Aegis of Queen Anne at Rodgers Park.

Residential Care Services Investigation Summary Report Provider/Facility: Aegis of Queen Anne at Provider Type: Assisted Living Facility Rodgers Park License/Cert.#: 2381 Intake ID: 137782 Compliance Determination #: 43812 Region/Unit #: RCS Region 2 / Unit J Investigator: Cathy Prentice Investigation Date(s): 07/09/2024 through 07/26/2024 Complainant Contact Date(s): 07/10/2024, 07/29/2024 Allegation(s): The named resident called for help with toileting and no one came. Staff was called and told the named resident to go to the bathroom in their brief and the staff would clean it up later because they were busy. Investigation Methods: Sample: Total residents: 76 Resident sample size: 3 Closed records sample size: 0 Observations: Named resident; delivery of care and services; staff interactions with residents; residents' appearance; environment Interviews: Named resident, other residents, staff, administration, collateral contacts. Record Reviews: Resident care records, Assessment, Negotiated Service Agreement (NSA), investigations, grievances, facility policies, other pertinent records. Investigation Summary: Observation, interview and record review showed, the facility completed an Assessment and Negotiated Service Agreement for the named resident as required. The facility completed a thorough investigation and substantiated that a staff caregiver told the named resident she was busy in the dining room and the named resident could be incontinent in the brief and she would return to clean up. According to the facility investigation, the caregiver returned and assisted the named resident to the bathroom and changed the soiled brief approximately 34 minutes after the initial call from the named resident. The facility terminated the staff member and provided all staff training. The facility failed to assure the caregiver had the required 70 hours of Basic Long Term Care training placing residents at risk of harm from care staff who was untrained. The named resident and other residents interviewed stated they felt safe at the facility. This document was prepared by Residential Care Services for the Locator website. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A 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.

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 20311 52nd Ave W, Suite 100, Lynnwood, WA 98036 Aegis Senior Communities LLC Aegis of Queen Anne at Rodgers Park 2900 3rd Ave W Seattle, WA 98119 RE: Aegis of Queen Anne at Rodgers Park License# 2381 Dear Administrator: This letter addresses Compliance Determination(s) 51688 (Completion Date 12/16/2024) and 47206 (Completion Date 10/14/2024). The Department completed a follow-up inspection of your Assisted Living Facility on 12/16/2024 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-2100-2-b-ii, WAC 388-78A-2140-1-a-iii, WAC 388-78A-2140-2-a, WAC 388-78A- 2140-2-b, WAC 388-78A-2140-2, WAC 388-78A-2140-5, WAC 388-78A-2210-1-b, WAC 388- 78A-2210-2-a, WAC 388-78A-2210-2-b, WAC 388-78A-2210-2, WAC 388-78A-2230-1-c-i, WAC 388-78A-2230-1-c-ii, WAC 388-78A-2230-1-c, WAC 388-78A-2230-2-b, WAC 388-78A-2230-2- a, WAC 388-78A-2320-1-b, WAC 388-78A-2320-3-c, WAC 388-78A-2320-2-b, WAC 388-78A- 2600-1-b, WAC 388-78A-2600-1-a, WAC 388-78A-2600-2-n, WAC 388-78A-3100-1, WAC 388- 78A-3100-2, WAC 388-78A-2120-1, WAC 388-78A-2120-2-a, WAC 388-78A-2120-2-b, WAC 388-78A-2120-2, WAC 388-78A-2240, WAC 388-78A-2305-1 The Department staff who