Guardian Angel Homes (the Cottage).

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Home and Community Living Administration PO Box 45600, Olympia, WA 98504-5600 January 2, 2026 ELECTRONIC-FACSIMILE Administrator GUARDIAN ANGEL HOMES (THE COTTAGE) 245 Van Giesen St Richland, WA 99354 Assisted Living Facility License # 1513 Licensee: CAMP I RICHLAND REAL ESTATE HOLDING CO, LLC IMPOSITION OF CIVIL FINE Dear Administrator: On December 18, 2025, the Department of Social and Health Services (DSHS), Residential Care Services completed a follow-up visit at your facility. This letter constitutes formal notice of a civil fine on the license for your assisted living facility, also known as GUARDIAN ANGEL HOMES (THE COTTAGE), located at 245 Van Giesen St, Richland, by the State of Washington, Department of Social and Health Services. These actions are taken under the authority granted pursuant to Laws of 1998, Chapter 272 and RCW 18.20.190. The civil fine on the license is based on the following violation of the RCW and/or WAC as described in the attached Statement of Deficiencies (SOD) report dated December 18, 2025. Civil Fine WAC 388-78A-2466 (1)(a) Background checks—Washington state name $300.00 and date of birth background check—Valid for two years—National fingerprint background check—Valid indefinitely. The licensee failed to ensure that staff that had a valid Washington state name and date of birth background check completed every two years for one staff member. This failure placed residents at risk of being cared for by staff member with unknown background history. This is an uncorrected deficiency, written on the Statement of Deficiencies dated October 27, 2025, for Washington Administrative Code 388-78a-2466(1a). Administrator GUARDIAN ANGEL HOMES (THE COTTAGE) License # 1513 January 2, 2026 Page 2 NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Attestation (Plan of Correction): Return the enclosed SOD within 10 calendar days with the following: • The date you have or will have each deficiency corrected; • A signature and date attesting that you are taking actions to correct and maintain correction for each cited deficiency. Return the signed and dated SOD to: Laura Williams-Davis, Field Manager Region 1, Unit C 1200 Alder St Union Gap, WA 98903 Phone: 509-208-5231 / Fax: (509) 454-4160 rcsregion1email@dshs.wa.gov Appeal Rights: You have two appeal rights: Informal Dispute Resolution (IDR) and an Administrative Hearing. Each has a different request timeline. Informal Dispute Resolution [RCW 18.20.195] You have an opportunity to challenge the deficiencies and/or enforcement actions through the state's IDR process. All IDR requests must be in writing and include: • The deficiencies you are disputing; and • The method of review you prefer (face-to-face, telephone conference or documentation review). The written request must be received by the 10th working day from receipt of this letter. During the IDR process, you will have the opportunity to present written and/or oral evidence to dispute the deficiencies. You can make an IDR request and find directions on the IDR web page at: http://www.dshs.wa.gov/altsa/idr. Administrator GUARDIAN ANGEL HOMES (THE COTTAGE) License # 1513 January 2, 2026 Page 3 Formal Administrative Hearing You may contest the civil fine by requesting a formal administrative hearing to challenge the deficiency, which resulted in the civil fine. All hearing requests must be in writing and include: • A copy of this letter; and • A copy of the Statement of Deficiencies. The written request must be received within twenty-eight (28) calendar days of receipt of this letter. Send your written request to: Office of Administrative Hearings PO Box 42489 Olympia, Washington 98504-2489 Payment: If you do not request a formal administrative hearing, the civil fine is due to the Office of Financial Recovery twenty-eight (28) calendar days after receipt of this letter. Mail a check for $300.00 payable to the ‘Department of Social and Health Services’, and if you have or have had a Medicaid resident(s), please include your ProviderOne ID Number # on the check, to: DSHS Office of Financial Recovery PO Box 9501 Olympia, WA 98507-9501 (360) 664-5919 / FAX: (360) 664-8401 OFRMMISVendor@dshs.wa.gov If the Office of Financial Recovery has not received your payment within twenty-eight (28) days after receipt of this letter, interest will begin to accrue immediately on the balance, at the rate of one percent per month. If you do not submit a hearing request or make payment within twenty-eight (28) days, the balance due will be recovered. Administrator GUARDIAN ANGEL HOMES (THE COTTAGE) License # 1513 January 2, 2026 Page 4 NOTICE: State and federal law provide protections to defendants who are in military service, and to their dependents. Dependents of a service member are the service member’s spouse, the service member’s minor child, or and individual for whom the service member provided more than one-half of the individual’s support for one hundred eight days immediately preceding an application for relief. One protection provided is the protection against the entry of a default judgment in certain circumstances. This notice pertains only to a defendant who is a dependent of a member of the National Guard or a military reserve component under a call to active service, or a National Guard member under a call to service authorized by the governor of the state of Washington, for a period of more than thirty consecutive days. Other defendants in military service also have protections against default judgments not covered by this notice. If you are the dependent of a member of the national guard or a military reserve component under a call to active service, or a national guard member under a call to service authorized by the governor of the state of Washington, for a period of more than thirty consecutive days, you should notify the Department in writing of your status as such within twenty days of the receipt of this notice. If you fail to do so, then a court or an administrative tribunal may presume that you are not a dependent of an active duty member of the national guard or reserves, or a national guard member under a call to service authorized by the governor of the state of Washington, and proceed with the entry of an order of default and/or a default judgment without further proof of your status. Your response to the Department about your status does not constitute an appearance for jurisdictional purposes in any pending litigation nor a waiver of your rights. If you have any questions, please contact Laura Williams-Davis, Field Manager, at 509-208- 5231. Sincerely, for Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 1, Unit G RCS Regional Administrator, Region 1 HCS Regional Administrator, Region 1 DDA Regional Administrator, Region 1 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW HP

