderson, Field Manager Region 2, Unit D Residential Care SelVices Endosure This document was prepared by Residential Care Services for the Locator website. Plan of Correction AaencvName Citation Date Overlake Terrace 12/11/2024 Subml~ed by Date of POC Submission Mindy Mendoza-Perry 12/31/2024 □ Complalnt Citation \(Certification atatlon Citation: (11st WAC):388-78A-3010 What initial or immediate Overlake Terrace did a room audit to identify what apartments were actions were taken to address without a lockable drawer, cupboard, or other secure space. The concerns affecting clients? Maintenance Director then purchased locks for those apartments identified not to have a lockable secure space. How wlll you apply the The maintenance department/ director wlll Install purchased locks and correction to all clients you ensure the locks remain In place by completing random audits of support? apartments to ensure there is a locked space. Who will be responsible to Maintenance Director or maintenance department will ensure overslsht implement chanse and monitor for residents to have lockable space. the corrections to ensure the problems do not reoccur? Date by which lasting Overlake Terrace wlll be In compliance with WAC 388-78A-3010 no later correction wlll be achieved than 1/25/2025 Additional Information Enter any additional information you " , , is pertinent such as I Pf' ro I · I IDR Submit to RCS within 10 calendar days of receipt of letter to: Laurie Anderson, Field Manager Residential Care Services Region 2, Unit D 20425 72nd Avenue S, Suite 400 Send copy to ODA Resource Manager or Residential Program Specialist for your region. This document was prepared by Residential Care Services for the Locator website. Plan of Correction Agency Name Citation Date OVerlake Terrace 12/11/2024 Submitted by Date of POC Submission Mlndv Mendoza-Perry 12/31/2024 I □ Complaint Citation ~C ertification Citation Citation: (11st WAC): WAC 388-78A-3100 What initial or Immediate . OVerlake Terrace ensures the safe storage of supplies and equipment by actions were taken to address providing a secure area for potentially hazardous supplies and equipment. concerns affecting clients? overtake Terrace Immediately ensured all housekeeping carts were locked and housekeeping staff were aware carts are to be locked anytime they are not visible. OVerlake Terrace removed the laundry detergent and hand sanitizer from the memory care apartment It was found In to ensure resident safety. How wlll you apply the To ensure WAC 388-78A-3100 ls followed there have been random checks correction to all clients you done by the Executive Director and Business Office Manager when support? housekeeping carts are unsupervised, all carts were found to be locked during the checks. Executive Director and Business Office Manager checked 4 random memory care apartments to ensure no products labeled "keep out of reach of children• were left unlocked, no apartments had such Items unlocked. Who will be responsible to To ensure WAC 388-78A-3100 Is followed and safe storage of supplies implement chan1e and monitor and equipment are secured In an area that avoids potentially hazardous the corrections to ensure the supplies and equipment from being accessed by residents the memory problems do not reoccur? care director and maintenance director will do random audits quarterly to ensure Items are locked and secure In resident apartments and housekeeping carts. Date by which fasting Overlake Terrace will be In compliance with WAC 388-78A-3100 by correction will be achieved 1/25/25. Additional Information I I r I I nr.1 n'o• t n t u l>t"1 •v 0 •t I l t l as t \ubrn·1 IDR Submit to RCS within 10 calendar days of receipt of letter to: Laurie Anderson, Field Manaser Residential care Services Reslon 2, Unit D 20425 72nd Avenue S, Suite 400 Send copy to ODA Resource Manager or Residential Program Speclallst for your region. This document was prepared by Residential Care Services for the Locator website. Plan of Correction Agency Name Citation Date Overlake Terrace 12/11/2024 su·bmltted by Date of POC Submission Mindy Mendoza-Perry 12/31/2024 □ Complaint atatlon ~ Certification Ctatlon Citation: (11st WAC): WAC 388-78A-2474 and WAC 38&-78A-2600 What