did the on-site verification: Keiko Kitano, Licensor Alma Duran, Licensor If you have any questions, please contact me at (253)312-1446. r s m r Sincerely, This document was prepared by Residential Care Services for the Locator website. Aegis of Queen Anne at Rodgers Park# 2381 12/16/2024 Page 2 of2 Jamie Singer, Field Manager Region 2, Unit J Residential Care Services Residential Care Services Investigation Summary Report Provider/Facility: Aegis of Queen Anne at Provider Type: Assisted Living Facility Rodgers Park License/Cert.#: 2381 Intake ID: 145151 Compliance Determination #: 47206 Region/Unit #: RCS Region 2 / Unit J Investigator: Keiko Kitano Investigation Date(s): 09/10/2024 through 10/14/2024 Complainant Contact Date(s): Allegation(s): The named resident (NR) developed a pressure wound. The NR’s pressure wound went from being Stage 2 to Stage 3 which led to hospitalization. Investigation Methods: Sample: Total residents: 100 Resident sample size: 10 Closed records sample size: Observations: The Assisted Living Facility’s (ALF) environment, staff and residents’ interaction Interviews: Administrative staff members, a licensed nurse, caregivers Record Reviews: Incident investigative document, resident’s records, the ALF's policies Investigation Summary: This investigation was conducted during the ALF’s licensing inspection. The Administrative staff members stated that a caregiver discovered an open wound on the NR’s buttocks. Licensed nurses assessed and monitored the NR’s wound. LNs had contacted the NR’s physician for treatment. The ALF followed the physician’s order for wound care, but the NR’s wound went from Stage 2 to Stage 3. The ALF sent the NR to the hospital for further treatment. The ALF reported the NR’s skin conditions to the NR’s representative. However, staff interview and records review showed that non-licensed staff members had applied prescribed ointment to the NR’s open wound. The ALF did not follow their policy of wound care being done only by licensed staff. See citation 388-78A-2600 (1). (a).(b). 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 20311 52nd Ave W, Suite 100, Lynnwood, WA 98036 Licensee: Aegis Senior Communities LLC Aegis of Queen Anne at Rodgers Park 2900 3rd Ave W Seattle, WA 98119 RE: Aegis of Queen Anne at Rodgers Park License # 2381 Dear Administrator: The Department completed a full inspection and a complaint investigation of your Assisted Living Facility on 10/14/2024 and found that your facility does not meet the Assisted Living Facility licensing requirements. The Department: • Wrote the enclosed Statement of Deficiencies (SOD) report; and • May take licensing enforcement action based on any deficiency listed on the enclosed report; and • May inspect the facility to determine if you have corrected all deficiencies. 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 Next to each deficiency, sign and date certifying that you have or will correct each cited deficiency; and o Mail the Plan/Attestation Statement and report with original signatures to: This document was prepared by Residential Care Services for the Locator website. Aegis Senior Communities LLC Aegis of Queen Anne at Rodgers Park # 2381 10/14/2024 Page 2 of 26 Jamie Singer, Field Manager Residential Care Services Region 2, Unit J 20311 52nd Ave W, Suite 100 Lynnwood, WA 98036 • 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. You May: • Receive a letter of enforcement action based on any deficiency listed on the enclosed report. 