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEAL TH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 1200 Alder Street, Union Gap, WA 98903 CAMP I RICHLAND REAL ESTATE HOLDING CO, LLC GUARDIAN ANGEL HOMES (THE COTTAGE) 245 Van Giesen St Richland, WA 99354 RE: GUARDIAN ANGEL HOMES (THE COTTAGE) License# 1513 Dear Administrator: This letter addresses Compliance Determination(s) 60640 (Completion Date 06/05/2025) and 56664 (Completion Date 04/10/2025). The Department completed a follow-up inspection of your Assisted Living Facility on 06/05/2025 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-?BA-2450-2-h-iii, WAC 388-?BA-2450-2-h-iv, WAC 388-?BA-2450-2-h-v, WAC 388- ?BA-2450-2-h-vi, WAC 388-?BA-2450-2-i-i, WAC 388-?BA-2450-2-i-ii, WAC 388-?BA-2450-2-i iii, WAC 388-?BA-2450-2-i, WAC 388-?BA-2450-2-j The Department staff who did the on-site verification: Melissa Milanez, Community Complaint Investigator If you have any questions, please contact me at (509)208-5231. Sincerely, Laura Williams-Davis, ALF Field Manager Region 1, Unit G Residential Care Services This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: GUARDIAN ANGEL Provider Type: Assisted Living Facility HOMES (THE COTTAGE) License/Cert.#: 1513 Intake ID: 171421 Compliance Determination #: 56664 Region/Unit #: RCS Region 1 / Unit G Investigator: Melissa Milanez Investigation Date(s): 03/20/2025 through 04/10/2025 Complainant Contact Date(s): Allegation(s): Fall with injury. Investigation Methods: Sample: Total residents: 80 Resident sample size: 6 Closed records sample size: Observations: Residents Dining Resident care equipment Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Identified staff Nursing staff Residents Family members Human resources Record Reviews: Medical records Hospital records State reporting log Incident investigation Facility policies Personnel files Staff training records Staff patterns Staffing agency contract) Investigation Summary: Interviews and record reviews showed that the facility investigated the fall and determined that agency staff did not have access to residents’ care plans and were not informed of the identified resident’s fall risk or care needs. Record review of the contract between the staffing agency and the facility showed that it was the facility’ This document was prepared by Residential Care Services for the Locator website. s responsibility to orient agency staff to the facility; its rules and regulations, to acquaint them with the facility’s policies and procedures, and to validate competency and ability of assigned employees. Failed practice identified, please see the Statement of Deficiency dated 03/12/2025 for WAC 388-78a-2450 (2)(h)(iii)(iv)(v)(vi)(i)(i)(ii)(iii)(j) for staff. 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 HEAL TH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 1200 Alder Street, Union Gap, WA 98903 Statement of Deficiencies License#: 1513 Compliance Determination# 56664 Plan of Correction GUARDIAN ANGEL HOMES (THE COTTAGE) Completion Date Page 1 of 5 Licensee: CAMP I RICHLAND REAL ESTATE HOLDING CO, LLC 04/10/2025 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 03/20/2025 of: GUARDIAN ANGEL HOMES (THE COTTAGE) 245 Van Giesen St Richland, WA 99354 This document references the following complaint number(s): 170344, 170886, 171421, 171577, 170903 The following sample was selected for review during the unannounced on-site visit: 6 of 80 current residents and O former residents. The department staff that investigated the Assisted Living Facility: Melissa Milanez, Community Complaint Investigator From: DSHS, Aging and Long-Term Support Administration Residential Care Services, Region 1 , Unit G 1200 Alder Street Union Gap, WA 98903 This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 1513 Compliance Determination # 56664 Plan of Correction GUARDIAN ANGEL HOMES (THE COTTAGE) Completion Date Page 2 of 5 Licensee: CAMP I RICHLAND REAL ESTATE HOLDING CO, LLC 04/1012025 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. ~W~D~ 04/22/2025 Residential Care Services Date I understand that to maintain an Assisted Living Faciltty license. the facility must be in compliance with all the licensing laws and regulations at all times. , Ad . . ( R . ) m1n1strator or epresentat1ve WAC 388-78A-2450 Staff. (2} The assisted living facility must: (h) Provide staff orientation and appropriate training for expected duties, including: (iii) Specific duties and responsibilities; (iv) How to report resident abuse and neglect consistent with chapter 74.34 RCW and assisted living facility policies and procedures; (v) Policies, procedures, and equipment necessary to perform duties; (vi) Needs and service preferences identified in the negotiated service agreements of residents with whom the staff persons will be working; and (i) Develop and implement a process to ensure caregivers: (i) Acquire the necessary infonnation from the preadmission assessment. on-going assessment and negotiated service agreement relevant to providing services to each resident with whom the caregiver works; (ii) Are informed of changes in the negotiated service agreement of each resident with whom the caregiver works; and (iii) Are given an opportunity to provide information to responsible staff regarding the resident when assessments and negotiated service agreements are updated for each resident with whom the caregiver works. U) Ensure all caregivers have access to resident records relevant to effectively providing care and services to the resident. This requirement was not met as evidenced by: Based on interview and record review the Assisted Living Facility (ALF) failed to ensure This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License#: 1513 Compliance Determination# 56664 Plan of Correction GUARDIAN ANGEL HOMES (THE COTTAGE) Completion Date Page 3 of 5 Licensee: CAMP I RICHLAND REAL ESTATE HOLDING CO, LLC 04/10/2025 caregivers had access to resident records and were properly trained and oriented to the facility in order to provide effective care and services for 1 of 6 residents (Resident 1). This failure resulted in unknowledgeable staff providing care to clients with chronic health conditions. Findings included: Review of the service agreement between Omni Staffing Services, Inc. (Omni [agency staff]) and Guardian Angels Richland (Facility) dated 10/18/2023, showed that the Facility Responsibilities are: Facility agrees to orient Omni employees to the facility; its rules and regulations, to acquaint them with the facility policies and procedures, and to validate competency and ability of assigned employees. Facility agrees to cooperate in an evaluation of each Omni Employee relative to such employee's ability to perform specific job functions upon completion of employee's assignment. Facility agrees to notify Omni within 24 hours of any event; competency issues, incidents, and/or complaints related to the Omni Employee and/or Omni Staffing Services. Client agrees to initiate communication with Omni whenever an incident/injury report related to the Omni Employee is completed. Upon notification, Omni shall document and track all unexpected incidents, including errors, sentinel events and other events, injuries and safety hazards related to the care and services provided. Review of Resident 1's Negotiated Service Agreement (NSA) dated 12/24/2024, showed that Resident 1 was at risk for falls due to age, anticoagulation therapy, and the use of a walker. The NSA also showed that Resident 1 required stand-by assistance with gait belt for all mobility, ambulation, and transfers. Resident 1' s diagnoses included and . Review of the facility's work schedule for March 2025, showed that on /2025 for evening shift 2:00 PM-10:30 PM, the facility utilized agency staff [Omni staff] to provide direct care services to residents. Record review of hospital summary dated /2025, showed the resident reported to the emergency room (ER) with complaints of a headache and had sustained a fall. Resident 1 was diagnosed with This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License#: 1513 Compliance Determination# 56664 Plan of Correction GUARDIAN ANGEL HOMES (THE COTTAGE) Completion Date Page 4 of 5 Licensee: CAMP I RICHLAND REAL ESTATE HOLDING CO, LLC 04/10/2025 . Record reviews also showed that the resident was admitted to the Intensive Care Unit (ICU), was put on comfort measures on 03/25/2025 and expired on /2025 at 9:27 AM. During an interview on 03/20/2025 at 12:35 PM, Staff A, Facility Licensed Nurse stated they conducted the initial investigation of the fall incident that occurred on /2025. Staff A stated that agency staff did not have access to the care plans. Staff A stated that the agency staff caregiver involved was defensive during the interview. Staff A also stated that the agency caregiver expressed concern regarding their lack of awareness of the resident's transfer status. In an interview on 03/20/2025 at 2:41 PM, Staff