initial or immediate Overlake Terrace shall ensure requirements for chapter 388-112A WAC are actions were taken to address followed to ensure residents are not at risk of unmet care needs from staff concerns affecting clients? because of Incomplete training. OVerlake Terrace aims to provide the necessary care and services for residents lncludlns those with special needs and supports services that are provided to residents within our care. OVerlake Terrace has completed an audit to identify staff r:nembers who need specialized training, CPR, or continuing education. Those staff Identified In the audit have either completed the required training or have been scheduled to complete the training no later than 1/25/25 with an outside trainer. The audit staff have been noted to have CPR and continuing education units as required by chapter 388-112A WAC. How will you apply the The Business Office Manager has scheduled tralnlns for dementia and correction to all clients you mental health specialty training with an outside provider on Jan 13, 2025. support? Staff lacking training have been informed the training Is mandatory. The Business Office Manager wlll see proper training has been completed by the appropriate staff or staff wlll be removed from the schedule startlns on 1/25/25 until the training Is complete. Additionally, to ensure the systemic and operational change for compliance of WAC 388-78A-2474 and WAC 388-78-2600 the Business Office Manager has created a spreadsheet with dates to track completion of training requirements. Who will be responsible to The Business Office Manaser will utilize the spreadsheet to track Implement change and monitor employee training requirements of chapter 388-112A WAC. The Executive the corrections to ensure the Director will randomly audit employee flies to ensure the training tracked problems do not reoccur? Is accurate and complete so resident are not placed at risk of unmet care needs from staff with incomplete training. Date by which lasting OVerlake Terrace will follow WAC 388-78A-2474 and WAC 388-78A-2600 correction will be achieved by 1/25/25. 1 Additional Information Enter any additional information you believe is , •1 en u JI lilt l l submit an IDR Submit to RCS within 10 calendar days of receipt of letter to: Laurie Anders~n, Field Manager Resldentlal care Services This document was prepared by Residential Care Services for the Locator website. Region 2, Unit D 20425 72nd Avenue S, Suite 400 Send copy to ODA Resource Manager or Residential Program Specialist for your region. ·, • This document was prepared by Residential Care Services for the Locator website. Plan of Correction AgencvName Citation Date Overtake Terrace 12/11/2024 Submitted bv Date of POC submission Mindy Mendoza-Perry 12/31/2025 ; D Complalnt Citation ~ Certification Citation Citation: (11st WAC): WAC 388-78A-2100 (2090) What initial or Immediate Overlake Terrace obtains sufficient information to assess the capabllltles, actions were taken to address needs and preferences of our residents. Overlake Terrace completes a full concerns affecting clients? assessment of our residents during admission (or within or within 14 days of the admission date) and at least annually. During the futl assessment If a resident Is found to use bed side rails the risks of using bed side rails will be discussed with the resident/ responsible party and an assessment will be completed to ensure the safety of each resident when using a medical device- such as bed side rails. Immediately staff identified what residents had bed side rails and educated families/ residents about the risks vs benefits of bed side rail usage. Staff ordered covers to protect residents from gaps between the rail support and the mattress-these will be put In place when received from vendor. Moblllty Device Assessments began on residents with the use of mobfllty enhancers such as bed side rails. How will you apply the To ensure WAAC 388-78A-2100 Is followed Overlake Terrace has correction to all cllents you implemented the following systemic changes. When any full assessment support? Is completed, and bed side rails are used Immediate completion of the Mobility Device Safety Assessment wlll be done by the nurse