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 Box 45600 Olympia, WA 98504-5600 If You Have Any Questions: • Please contact me at (253)312-1446. Sincerely, Jamie Singer, Field Manager Region 2, Unit J Residential Care Services Enclosure This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. 10.18.2024 15:09:14 State of Washington 3/27 STATE OF \"v.◄-~SHl:l~GT0f6-1 DEPARTk1Er·--JT OF SOCIAL AND HEALT H SER\/iCES A.G?Ju AND LO!--iG-TERM SUPPORT AD~W'~\STRAT!ON W3t1 52nd A.-~ W, Suite tG1l,.Lynnwood,. WA 98036 ~~t;3te.n~ent o1 L}ef1i:::tn~1~s L~cB·~::se tt-.1.JB1 Gon~pfH~~cB· L~~~'=rmin.3t:-on #4l2 0b P1an af C,),t8t!ion Ar:gis of Q~;een }\nne i3:t R.otlg~·JS Park C{~n1p;~~bon 0~1t1 U-;:.s11s'='a. ·Aegi<:;Sianioi· Comn-1,.ml!ies LLC H.)/14i2024 '{•iLr are requir;;:cl t,:i be in ·rnr~ipiim,c.e 4t i>II tirn;e,.;: ,... _,th <JH li::::e,fsing laws and regulations tG rnai:ntain '{G:i.,r As:s\sti:;d Uvi.n!..:i Faci,fity· lit;::nse Th1:: dep;2orYnent ,ci:mipl<.oted d:ata ,:cH:=cfo:wi foi trli= Ur,2.r,nn;_mc:::d :.:m-sit-1:: f:..111i nspe::::.ti;:in ar:d c:bfrip:lc~i:nt jnv·~sti~1~~tion · on 09/10/2024 Etnd ntu·1 :~t:?t124-uf. .li.:egis cf 'C)ue~n .Ann~ at fiod{Jers Park :}900 Jnj ~A\•·r~ \-~j . . Seattie. VVA. BB 1· 18 The foHc;N,ng s2,mp1e vwis s:~tected for review durinn th::: unannoun::::.ed Gn-site -.,nsit 1D of HJIJ currEnt resid~nts'"-8nd G fc'Jrtner r~sidents. tdm<: Duran, License=!· fZtil-<:o h:it:anct, Lh:;ensc! Fn::rn: OSHS, .~,£WlJ and L..ong-Terrn Si,pport Administrntwn R2:s1dential C.Jre, Scervices. Re,;iion 2 . Un.iU 20'3·; 1 S2nd A1,1e \/V, Suite ~ Oll L:/nnvvt1ocl_. \\/A f.H~OaG As<: r,;s,u\t of the ,:m-s,te visit(s) the: ci".:pieirtrnent found that yo<1 are n(ftin c0rnpii,1w>= ,•.ith tr,;:_; ne~nslrig t:=~\.:i\s and rt9ul~1ticns as .stated in the :.it'ed deflc.1enci•::s ~r: th-e ~nc.t1-s.t::d r£:pt:~n: 1 10/18/2024 1 undet·stand thi!tt t:;; n,ainrJin J:n A ssis.te.d L.lvin.g F ,~c.i\ity iicense, U7 e faci;ity ff1ust. be in cotr:pL,H~1,::e i/,:it': all the H•::ensm~1 ia\-VS ;;:ind r-::JUl;;;t1ons at rdl tn1es. STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20311 52nd Ave W, Suite 100, Lynnwood, WA 98036 Statement of Deficiencies License #: 2381 Compliance Determination # 47206 Plan of Correction Aegis of Queen Anne at Rodgers Park Completion Date Page 3 of 26 Licensee: Aegis Senior Communities LLC 10/14/2024 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 the unannounced on-site full inspection and complaint investigation on 09/10/2024 and 09/13/2024 of: Aegis of Queen Anne at Rodgers Park 2900 3rd Ave W Seattle, WA 98119 This document references the following complaint numbers: 145151, 146843. The following sample was selected for review during the unannounced on-site visit: 10 of 100 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Alma Duran, Licensor Keiko Kitano, Licensor From: DSHS, Aging and Long-Term Support Administration Residential Care Services, Region 2 , Unit J 20311 52nd Ave W, Suite 100 Lynnwood, WA 98036 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. 10.18.2024 15:09:14 State of Washington 4/27 Statr€w~nt of Detic/endes Gornpliar,c.e Dete~mins1iD<n # 4i'205 Pian ;-;f Cc;,rrnctinn Aegis Gl° (hrnsn Arin,;; ;;1 Rodgern P,uk Cr.rnplefa,n Date Page 4 of 26 L~c~nsi:➔: ..4 e.gis S!