B, Medication Technician (MT), stated agency staff did not have access to the care plans and that they relied on facility staff to give them information about the residents. In an interview with on 04/01/2025 at 12:55 PM, Collateral Contact 1 (CC1), Human Resources (contracted agency company) stated they had a contract with the facility and per their signed contract, it was the facility's responsibility to supervise and orient staff to the facility. CC1 stated that their agency staff did not have access to the residents' care plans and were not aware of their facility's fall policy. In an interview on 04/01/2025 at 2:54 PM, Staff C, Health and Wellness Director stated that on 12/09/2024, the facility transitioned to a new electronic health record system, and agency staff did not have access to the residents' care plans. Staff C stated they felt that agency staff not having access to the residents' care plans and not knowing the residents' transfer status may have contributed to Resident 1's fall on /2025. Staff C stated they weren't sure if they had an actual fall policy but had an incident policy. They stated that if a resident hits their head, it's an automatic emergency call to 911 for further evaluation. They stated, "I don't think it's written anywhere and if it's not, I think it's time to reevaluate our policies." During an interview on 04/04/2025 at 11 :55 AM, Collateral Contact 2 (CC2), Agency staff caregiver, stated that they were not provided access to the resident's service plan and were unaware of the resident's mobility limitations when they worked with Resident 1 on /2025. CC1 stated they assumed that the resident was not a fall risk because they had previously observed them ambulating independently with a walker. CC1 further stated that they were not informed that the resident was at risk for falls or required safety checks and that the only reason they knew anything about the resident was by talking to the residents' wife, who was also a resident at the facility. During an interview on 04/09/2025 at 4:00 PM, Staff D, Executive Director stated in response to the fall incident on /2025, the facility had created an orientation checklist specifically for agency staff working in the building. They recognized the importance of agency caregivers understanding what to do in the event of an emergency and being familiar with facility expectations before providing care. They This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 1513 Compliance Determination # 56664 Plan of Correction GUARDIAN ANGEL HOMES (THE COTTAGE) Completion Date Page 5 of 5 Licensee: CAMP I RICHLAND REAL ESTATE HOLDING CO, LLC 04/1012025 stated that moving forward, any new agency staff would be required to review the information with facility staff prior to picking up shifts at the facility. 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, GUARDIAN ANGEL HOMES (THE COTT~GE) iL or will be in compliance with this law and/ or regulation on (Date) OC";?1 22 _2 6 2.t;; j In addition, I will implement a system to monitor and ensure continued compliance with this requirement. ~fu.Ac Aminitrator (or Representative) Date This document was prepared by Residential Care Services for the Locator website. WAC NUMBER; 388-78a-2450 STEP ONE How the facility will correct the deficiency for each numbered resident. The resident is no longer at the facility. We intend to provide orientation for each agency staff member that works at Guardian Angel Homes. We have provided a log-in for each agency staff member to access Individual service plans on our computer system PCC. We have binders in the houses with the care plans in case they cannot access our computer system, PCC, they will have access to care plans. STEP TWO Measures the facility will take or the systems it will change to ensure the problem does not recur. We intend to provide orientation for each agency staff member that works at Guardian Angel Homes. We have provided a log-in for each agency staff member to access Individual service plans on our computer system PCC. We have binders in the houses with the individual service plans in case they cannot access our computer system, PCC, they will have access to individual service plans. STEP THREE Measures the facility will take or the systems it will change to ensure the problem does not recur. Continued education specifically to staffing agency staff with orientation and signed acknowledgement. Change in orientation policy for agency staff. Binders in the houses with each resident care plan and face sheet. STEP FOUR How the facility plans to monitor its ongoing performance to sustain compliance We acknowledge that we did not have proper training in place for our agency staff members working at Guardian Angel Homes. Staffing department and administration department will ensure the orientation is done properly for every agency staff member. Nursing will update individual service plans as changes occur. STEP FIVE Dates corrective action will be completed. 5/22/2025 STEP SIX person responsible for this plan Laura Miller, administrator. This document was prepared by Residential Care Services for the Locator website.

Residential Care Services Investigation Summary Report Provider/Facility: GUARDIAN ANGEL Provider Type: Assisted Living Facility HOMES (THE COTTAGE) License/Cert.#: 1513 Intake ID: 187910 Compliance Determination #: 63690 Region/Unit #: RCS Region 1 / Unit G Investigator: Melissa Milanez Investigation Date(s): 08/05/2025 through 08/22/2025 Complainant Contact Date(s): Allegation(s): Facility's transfer switch panel caught fire. Investigation Methods: Sample: Total residents: 77 Resident sample size: 77 Closed records sample size: Observations: Residents Interviews: Maintenance staff Staff Fire Marshal Record Reviews: Fire Marshal inspection reports Facility policies Characteristic roster Investigation Summary: Interview and record review showed that a fire occurred at the facility. The facility did not follow their emergency preparedness plan. The Washington State Patrol Fire Protection Bureau cited the facility for two violations: failing to notify the fire department and unable to provide documentation on fire watch. Failed facility practice identified for 388-78A-2040(1). 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.

Residential Care Services Investigation Summary Report Provider/Facility: GUARDIAN ANGEL Provider Type: Assisted Living Facility HOMES (THE COTTAGE) License/Cert.#: 1513 Intake ID: 150997 Compliance Determination #: 49474 Region/Unit #: RCS Region 1 / Unit G Investigator: Melissa Milanez Investigation Date(s): 10/30/2024 through 11/07/2024 Complainant Contact Date(s): Allegation(s): Resident fall with injury. Investigation Methods: Sample: Total residents: 67 Resident sample size: 4 Closed records sample size: Observations: Identified resident Residents Activities Dining Resident care equipment Resident rooms Staff to resident interactions Resident to resident interactions Outside secured courtyard Interviews: Identified resident Identified staff Nursing staff Residents Family members Record Reviews: Medical records State reporting log Incident investigation Facility policies Personnel files Staff training records Staff patterns Investigation Summary: Observations, interviews and record review showed that the facility did not provide the care and services as agreed upon in the Negotiated Service Agreement (NSA). Failed practice identified. See the Statement of Deficiency dated 11/07/2024 for This document was prepared by Residential Care Services for the Locator website. implementation of negotiated service agreement, Washington Administrative Code WAC 388- 78a-2160. Observations showed uneven walkways for residents. The facility was aware of safety issues and have started making repairs. Failed practice identified. Consultation was written for WAC 388-78a-2138 (2)(iv) Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website.