completing the assessment. Addltlonally, the nurse will engage In a conversation with the resident/ responsible party to ensure the risks of using bed side rails Is discussed. Only after the resident/ responsible party agree to the use of bed side rails will the bed side rails be used and not prior to the facility coverlns them with a protective cover to avoid strangulation, suffocation, or bodily lnJury. Who wUI be responsible to To ensure WAC 388-78A-2100 2'nd WAC 388-78A-2090 are followed the Implement change and monitor community Licensed Nurse/ Health and Wellness l;)lrector shall complete the corrections to ensure the an audit for use of bed side rails. During the audit the nurse or director problems do not reoccur? shall ensure bed side rails have covers, risks have been discussed with the resident/ responsible party, and a Mobility Device Safety Assessment has been completed. Date by which lasting Overtake Terrace wlll ensure compliance with WAC 388-78A-2100 and correction will be achieved WAC 388-78A•2090 by 1/25/25. Additional Information Enter any additional information you 1 is pertinent such as intent to , an IDR This document was prepared by Residential Care Services for the Locator website. Submit to RCS within 10 calendar days of receipt of letter to: Laurie Anderson, Fleld Manager Residential Care Services Region 2, Unit D 20425 72nd Avenue S, Suite 400 Send copy to ODA Resource Mana1er or Residential Program Specialist for your region. This document was prepared by Residential Care Services for the Locator website. Plan of Correction Agency Name Citation Date Overlake Terrace 12/11/2024 Submitted by Date of POC Submission Mindy Mendoza-Perry 12/31/2024 .I D Complaint Citation ~ Certification Citation Citation: (11st WAC): WAC 388-78A-3090 What initial or Immediate Overlake Terrace adheres to WAC 388-78A-3090 to keep equipment and actions were taken to address furnishings clean and In 100d repair. Addltlonally Overlake Terrace's goal is concerns affectlns clients? to keep residents safe and free from the risk of potential entrapment and Injury from use of unsafe medical equipment. On 12/6/24 Overlake Terrace checked all residents bed side rails to ensure they were not loose to avoid Injury to a resident from unsafe medical equipment. Overlake Terrace adjusted equipment, as needed, to ensure bed rails were tight and did not shake for stability. How will you apply the The f(?llowlng systemic and operational changes will be Implemented to correction to all clients you ensure WAC 388-78A-3090 Is met. A new system has been Implemented support? to ensure bed side rails are tight and firmly attached to the bed to avoid risks associated with unsafe medical equipment; Maintenance department will check the equipment regularly to ensure it Is In good repair. Overlake Terrace nurse will complete a Moblllty Device Safety Assessment on residents who utilize bed side rails. A discussion with resident/ responsible party will be prompted to ensure risks of use of bed side rails are disclosed. Overlake Terrace will ensure covers for slderalls are used to avoid suffocation, strangulation, or bodily Injury. Who wlll be responsible to Maintenance Director/ Licensed Nurse/ Health and Wellness Director, implement change and monitor Memory Care Director will each be part of the auditing process to ensure the corrections to ensure the bedrails are In good repair, assessed properly, risk of slderalls are problems do not reoccur? explained to resident/ responsible party, and covers are placed on side rails. Random audits by Executive Director/ deslgnee will be completed to ensure all parties responsible are following WAC 388-78A-3090. Date by which lasting Overlake Terrace will be In compliance with WAC 399-78A-3090 by correction wlll be achieved 1/25/25. Additional Information Enter any additional information you believe is t n n• I ntr I t • submit an IDR Submit to RCS within 10 calendar days of receipt of letter to: Laurie Anderson, Fleld Manager This document was prepared by Residential Care Services for the Locator website. Resldentlal Care Services Region 2, Unit D 20425 72nd Avenue S, Suite 400 Send copy to ODA Resource Manager or Resldentlal Program Specialist for your region.