=rt:jor CornrntH1i1i~s lLC ·\0/-14/2014 IO/t.a-L~1 WAC 388•7ilA~2100 Ongoing assessments. (b} Cbmpletc an as,;;e.s.srnent spedfical%y for.used {rn a resident's ideritified v11ble,,1s and related i-ssues. (i) \.i\lh,::n the residents negotiated sN-viee agreeme.m ;w kfriger a,j,:!resse$. fhi:: re~ident's ;::unent neds and preierances:: · This requirement was not met as evidenced by; Based (1n obse!vatiun, intervie\-v_, and :e<:or<l n:v,e\'\'. ·tJ·ie .A~-sisted L;ving Faci\ity (.4LF j tiled to A .,. f 1< " : 4 : jyo . ? .... . ,, ' t. T . " .. < . G " ' " ,; t a - '' ~ U ,, SS • ._ : . " .... ' " ~ C ... : . , '' - f'l . " ,_. ' rl · . " t ' f: - ·~ · r · • 1 of · ~ ) 0- · .) 1 . .. n~ · p - b ~ .... d t ~ i - : s . ; , ·~ .... c -- h 1 t , < . ' R;: ., i . . .. " .,j, i !, , V • e - iit ? ·· - ' " ~ ' - , , ; .. , ,, ; . a •~ ~ - : ~ · : 1 . ; ·V ·•a t;, i- . •U -- ! ~ '1. c irv 1·- l · ud~ ..., , .: - .J - f ~ -.. f C -:s t 'j , • _ c-::mside~i1tic:ns arid th-e Hbihty tu saf~ly tist a mobil;ty dev;,ce. This foil,.He placei:.J Resident S at nsk al' harm ;_:ir injury from a rnc.biilt)' d£:vice NOTE: \1Vashin;:;;ton f.,drninistratve Code 388-7BA.-209G full assessrr1ent tcpics The assistei:1 l_ivii1g fodlit.y n,ust ohtali, sufficient idorrn-atic•n t() be t-,t,le.to :;,ssass t~,e ~:ap~ibHities needs. and pr2forences fore aa1 r%ident, and must cori'rpiete -a !:.;I! assessrrn,mtad,jr;:;ssinf1 -t·ie fol/,),-\'ing, 1;vithirdcurte-ed day'S d the re<;;ldent·s ,Y~Gve-.in date, unl-ess ext-ended-tiy the departmem f•)r good ~ausce. (8-l S,,;inific.-ant known bt-,havi01s or syniptGrns :Jf the individual ,::Jus,ng cot'\Cern Gf requir(ng spe::::iai care, indut:iing· (e) Other safet,.- consideiations tnat rnay pose a danger to the if"K1ividuat c.r others, such as. use· of n·1e(k:al devkes or t1c: indiv1du~;i's ability tG sm:)ke: unsupefvised_. :f snxil<:r:ng is pi;rmitted H, tht assisted living facility. · F~e::ords r€vievv shcw'eci the .t..LF adrnitted Resident 5 cri /2(i 17 ,Nith i~r. ., ltiple. (hsab!irig diagnos<::s. EevFjw cf Resident s·s lndiv;ti\.izd Si:,tvic,:; Plan (lSP - e:quivafctittc? F,.tl .t~-s~essment ·a~ 1·1 u i•l - - :} , t -. , ; ' :. - . .- .., - ~• - ! . ' - •• ,~ t..: ,at t - ' - . · w d - 0 -.... : ,, : _ : -. . . : , . . , : , - - ~ ,., , , , , . - .. - . ; .. . . : ., , 1" l '" l " , !' " -t~ '" 1.. " -- " .., ' , '" ,~ ' \ " .:.. ' ~ ·· 1 . t1 . . \ + .>. , -. . J r -t , ., : . , . - '. . J J ,0·1 • r n .:. . . c ...~. . , n .:.. ; .1 ) .. ' . ) :-. -{ 7 . c ... L . •r 7 ·. ; - ..J ," '1: ' 1 '- 1t 1 :' d f ... ~~.--:ut:~~ o ri: < < > v ~ ~· ·,• . · .. i . , ,, : - : • . , ,- ~ :i t - .. ; .. : ..~ : " !¥ " 1, V ,.,.• ' Y l d' • ~ · t : . 0 .. . • : 1,·. . . : , - . •. , .. . a t • r ·, Q 1 ·1-s , f .. _ . , , , ,i (r , - - , . . : ,' - v ~ . , :c ·· l~ t .\ i opi , • , ~ ,· · ::_ , t ' v ~ e , v , • , r ., e • t ~ ,-: v :_ ·~';Cv"-.c_: •~ ...:,:L• , , . - .. , . ~ . ·tl-· , rn • , " , - i '·' ~ -• j , i , i .{ t .. v ; an >, ·: i- < 't ' _ ' , f rn-· ·c ~ c ...i..~... :', O" r > O ~ " ' ' - . c , 1 id , n .,.l · _ " ;\ · . 1·J- ~ , - , ~ , - , .. i . jj ) \ -' , ·Nil::.li _ ' . l . < , i ,. 'ld o-f rnokity· devire R'esidtnt 5 h8d been using. R;;;sord fE:Vie~•,i of a Physicr.ll Thernps.t's (PTJ n;)te, dat~d D8/08i:?014, si•10~•.