This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website.

—: WA DSHS report: Investigations (04/2024)

This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: GUARDIAN ANGEL Provider Type: Assisted Living Facility HOMES (THE COTTAGE) License/Cert.#: 1513 Intake ID: 98453 Compliance Determination #: 29947 Region/Unit #: RCS Region 1 / Unit G Investigator: Melissa Milanez Investigation Date(s): 09/22/2023 through 10/10/2023 Complainant Contact Date(s): Allegation(s): Identified resident reported mental, physical and sexual abuse. Investigation Methods: Sample: Total residents: 71 Resident sample size: 7 Closed records sample size: Observations: Environment, cares, residents, resident rooms, staff availability and response to resident's needs, staff to resident interactions. Interviews: Residents, staff, and others associated with the facility. Record Reviews: Characteristic roster, Resident Records (Face sheet, Assessment, Care Plan, Progress Notes, Physician orders), facility policies, investigation reports, staff schedules, staff phone list, staff records. Investigation Summary: Observation, interview, and record review showed that the named resident reported to a caregiver that they had been sexually abused by a named staff member. The named resident showed that they did not feel safe and had concerns that the alleged perpetrator would be back to harm them. Interviews and record review showed that a thorough investigation was not completed, and resident were not kept safe during the investigation. Deficient practice identified, see the statement of deficiency for failing to thoroughly investigate, determine the circumstances of the event, and failed to protect all residents during the investigation WAC 388- 78A-2371 dated 10/10/2023. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 1200 Alder Street, Union Gap, WA 98903 Statement of Deficiencies License #: 1513 Compliance Determination # 29947 Plan of Correction GUARDIAN ANGEL HOMES (THE COTTAGE) Completion Date Page 1 of 4 Licensee: CAMP I RICHLAND REAL ESTATE HOLDING CO, LLC 10/10/2023 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 09/22/2023 and 09/22/2023 of: GUARDIAN ANGEL HOMES (THE COTTAGE) 245 Van Giesen St Richland, WA 99354 This document references the following complaint number(s): 98453 The following sample was selected for review during the unannounced on-site visit: 7 of 71 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Melissa Milanez, Community Complaint Investigator From: DSHS, Aging and Long-Term Support Administration Residential Care Services, Region 1 , Unit G 1200 Alder Street Union Gap, WA 98903 As a result of the on-site visit(s), the department found that you are not in compliance with the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. 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. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 1513 Compliance Determination # 29947 Plan of Correction GUARDIAN ANGEL HOMES (THE COTTAGE) Completion Date Page 2 of 4 Licensee: CAMP I RICHLAND REAL ESTATE HOLDING CO, LLC 10/10/2023 Administrator (or Representative) Date WAC 388-78A-2371 Investigations. The assisted living facility must: (1) Investigate and document investigative actions and findings for any alleged or suspected abuse, neglect, or financial exploitation; or accident or incident jeopardizing or affecting a resident health or life; (2) Determine the circumstances of the event; (4) Protect residents during the course of the investigation. This requirement was not met as evidenced by: Based on observation, interview, and record review, the Assisted Living Facility (ALF) failed to thoroughly investigate, determine the circumstances of an allegation of abuse for 1 of 7 residents (Resident 1) and failed to protect Resident 1 and other residents who resided in the ALF during the investigation. These failures placed the residents at risk of abuse and at risk of receiving care from an alleged perpetrator. Findings included… Record review of the facility’s policy titled, “Prevention of Abuse,” dated as 2022, showed the Community has designated the Administrator as the person responsible for internally receiving the reports of resident abuse, including physical and sexual assault, neglect, abandonment, financial exploitation and to also promote the safety and well-being of their residents. If upon receiving a report of the above, an employee has been named as the person who may have committed the act, that employee will not be permitted to have any resident contact until the community completes the investigation and both the community and the Department of Social and Health Services are satisfied that the resident will be safe if the employee returns. The community has designated the Administrator as the person responsible for promptly initiating the investigation. Interview on 09/22/2023 at 12:58 PM, Staff A, Administrator, stated that they received a phone call regarding an allegation Resident 1 made of sexual abuse on 09/15/2023. Staff A stated they did not have an investigation report put together for the sexual abuse allegation but did not think it had happened because the Resident 1 had made similar accusations in the past. Staff A also confirmed that they had not reported the incident to the Department. Interview on 09/22/2023 at 1:05 PM, with Staff B, Health and Wellness Director, stated that This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 1513 Compliance Determination # 29947 Plan of Correction GUARDIAN ANGEL HOMES (THE COTTAGE) Completion Date Page 3 of 4 Licensee: CAMP I RICHLAND REAL ESTATE HOLDING CO, LLC 10/10/2023 Resident 1 was alert and able to make their needs known. Additionally, Staff B stated that this was not the first time that Resident 1 had made these types of accusations but stated there was nothing to show in the Resident 1’s records or history of similar allegations. Staff B stated that they had just become aware of bruising to Resident 1’s breast and had not been previously aware of bruising. Because of this, Staff B had not yet completed a skin and body assessment of Resident 1. Staff B stated they only became aware of the bruising because a different investigative authority informed Staff A of the bruising on 09/21/2023. Interview on 09/22/2023 at 1:54 PM with Staff C, Caregiver, stated that they had not been interviewed by Staff A or other administrative staff regarding the incident (allegation of abuse) on 09/15/2023. Staff C stated that Resident 1 had been telling them for two weeks that a tall man had been entering their room and touching their breast, but that they had not told anyone about the allegations because they were new to working with the resident and was not sure if they had Dementia (memory loss). Staff E also stated that prior to this incident Resident 1 spent most of their time in their room alone but had noticed a recent change in behavior. They stated that Resident 1 had stated they were scared to be alone because a tall man had touched their breasts. Staff C stated that now Resident 1 spent most of their time with other residents in the common area. Interview and observation on 09/22/2023 at 2:07 PM, Resident 1, was observed sitting in the living room area with other residents, watching television. Resident 1 stated that there was a tall, skinny man, that always wore a black cap that worked at the facility who grabbed their breasts and told them they would be back to rape them. Additionally, they stated that they had told a staff member about the incident the night it happened, but they did nothing about it. Resident 1 also stated that they had bruises on their breast. They also stated that they were afraid at night because they had saw the same man at their window. Interview on 09/22/2023 at 2:24 PM with Staff D, Caregiver, stated that on 09/15/2023 they reported to Staff A abuse allegations that had been reported to them by Resident 1. Staff D stated that they had not been asked to write down their statement until 09/22/2023 as they arrived to work that evening shift and prior to speaking on this interview. Staff D stated that they reported to Staff A that Resident 1 had stated to them that on several occasions a tall, skinny man carrying a red jug, wearing a cap and all black had entered their room and touched their breast. Staff C also stated that Resident 1 stated that the unidentified man threatened them that they would return. Staff C stated they observed the bruises on Resident 1’s breasts and had taken pictures for another investigative authority but did not report it to Staff A because it was the end of their shift. Interview on 10/09/2023 at 3:46 PM, Staff B, Caregiver/alleged perpetrator confirmed that they worked from 10:00 PM through 6:00 AM the night of 09/15/2023 (the day after the alleged incident). Staff B also confirmed that they entered Resident 1’s place of residence after the alleged allegations unfolded to assist another caregiver providing care to another resident. Staff B stated that they did not feel comfortable re-entering the unit, but that they had been the only float person available that night and needed to assist another caregiver with a two-person resident brief change. Staff B confirmed that they were never told to not enter the house. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 1513 Compliance Determination # 29947 Plan of Correction GUARDIAN ANGEL HOMES (THE COTTAGE) Completion Date Page 4 of 4 Licensee: CAMP I RICHLAND REAL ESTATE HOLDING CO, LLC 10/10/2023 Interview on 09/22/2023 at 4:26 PM, Staff A, confirmed that Staff B was allowed to work the rest of their shift and stated that they did not do additional interviews with other residents to see if anyone else had been potentially abused, nor had written statements from staff members who had awareness of the allegations. Staff A acknowledged that they had not completed a thorough investigation that they had “messed up,” and felt terrible about it. Staff A stated they did not implement the ALFs abuse investigative procedures because they did not think that the incident had occurred. 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, GUARDIAN ANGEL HOMES (THE COTTAGE) 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.