This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: Overlake Terrace Provider Type: Assisted Living Facility License/Cert.#: 2551 Compliance Determination #: 49811 Intake ID: 150392 Investigator: Harrison Udoye Region/Unit #: RCS Region 2 / Unit D Investigation Date(s): 10/28/2024 through 11/15/2024 Complainant Contact Date(s): Allegation(s): Medication service. Investigation Methods: Sample: Total residents: 69 Resident sample size: 1 Closed records sample size: 0 Observations: Residents Activities Resident care equipment Resident rooms Staff to resident interactions Resident to resident interactions Medication administration Interviews: Identified resident Identified staff Nursing staff Residents Social services staff Staff development coordinator Human resources Record Reviews: Medical records Hospital records State reporting log Incident investigation Facility policies Investigation Summary: Report of medication error in the Assisted Living Facility (ALF). Interview and record review showed that Named Resident was hospitalized due to rectal bleeding. Hospital discharge Named Resident on /2024 with new orders for the blood thinner (Eliquis). New order showed medication for Eliquis to restart with a lower dose of 2.5 milligrams (mg) which was different from the previous dose This document was prepared by Residential Care Services for the Locator website. of 5 mg. New medication order of 2.5 mg dose was scheduled to begin on /2023. Investigation showed Named Resident received the Eliquis 2.5 mg medication early on /2024, not as ordered. Named Resident returned to the hospital the next morning /2024 for worsening of rectal bleeding. Facility staff failed to follow their medication policy and procedure to clarify physician's order of medication change and check the order was correctly written by the pharmacy on the electronic medication administration record to ensure medications administered safely and as ordered. Failed practice identified. Citation issued. 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. STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20425 72nd Avenue S, Suite 400, Kent, WA 98032 Statement of Deficiencies License #: 2551 Compliance Determination # 49811 Plan of Correction Overlake Terrace Completion Date Page 1 of 3 Licensee: HSRE-Stellar II TRS LLC 11/15/2024 You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for an unannounced on-site complaint investigation on 10/28/2024, 10/28/2024 and 10/28/2024 of: Overlake Terrace 2956 152nd Ave NE Redmond, WA 98052 This document references the following complaint number(s): 150392 The following sample was selected for review during the unannounced on-site visit: 1 of 69 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Harrison Udoye, Community Complaint Investigator From: DSHS, Aging and Long-Term Support Administration Residential Care Services, Region 2 , Unit D 20425 72nd Avenue S, Suite 400 Kent, WA 98032 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. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2551 Compliance Determination # 49811 Plan of Correction Overlake Terrace Completion Date Page 2 of 3 Licensee: HSRE-Stellar II TRS LLC 11/15/2024 Administrator (or Representative) Date WAC 388-78A-2210 Medication services. (1) An assisted living facility providing medication service, either directly or indirectly, must: (b) Develop and implement systems that support and promote safe medication service for each resident. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to implement and provide safe medication service for 1 of 1 sampled resident (Resident 1). This failure placed Resident 1 at risk for compromised health related to medication errors. Finding included… Review of the facility’s Characteristic Roster showed the facility provided medication management assistance for 49 residents. The roster showed the assistance provided included: clarification of physician’s orders, ordering medications, medication administration, and accurate documentation in the residents’ electronic medication administration records (eMAR). Review of the facility’s policy titled, “Medication Policy”, updated on 05/29/2024, showed that any medication received by the community was checked against a physician order for Resident’s name, medication name, date and route of administration, frequency of administration, time of administration, strength of the medication, and number of tablets/capsules received. During an interview on 10/28/2024 at 10:14 AM, Staff A (Executive Director), stated that on /2024 at 1:01 PM Resident 1 returned from facility after a recent hospitalization. Resident 1 returned to the facility with a change for their blood thinner (Eliquis) medication. Prior to hospitalization, Resident 1 received five milligrams (mg) of Eliquis. Upon return to facility, Resident 1’s physician ordered 2.5 mg of Eliquis to start on /2024. Facility staff received the new order and faxed it to the pharmacy to be added to Resident 1’s electronic Medication Administration Record (eMAR). Facility received an updated eMAR from pharmacy that showed incorrect orders. Staff A stated that the staff did not clarify the orders with the physician and pharmacy when the eMAR showed incorrect orders. Review of Resident 1’s October 2024 eMAR showed Resident 1’s physician ordered the This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2551 Compliance Determination # 49811 Plan of Correction Overlake Terrace Completion Date Page 3 of 3 Licensee: HSRE-Stellar II TRS LLC 11/15/2024 Eliquis medication to be re-started on /2024. The eMAR showed Resident 1 received 2.5 mg of Eliquis on /2024, three days before the order to re-start the medication, when Staff D (Med Tech) administered Resident 1 their evening medications. Review of Resident 1’s undated “Observation Notes” showed that on /2024 at 10:15 AM, Resident 1 was sent to the hospital again due to increased rectal bleeding. 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, Overlake Terrace 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.

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