--e,j tl7:at me FT instmcted the F.LF's rnciintenan,~e staff tr~ instal! cne transfer pole (TP) m~>-;t t(1 tfo: bed ami a s~ c,md TP in frent cf-the ,::cuch. Statement of Deficiencies License #: 2381 Compliance Determination # 47206 Plan of Correction Aegis of Queen Anne at Rodgers Park Completion Date Page 4 of 26 Licensee: Aegis Senior Communities LLC 10/14/2024 Administrator (or Representative) Date WAC 388-78A-2100 Ongoing assessments. (2) The assisted living facility must: (b) Complete an assessment specifically focused on a resident's identified problems and related issues: (ii) When the resident's negotiated service agreement no longer addresses the resident's current needs and preferences; This requirement was not met as evidenced by: Based on observation, interview, and record review, the Assisted Living Facility (ALF) failed to ensure that an Assessment for 1 of 1 sampled resident (Resident 5) was updated to include safety considerations and the ability to safely use a mobility device. This failure placed Resident 5 at risk of harm or injury from a mobility device. Findings included… NOTE: Washington Administrative Code 388-78A-2090 Full assessment topics. The assisted living facility must 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 permitted in the assisted living facility. Records review showed the ALF admitted Resident 5 on /2017 with multiple disabling diagnoses. Review of Resident 5’s Individual Service Plan (ISP - equivalent to a Full Assessment and a Negotiated Service Agreement), dated 07/25/2024, showed that Resident 5 would utilize a transfer/positioning device to assist with mobility and/or position but did not identify what kind of mobility device Resident 5 had been using. Record review of a Physical Therapist’s (PT) note, dated 08/08/2024, showed that the PT instructed the ALF’s maintenance staff to install one transfer pole (TP) next to the bed and a second TP in front of the couch. Observation and interview, on 09/13/2024 at 11:10 AM, showed a TP installed at the left This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. 10.18.2024 15:09:14 State of Washington 5/27 Statt!rn~nt cf Defic/;:-ncies PJa~ ;if Correction .A,egis Gl' Qu-3sn .A:ins a! Rodg~H, Park Cr,mpisfa,n b.:itii Pa~w f. of 26 L~c~nsce-: _.t;.egj.s S~r.1jor-. C ?rn~1unf~i~s lLC ·10/14/2024 si;fo Gf tl:c cGu,~h In th= living r-:wm in Re:sider.t !:i's apartrnent. C.,tsetvation a\.~o ::,i,c,v,'=ci another TP with a curved grab bar instt11i.e-:.i on the ;dt £Ide •Jl' ttii:i bed fiwn ctilin9 tc\ flcnr. R£:sident 5 stated that the TPs hcip~d them to get in a,,d out of bed and fr<)rn the; ::,nud, F~<€ ::o n:h; rivie~-v shu~•'.'ed thi:; .,\LF did not up<:iate(i Resid•Jnt 5's .A:sse~,smei~;: ,aftenhe TP order· of 0£1i0&/2C!24 vvitf.1 ,nfonna(k·,n including ab,)ity to use tl,t TPs unsup€r v,sed. safety ,::onsi,:lerntons, r· . , - s' t , '\ · . . . : .} U '' !" i> " . . ' . " \. ~ ~• r . ~ . "" ,. r .._ · . :1 . · " h ' c ~ :· ; ,o,, . · " -. ' ..1. ' , " ~~ 'u · 1-1'11 . g . · t~_;.,-..~ •.t. . 1t " -(1 · U",,_.1,".."_,t , i. , :. , 1 , . w ,u, i , s • : . : _ i ,. . .. t _ ., ., , · , ' • l '" J. '~ .J: · ) ~ ,Q J _ 1 , ' , - ~ '' t - : ' , ';, , . n . o·~ J' ·• \. h • < !\ > ..· 'T'P'·. ; : : , ) . In an interv'ii::v-.•, Dr, 09113/2024at 2:40 PM. Stzdf .A tHea,u·, Servi'-::e.s Oired"<:rr} stated thart1·1,::y 1·1act not i::0mieted an assessment for Resid.ent 5·s TPs. WAC 388-78A-2l40 Negotiated service agreement contents. The-assisted l:iving facility must develop, and doeum ent fn the resident's reco:rd, the agreed upon plan to address and support eaeh re-sident>s assessed eapa:bi!itie:s, needs and preferen~es, irseiuding the following: (a) The p!.ir, to monitor-thB resi;jent an,J addrf.ss interventions fm- (Urrent (sxs: to (hf:: res\Jent's health and safe(y·that vvHe 1(lentifit:d in <'lne nr mar;::. tiI