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 1200 Alder Street, Union Gap, WA 98903 CAMP I RICHLAND REAL ESTATE HOLDING CO, LLC GUARDIAN ANGEL HOMES (THE COTTAGE) 245 VAN GIESEN ST RICHLAND, WA 99352 RE: GUARDIAN ANGEL HOMES (THE COTTAGE) License# 1513 Dear Administrator: This letter addresses Compliance Determination(s) 28600 (Completion Date 08/21/2023) and 26724 (Completion Date 07/18/2023). The Department completed a follow-up inspection of your Assisted Living Facility on 08/21/2023 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-2450-2-b, WAC 388-78A-24701-1, WAC 388-78A-2484-1, WAC 388-78A-2484- 2, WAC 388-78A-2484, WAC 246-980-030-1-b, WAC 388-78A-2140-1-a-ii, WAC 388-?SA- 2140-1-c, WAC 388-78A-2160, WAC 388-?BA-2210-1-b The Department staff who did the on-site verification: Anna Cairns, ALF Long Term Care Surveyor If you have any questions, please contact me at (509)208-5231. Sincerely, Gwin Kaercher, Field Manager Region 1, Unit G Residential Care Services This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: GUARDIAN ANGEL Provider Type: Assisted Living Facility HOMES (THE COTTAGE) License/Cert.#: 1513 Intake ID: 86640 Compliance Determination #: 26724 Region/Unit #: RCS Region 1 / Unit G Investigator: Tracy Ramirez Investigation Date(s): 07/10/2023 through 07/18/2023 Complainant Contact Date(s): Allegation(s): The facility had one staff member that provided care to the named resident that required a two- person assist. Investigation Methods: Sample: Total residents: 71 Resident sample size: 9 Closed records sample size: 0 Observations: The facility’s common areas, resident rooms, resident to resident and staff to resident interactions were observed. Interviews: Facility staff, sampled residents, and others not associated with the facility. Record Reviews: Resident characteristic roster, resident records (face sheets, care plans, progress notes, medication administration records, change and service plans (temporary service plan), incident/investigation, and staff records. Investigation Summary: The facility failed to implement two-person cares as indicated in the Negotiated Service Agreement and failed practice identified WAC 388-78A-2160. Reference Statement of Deficiencies (SOD) 07/18/2023. 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 HEAL TH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 1200 Alder Street, Union Gap, WA 98903 CAMP I RICHLAND REAL ESTATE HOLDING CO, LLC GUARDIAN ANGEL HOMES (THE COTTAGE) 245 VAN GIESEN ST RICHLAND, WA 99352 RE: GUARDIAN ANGEL HOMES (THE COTTAGE)# 1513 Dear Administrator: This document references the following complaint numbers 86640. The Department completed a full inspection of your Assisted Living Facility on 07/18/2023 and found that your facility does not meet the Assisted Living Facility requirements. The Department: • Wrote the enclosed report; and • May take licensing enforcement action based on many deficiency listed on the enclosed report; and • May 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. You Must: • Begin the process of correcting the deficiency or deficiencies immediately; • Contact the Field Manager for clarifications related to the Statement of Deficiencies (SOD); • Within 10 calendar days after you receive this letter, complete and return the enclosed 'Plan/Attestation Statement'; o Sign and date the enclosed 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: Gwin Kaercher, Field Manager Residential Care Services This document was prepared by Residential Care Services for the Locator website. GUARDIAN ANGEL HOMES (THE COTTAGE)# 1513 07/18/2023 Page 2 of 3 Region 1, Unit G 1200 Alder Street Union Gap, WA 98903 • 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-2620 Pets. If an assisted living facility allows pets to live on the premises, the assisted living facility must: (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 Assisted Living Facility failed to ensure current pet immunization and examination records were maintained at the facility for one pet in the home. 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: IDR Program Manager Department of Social and Health Services Aging and Long-Term Support Administration Residential Care Services PO Box45600 Olympia, WA 98504-5600 This document was prepared by Residential Care Services for the Locator website. GUARDIAN ANGEL HOMES (THE COTTAGE)# 1513 07/18/2023 Page 3 of 3 If You Have Any Questions: • Please contact me at (509)208-5231. Sincerely, q~/;~ ~win Kaercher, Field Manager Region 1, Unit G Residential Care Services Enclosure 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 1200 Alder Street, Union Gap, WA 98903 Statement of Deficiencies License#: 1513 Compliance Determination# 26724 Plan of Correction GUARDIAN ANGEL HOMES (THE COTTAGE) Completion Date Page 4 of 15 Licensee: CAMP I RICHLAND REAL ESTATE 07/18/2023 You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for the unannounced on-site full inspection and complaint investigation on 07/10/2023, 07/11/2023, 07/12/2023 and 07/13/2023 of: GUARDIAN ANGEL HOMES (THE COTTAGE) 245 Van Giesen St Richland, WA 99354 This document references the following complaint numbers: 86640. The following sample was selected for review during the unannounced on-site visit: 9 of 71 current residents and O former residents. The department staff that inspected the Assisted Living Facility: Tracy Ramirez, Assisted Living Facility Licensor Anna Cairns, ALF Long Term Care Surveyor Elaine Lopez, Licensor Robin Rainville, Assisted Living Facility Licensor From: DSHS, Aging and Long-Term Support Administration Residential Care Services, Region 1 , Unit G 1200 Alder Street Union Gap, WA 98903 As a result of the on-site visit(s) the department found that you are not in compliance with the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. 07/27/2023 sidential Care Services Date This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License#: 1513 Compliance Determination# 26724 Plan of Correction GUARDIAN ANGEL HOMES (THE COTTAGE) Completion Date Page 5 of 15 Licensee: CAMP I RICHLAND REAL ESTATE 07/18/2023 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. WAC 388~78A-2450 Staff. (2) The assisted living facility must: (b) Verify staff persons' work references prior to hiring; This requirement was not met as evidenced by: Based on interview and record review. the Assisted Living Facility (ALF) failed to ensure that staff that were hired had professional work references verified prior to hiring for 1 of 1 Supplemental Staff (G). This failure placed residents at risk of being cared for by unqualified staff. Findings included ... Staff records were reviewed with Staff H, Business Office Manager, and Staff I, Staffing Director, on 07/11/2023 at 3:00 PM. Review of staff records showed that Staff G, Supplemental Staff no longer employed at the ALF, was hired as a caregiver on 05/30i2023. Staff G's file did not have three professional references that were verified by the facility. On 07/11/2023, Staff H, Business Office Manager, stated they attempted to call Staff G's references one time and did not receive any calls back from their references. Staff H stated that Staff G was hired and allowed to work unsupervised, without professional references being verified. 