the foilcv-1,ng: (2) ClE: arly ddintd respective roles ;;,nd respcnsibil1ties c1f tr:e re,sident t"le assitted :iv!ng fm::il!ty· staff, ,~nd r:::sldenrs fami!y or ::ith::H s-i~1rnficant pers;:ins: in meeting the resKient's nei;ds and pref<:.rern:es. b:ci::pt $s. spB,:ihed in ·vv'A.C 388-78.A-22~H} 2<,)d JBB-78.A-1340 (5). ff a p£':sc;r, other than a i:aref1lver is to be responsibie fo.i providing care or ser,,icc::s to tt1e re side;nt in the assis.t::ed living fadh!.y, tt-1e assisb::d iivng fJdiiy mus!. s.pe,_~;1\ in the new,b~itEd se.rvice. ag,eerne;nt an .:iit,::rnate plan for ;::,rovic.iing -:.ari?. or service t0 the resid<::nt ;n th,e- event the necBss:c,ry services <>f,:; not prcv,,:ied, T!ie as:s,sted frv·in{1 fa,,j'iit-/ ir~ay de·..:e\,:1i:,- an a/tern at;:, plan: Statement of Deficiencies License #: 2381 Compliance Determination # 47206 Plan of Correction Aegis of Queen Anne at Rodgers Park Completion Date Page 5 of 26 Licensee: Aegis Senior Communities LLC 10/14/2024 side of the couch in the living room in Resident 5’s apartment. Observation also showed another TP with a curved grab bar installed on the left side of the bed from ceiling to floor. Resident 5 stated that the TPs helped them to get in and out of bed and from the couch. Records review showed the ALF did not updated Resident 5’s Assessment after the TP order of 08/08/2024 with information including ability to use the TPs unsupervised, safety considerations, risks and benefits, or ensuring the proper and safe installation of the TPs. In an interview, on 09/13/2024 at 2:40 PM, Staff A (Health Services Director) stated that they had not completed an assessment for Resident 5’s TPs. 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, Aegis of Queen Anne at Rodgers Park is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date WAC 388-78A-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: (iii) On-going assessments of the resident; (2) Clearly defined respective roles and responsibilities of the resident, the assisted living facility staff, and resident's family or other significant persons in meeting the resident's needs and preferences. Except as specified in WAC 388-78A-2290 and 388-78A-2340 (5), if a person other than a caregiver is to be responsible for providing care or services to the resident in the assisted living facility, the assisted living facility must specify in the negotiated service agreement an alternate plan for providing care or service to the resident in the event the necessary services are not provided. The assisted living facility may develop an alternate plan: (a) Exclusively for the individual resident; or This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2381 Compliance Determination # 47206 Plan of Correction Aegis of Queen Anne at Rodgers Park Completion Date Page 6 of 26 Licensee: Aegis Senior Communities LLC 10/14/2024 (b) Based on standard policies and procedures in the assisted living facility provided that they are consistent with the reasonable accommodation requirements of state and federal law. (5) Appropriate behavioral interventions, if needed; This requirement was not met as evidenced by: Based on observation, interview, and record review, the Assisted Living Facility (ALF) failed to ensure the Negotiated Service Agreement (NSA) included all required contents for 2 of 2 sampled residents (Residents 5 and 10). This placed Resident 5 at risk for not having their care and services needs met and placed Resident 10 at risk for not receiving the appropriate care to meet their mental health needs. Findings included… RESIDENT 5 Records review showed the ALF admitted Resident 5 on /2017 with multiple disabling diagnoses. Review of the undated ALF Residents Characteristics Roster showed Resident 5 had a private caregiver (PCG). In an interview, on 09/12/2024 at 10:30 AM, Staff H (Resident Care Director) stated that Resident 5’s family had hired a PCG for them. Staff H stated that the ALF staff were still providing direct care for Resident 5 and the PCG was more like a companion. Observation and interview, on 09/13/2024 at 10:45 AM, showed a PCG standing at the counter in the main dining room. The PCG stated that they would deliver breakfast for Resident 5. The PCG stated they had been visiting Resident 5 three days a week for one year and assisting with a shower twice a week. Review of an Occupational Therapist’s (OT) Visit Note, dated 07/25/2024, showed that the OT instructed Resident 5 to take showers only with a caregiver’s assistance for safety. Review of Resident 5’s Individual Service Plan (ISP - equivalent to a Full Assessment and an NSA), dated 07/25/2024, showed Resident 5 as being independent for bathing. The ISP did not address Resident 5’s need for shower assistance. There was no information about Resident 5 having a PCG. The ISP did not clearly define roles and responsibilities of the PCG, and there was no back-up plan for when the PCG was not available. In an interview, on 09/13/2024 at 2:40 PM, Staff A (Community Health Director) acknowledged that Resident 5’s ISP did not include information about the PCG and a back-up plan. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2381 Compliance Determination # 47206 Plan of Correction Aegis of Queen Anne at Rodgers Park Completion Date Page 7 of 26 Licensee: Aegis Senior Communities LLC 10/14/2024 RESIDENT 10 Record review showed the ALF admitted Resident 10 on /2024 with multiple diagnoses including , and . Review of the Preadmission Assessment (PA), dated 01/31/2024, showed Resident 10 required staff assistance and intervention when Resident 10 experienced behaviors such as anxiousness, mood changes, restlessness, delusions (false beliefs) or hallucinations (sensing things that do not exist). The PA showed staff were to provide redirection, intervention, and/or coordination with healthcare resources, and to intervene with validation and/or redirection techniques to calm resident. Review of a Consultation Notes from an Advanced Registered Nurse Practitioner, dated 06/10/2024, showed Resident 10 had a diagnosis of , and an extensive psychiatric history that may be contributing to Resident 10’s cognitive status. Review of Physician’s Orders, dated 02/14/2024, showed Resident 10 was prescribed apiprazole (used to treat schizophrenia, bipolar, and depression), clonazepam (used to treat anxiety), and Cymbalta (used to treat depression and anxiety). Review of Resident 10’s combined Assessment/Individual Service Plan (A/ISP – ISP is equivalent to NSA), dated 09/06/2024, showed no behavior issues related to their diagnosis and history, what intervention would be needed should Resident 10 experience behavior issues, and no instructions to staff should Resident 10 exhibit or demonstrate mental decompensation (worsening condition of mental illness) issues requiring staff interventions. In an interview, on 09/13/2024 at 1:20 PM, Staff A (Health Services Director and Staff I (Director of Operation) stated acknowledged that lack of a behavior plan for Resident 10. This is a deficiency previously cited on 01/27/2023. Plan/Attestation Statement This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. 