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, GUARDIAN ANGEL HOMES (THE COTTAGE) is or will be in compliance with this law and/ or regulation on t] ?,/~'i>:J-3 . (Date) In addition, I will implement a system to monitor and ensure continued compliance with this requirement. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License#: 1513 Compliance Determination# 26724 Plan of Correc,iion GUARDIAN ANGEL HOMES (THE COTT AGE) Completion Date Page 6 of 15 Licensee: CAMP I RICHLAND REAL ESTATE 07/18/2023 Administrator (or Representative} WAC 388-78A-24701 Background checks Employment Nondisqualifying information. (1) If the background check results show that an employee or prospective employee has a criminal conviction or pending charge for a crime that is not a disqualifying crime under chapter 388-113 WAC, then the assisted living facility must determine whether the person has the character, competence and suitability to work with vulnerable adults in long-term care. This requirement was not met as evidenced by; Based on interview and record review, the Assisted Living Facility (ALF) failed to complete a review to determine if 1 of 1 Supplemental Staff (G), with non-disqualifying background check results, had the character, competency, and suitability (CCS) to work with the vulnerable adults who resided at the facility. This failure placed the residents at risk for abl1se from being cared for by staff members who were not appropriate to work with vulnerable adults. Findings included ... Staff records were reviewed with Staff H, Business Office Manager, and Staff I, Staffing Director, on 07/11/2023 at 3:00 PM. Staff Hand Staff I stated ihat they were responsible for ensuring that a CCS review was completed when required. Review of staff records showed that Staff G, Supplemental Staff no longer employed at the ALF, was hired as a caregiver on 05/30/2023. The file for Staff G showed a fingerprint background check result dated 06/15/2023, which indicated that a CCS review was required. Staff G's file did not show that a CCS review was completed as required. On 07/11/2023 at 3:50 PM, Staff Hand Staff I stated that they had not completed a CCS that was required for Staff G. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measuCreOsT toT ct:oErr)e ct this deficiency. By taking this action, GUARDIAN ANGEL HOMES (THE is or will be in compliance with this law and/ or regulation on <Z~I 2:'0r-3 . (Date) In addition. I will implement a system to monitor and ensure continued compliance with this requirement. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License#: 1513 Compliance Determination# 26724 Plan of Correction GUARDIAN ANGEL HOMES (THE COTTAGE) Completion Date Page 7 of 15 Licensee: CAMP I RICHLAND REAL ESTATE 07/18/2023 ······-··iJ. . a1_.cr1)__d::-3_ _ _ Date 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. This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure the initial screening for Tuberculosis (TB) was completed within three days of hire for 1 of 3 Staff (C) and failed to ensure that the second step Skin Test was completed within one to three weeks of the First Step TB test for 1 of 3 Staff (B), hired since the last full inspection. This failed practice placed residents at risk of potential exposure of a communicable disease. Findings included ... Staff records were reviewed with Staff H, Business Office Manager, and Staff I, Staffing Director, on 07/11/2023 at 3:00 PM. Staff Hand Staff I stated that they were responsible for tracking TB testing. Staff B, Caregiver, was hired 08/29/2022. Staff B's file showed a first step TB test done on 08/29/2022. The file showed that there was not a Two-Step TB test completed within one to three weeks of the One-Step TB test. On 07/11i2023 at 3:50 PM. Staff Hand Staff I stated that there was not a Two-Step TB test completed for Staff B due to staff non-compliance with testing. -Staff C, Caregiver. was hired 01/23/2023. Staff C's file showed that there was not an initial TB test completed. On 07/11/2023 at 3:50 PM, Staff Hand Staff I stated that there was not an initial TB test completed within 3 days of hire for Staff C. They stated that the initial TB test was initiated 07/1112023, 169 days after they were hired. Plan/Attestation Statement This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 1513 Compliance Determination # 26724 Plan of Correction GUARDIAN ANGEL HOMES (THE COTTAGE) Completion Date Page 8 of 15 Licensee: CAMP I RICHLAND REAL ESTATE 07/18/2023 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, GUARDIAN ANGEL HOMES (THE COTTAGE) is or will be in compliance with this law and/ or regulation on cg\?\ 20'.l-?.? . (Date) In addition, I will implement a system to monitor and ensure continued compliance with this requirement. ~ -.~I . 3Ja v~,=::, ··-· ... ··-··· ·····-·--·--· Administrator (or Representative) Date WAC 246#980-030 Can a nonexempt long-term care worker work before obtaining certification as a home care aide? (1) A nonexempt longNterm care worker may provide care before receiving certification as a home care aide if all the following conditions are met: (b} The long-term care worker must submit an application for home care aide certification to the department within fourteen calendar days of hire. An application is considered to be submitted on the date it is post-marked or, for applications submitted in person or online, the date it is accepted by the department. This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure that a Horne Care Aide (HCA) application was sent to the department within 14 days of hire for 1 of 1 Supplemental Staff (G), who had provided unsupervised care to the residents in the facility. This failure placed residents at risk of being cared for by unqualified staff and disallowed the department from the ability to track and monitor home care aide applicants. Findings included ... Staff records were reviewed with Staff H, Business Office Manager, and Staff I, Staffing Director, on 07/11/2023 at 3:00 PM. Staff Hand Staff I stated that they were responsible for ensuring HCA applications were submitted within 14 days. Review of staff records showed that Staff G, Supplemental Staff no longer employed at the ALF was hired on 05/30/2023 as a caregiver. Staff G's file did not include an HCA application that was submitted to the department within 14 days of hire. On 07/11/2023 at 3:55 PM, Staff I stated that the HCA application for Staff G was not mailed to the department Plan/Attestation Statement This document was prepared by Residential Care Services for the Locator website. Statement ot Deficiencies License#: 1513 Compliance Determination# 26724 Plan of Correction GUARDIAN ANGEL HOMES (THE COTT AGE) CompJetion Date Page 9 of 15 Licensee: CAMP I RICHLAND REAL ESTATE 07118/2023 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. GUARDIAN ANGEL HOMES (THE COTTAGE) is or will be in compliance with this law and I or regulation on '<{?;\ (Date) ~:O . In addition, I will implement a system to monitor and ensure continued compliance with this requirement ··-··-·--····~-l~.L~.~ ----····· Date WAC 388-78A-2140 Negotiated service agreement contents. The assisted living facility must develop, and document in the resident's record, the agreed upon plan to address and support each resident's assessed capabilities, needs and preferences, including the following: (1) The care and services necessary to meet the resident's needs, including: (a) The plan to monitor the resident and address interventions for current risks to the resident's health and safety that were identified in one or more of the following: (ii) The resident's full assessments: (c) The plan to provide necessary intermittent nursing services, if provided by the assisted living facility; This requirement was not met as evidenced by; Based on observation, interview and record review, the Assisted Living Facility (ALF) failed to ensure Negotiated Service Agreements (NSAs) were developed with a documented plan to provide clearly defined roles and responsibilities to meet the assessed needs for 5 of 6 Residents (1, 4, 5. 6, 7) who required monitoring, interventions, and nursing services. This failure placed the residents at risk of unmet needs and complications of their chronic health conditions. Findings included ..• Resident 1 Record review of Resident 1·s assessment and NSA dated 01/12/2023 showed that the resident had diagnoses which included , and they were on hospice (end of life care). Record review of the April 2023 through July 2023 Medication Administration Record (MAR} This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License#: 1513 Compliance Determination# 26724 Plan of Correction GUARDIAN ANGEL HOMES (THE COTT AGE) Completion Date Page 10 of 15 Licensee: CAMP I RICHLAND REAL ESTATE 07/18/2023 for Resident 1 showed that the resident was on the following medication: Morphine Sulfate (for pain). Depakote (to prevent seizures), and Digoxin (for heart disease). Resident 1 's July 2023 NSA did not contain direction for staff of what to monitor for related to the resident's significant diagnoses and medications. The NSA did not address Resident 1's seizures and pain control. Additionally, the NSA did not provide direction to the staff regarding what the facility staff were responsible for and what hospice was responsible for. Resident 4 On 07/12/2023 at 2:35 PM, Resident 4 stated that the staff helped them with their medication which included insulin injections (a medication ta regulate blood sugar), checked their blood sugar levels, and gave them snacks wtien their blood sugar was too low. Record review of Resident 4's assessment and NSA dated 05/09/2023 showed that the resident had diagnoses which included , and . Additionally, the NSA showed that Resident 4 had a pacemaker (an implanted device to regulate the heart rate). Resident 4's April through July 2023 MA Rs showed that the resident required insulin injections and blood sugar checks twice daily. The MARS also showed that Resident 4 took mo different medications to prevent blood clots (which increases the risk of uncontrolled bleeding) as well as three medications to regulate blood pressure and heart function. Resident 4's NSA did not contain direction for staff of what to monitor for related to the resident's significant diagnoses and medications. The NSA did not provide direction to the staff regarding special care needs for the resident with their pacemaker or who was responsible for monitoring the function of the pacemaker. Resident 5 Resident S's 05/08/2023 NSA showed that the resident had diagnoses which included , and was on a blood thinner medication. The most recent physician orders in Resident S's chart dated 12/08/2022 showed that the resident was on a blood thinner medication as well as medication to prevent seizures. The orders also showed that Resident 5 was allergic to cinnamon. On 07/11/2023 at 3:36 PM, Resident 5 stated that the staff helped them with their medications and daily care needs. Resident 5 also stated that their allergy to cinnamon This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 1513 Compliance Determination # 26724 Plan of Correction GUARDIAN ANGEL HOMES (THE COTT AGE) Completion Date Page 11 of 15 Licensee: CAMP I RICHLAND REAL ESTATE 07f18/2023 resulted in a rash to their skin if it was eaten. Resident S's NSA did not show direction for the staff on what a seizure looked like for Resident 5, or for what to do if the resident had a seizure. The NSA did not include information for what to monitor related to the resident's blood thinner medication. Additionally, the NSA did not show what the allergic reaction to cinnamon was for Resident 5. Resident 6 On 07/12/2023 at 11:37 AM, Resident 6 was observed in their recliner, wearing black gloves on their hands, and a dressing was visible on their right lower leg. A Collateral Contact (CC1), Resident Representative, for Resident 6 was present and stated that the gloves prevented the resident from scratching their fragile skin. CC1 also stated that Resident 1 had a wound on their leg which an outside Home Health (HH) agency was treating. Record review of Resident 6's 06/21/2023 NSA showed that the resident had diagnoses of , and was on a blood thinner medication which required frequent blood tests to monitor therapeutic levels. The NSA showed that the resident was at risk of skin injury due to their blood thinner use. Review of Resident 6's progress notes showed that on 06/05/2023 the HH agency provided wound care and tested the resident's blood thinner levels. Resident 6's record showed a 06/09/2023 doctor's order to have the HH agency recheck the blood thinner medication level in two weeks. A 06/21/2023 progress note in Resident 6's record showed that the resident was due for a blood thinner medication level test the day prior. The note showed that the facility did not have a way to perform the test there, so it was not done. On 07/12/2023 at 4:40 PM, Staff F, Licensed Practical Nurse, stated that they did not know why the resident's home health agency did not do the blood thinner medication level test. Resident 6's NSA did not include directions for who was responsible to manage the blood thinner level testing, did not contain direction for staff of what to monitor for significant diagnoses and medications, or for what to do if the resident experienced unusual bleeding. Additionally. the NSA did not show that the staff were to ensure the resident had gloves on daily to protect their skin, nor did the NSA direct the staff on what to monitor for regarding Resident 6's right lower leg wound. Resident 7 This document was prepared by Residential Care Services for the Locator website. S1atement of Deficiencies License#: 1513 Compliance Delermination # 26724 Plan of Correction GUARDIAN ANGEL HOMES (THE COTTAGE) Completion Date Page12of15 Licensee: CAMP I RlCHLAND REAL ESTATE 07/18/2023 On 07/11/2023 at 2:00 PM CC2, Resident Representative for Resident 7, stated that staff assisted the resident with their medication which included obtaining a blood sugar level and giving their insulin. Record review of Resident 7's assessment and NSA dated 05/03/2023 showed diagnoses which included , and . Additionally, the NSA showed that Resident 7 had a pacemaker. Review of Resident 7's current prescribed medication orders dated 03/31/2023 showed that the resident required insulin injections twice daily by staff The orders also showed the resident was on two oral (by mouth) medications for their diabetes. Resident Ts NSA did not contain direction for staff of what to monitor for related to the resident's significant diagnoses and medications. The NSA did not provide direction to the staff regarding special care needs and or who was responsible for monitoring the function of the pacemaker. 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, GUARDIAN ANGEL HOMES (THE COTTAGE) is or will be in compliance with this law and/ or regulation on 2 ¼/d ,o;,3 . (Date) In addition, I will implement a system to monitor and ensure continued compliance with this requirement. ...... 8[ 7.>I ?-0~3 .· -··········- Administrator (or Representative) oate 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 observation. interview and record review, the Assisted Living Facility (ALF) failed to provide two-person staff during care per the Negotiated Service Agreements (NSA's) for 1 of 6 Residents (1) who required two-person assistance with personal care. This failure contributed to a fall from the bed resulting in injuries. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License#: 1513 Compliance Determination# 26724 Plan of Correction GUARDIAN ANGEL HOMES (THE COTTAGE) Completion Date Page 13 of 15 Licensee: CAMP I RICHLAND REAL ESTATE 07/18/2023 Findings included ... Review of the record showed Resident 1 admitted on /2021, with diagnosis of , and they were on hospice {end of life care). The NSA showed that the resident was bedbound and required two person assistance for personal cares. On 07/12/2023 at 12:15 PM Resident 1 stated that "a couple weeks ago" a staff member tried to assist with care, dropped them off the bed, and were not strong enough to get them off the floor. Resident 1 stated there should have been tvvo staff helping, but there was only one. Record review of the facility's investigation dated 06/22/2023 showed that Resident 1 had been dropped during a brief change on 06/19/2023 when Staff G, Caregiver, was the only staff assisting the resident. Two staff were not present for Resident 1 's care needs as shown in the NSA Record review of an incident report dated 06/20/2023 showed that Resident 1 had a skin tear on their right elbow, a scratch on their left arm, abrasions on the top of their toes, and the resident was complaining of pain. The resident was given morphine (narcotic pain medication). The report showed that Resident 1 stated they were thrown to the floor last night, there was a new staff not paying attention, they were rolling them to get them into position. On 07/10/2023 at 11 :15 AM Staff A, Administrator, stated that Resident 1 was a two-person assist and was dropped from their bed, while being repositioned, when only one staff assisted with 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, GUARDIAN ANGEL HOMES (THE CO¥AGE) is or will be in compliance with this law and / or regulation on ~l?;) \ ~3, . (Date) In addition, I will implement a system to monitor and ensure continued compliance with this requirement. ~~ Administrator (or Representative) WAC 388-78A-2210 Medication services. (1) An assisted lfving facility providing medication service, either directly or indirectly, must This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 1513 Compliance Determination # 26724 Plan of Correction GUARDIAN ANGEL HOMES (THE COTTAGE) Completion Date Page 14 of 15 Licensee: CAMP I RICHLAND REAL ESTATE 07/18/2023 (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 Assisted Living Facility (ALF) failed to ensure that doctor's orders were followed, and residents received medications and/or blood tests as prescribed, for 2 of 9 Residents (4, 6) who required medication assistance. This failure placed the residents at risk of adverse effects and complications of their health conditions. Findings included ... Resident 4 Review of Resident 4's record showed a 05/26/2023 doctor's order for an antibiotic medication to be given twice daily for ten days for a total of 20 doses, to treat an acute respiratory infection. Review of Resident 4's Medication Administration Records (MARS) showed that the medication was started on 05/27/2023 in the evening. The MARS showed that the medication was stopped after the morning dose on 06/01/2023, which indicated that only ten doses had been given, over a span of five days. In an interview on 07/13/2023 at 10: 15 AM with Staff F, Licensed Practical Nurse (LPN), they stated that they had discontinued the order for the antibiotic because tt,e Medication Technician (MT) had told them there was no more medication in the cart, so the course was completed. Staff F, LPN, stated that they checked the medication cart on 07/13/2023 and realized that the antibiotic medication was still in the cart, and that they had just trusted that the MT was right when they said that the medication course was completed. Staff F, LPN, stated that Resident 4 received only five days of their antibiotic. and not the ten days that were ordered. Resident 6 Record review of Resident 6's 06/21/2023 Negotiated Service Agreement (NSA) showed that the resident had diagnoses of and and was on a blood thinner medication which required frequent international nonnalized ratio (INR) blood tests to monitor therapeutic levels. Review of a 04/06/2023 doctor's order in Resident 6's record showed that an INR was done that day and needed to be repeated in one month. Resident 6's record did not show that an INR had been done in May 2023, one month from the previous test. as ordered. This document was prepared by Residential Care Services for the Locator website. statement of Deficiencies License#: 1513 Compliance Determination# 26724 Plan of Correction GUARDIAN ANGEL HOMES (THE COTTAGE) Completion Date Page 15 of 15 Licensee: CAMP I RICHLAND REAL ESTATE 07118/2023 On 07/13/2023 at 11:23 AM, Staff F, LPN, stated that they could not find documentation of the INR • test for May 2023; it was not done. Resident 6's record showed that the Home Health (HH) agency did an INR test on 06/05/2023. The result was low and not in range, compared to the previous INR. Resident 6's record showed that their doctor sent an order on 06/09/2023 to change the dose of the resident blood thinner as a result of the INR done on 06/05/2023. The order stated to have the HH agency recheck the blood thinner level in two weeks. A 06/21/2023 progress note in Resident 6's record showed that the resident was due for a blood thinner level test the day prior, but the facility did not have a way to perform the test there, so ilwas not done. On 07/12/2023 at 4:40 PM, Staff F, LPN, stated that they did not know why the resident's HH agency did not do the INR test. 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. GUARDIAN ANGEL HOMES (THE COTTAGE} is or will be in compliance with this law and/ or regulation on 't/ I (Date) 1, '?10'2....". ) . tn addition, I will implement a system to monitor and ensure continued compliance with this requirement -··-··~I ::,Jun.,3 ······----.. ·· --···············-······•···-- ~ . Administrator (or Representative) Date This document was prepared by Residential Care Services for the Locator website.