10.18.2024 15:09:14 State of Washington 8/27 Stat~m~nt cf Deficiencies Ucense #. 2381 Cornpli,mc.e D2tem1instii:-n # 4/206 F'ian gf Ccnrnction Aegis d i:Jti<?.ert .A.:ins .s1 Rodge-ts Paik CfitT,pistic.n D.at1r L~c~nsc,a.: :4agis Senior. CO t~~1~ntties lLC 10/14!2CC4 ln add1ti;)!\ I ,"<lilt ,mpiement a systtrn to mJnitor and ensure contiDued ~omp[iance .~.it1 this requirernent. lj\l:f!2~jJ!Ji!£v~ /2/2-r;(,z1 f WAC 388-78A-2210 Medieatlon services. (b; Develop aM irnpl<::rn-ent s.ysterns that m..ipport anci prGrn.ote &afe rnedrcation servk:e f-or-<::::ich resident (2) The as&isted living foci!ity must et1sure the follov,ing ri::sicer1ts reci:cive their medic,-itions as pr~s,:ribed, ex,:€p! as prn•,;idf.d foriri \iVA.C 388-78A.-'.n30 and ~rnB--78A-22t,iJ : (b} If the ;:.issist,:_;d living tac!l1ty prnvldes r11edic-Btcm adrnini·stratian ser.-i-~es. tach re-s\dent wtw rs:•~uir:es. med.\catic-n acimtnistr-aton ,rni.1 i':L~-0r r,;?.r n~gi:rnated si::r,··icf. agn?.;:;n,ent indkates the assisted fr~--ln:.:i facility will µi,Nide '!'nedk:ii,tion admlnisk:Jt1Cn,. This requirement was not met .is evidenced by: 8a$ed :Jn intt:r,tievv and record reviHv. tt,f .Ass,sted Uvin9 F adjity· lALF': f.B\ied ·w imp/e?Y,~nt a :syste111 th3t supported ai1d pr;:.motcct safe medisation ser.·i,~es kr 2 of 2. sarrp!Bdresidents 5; (Resk1eds 1 and '.,;\•l·w requir,7!d staff tc administe1 <::1-r assist. ~•vitr1 rne..:k.:"itons Ttw,, fJHurn res.uited in Residents 1 and 5-r1ot re:ceNlnq rnedicatbns --a'S :?ri::scril::-ed and placed Res,dBnts 1 i3:t1d 5 at r~s:k f·, U . , ,· c ... < . ~ " ~ ', ~ ,, > -w t- · - :r't> " t1·~ . ·,. · , .:> . e d h1 . - _ " . . , . ~ .,, i t1 I · 1 . ~ ,- , . " ... ,: . • , , u -~ ; , ·u· V , -./ ~ ~ -- . . R~\,·ievv nft~-!e .ALf=''s pchty t1ti.ed Oucurnentation St:!ndc~rds :3f f\-~etj;cat-on, rtvi:s~d 04/12/202·~ under = t • he . . v ::, - ._ '- . ' . c .. t . i< . ... ' > " •) r ': - J f (~f .. : .... \ M ._ , , . Jr . d· ~ ·• I · - ~ ~ 3:! > ' '- ' ) ' r• '!:i : )" \. " , · \ ' . i , : . c ,. 3t· ~ r -- , · n " C -· ~ ·· r de ~ > - ' C ✓ li3 . ' . ' ,'!':;:::>,-t-<·--: . a<,"',' ( ' " " ·' ' • - ·" - " - · U ~ . '"1-.J J e '') , ,, l ' .. " l!- " ·~J ' : e ' • · and 1 r t · 'P 1 .. . . · • · . i .. , 1 : . • :- · - ; 0 , : : . t .. : . ,v·, n on:i,;;r ,::h~nges 2::e fa:.:,::d t() the pharmaq--for pr0,~essing and 1::ntr/ irito the cornp~,t~r system :-' Reviev.- afthe ,tl,LF·s p,::lli:i.".y' titler.~ O-:,,:-umtntation Standard i-.1 £;d!catlon, revis,e,j 04/12/2_;):,?<:i, under the section ,Jt Omitt1:d fvledic-afr..-rn shm1<1'::d. 'it is-not ac,:ept<.1bb to ,Jrn1t J rni:..:fo::<'1tion b-e(ause: it ,snot ava~t21bie.• · Statement of Deficiencies License #: 2381 Compliance Determination # 47206 Plan of Correction Aegis of Queen Anne at Rodgers Park Completion Date Page 8 of 26 Licensee: Aegis Senior Communities LLC 10/14/2024 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, Aegis of Queen Anne at Rodgers Park is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date WAC 388-78A-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. (2) The assisted living facility must ensure the following residents receive their medications as prescribed, except as provided for in WAC 388-78A-2230 and 388-78A-2250 : (a) Each resident who requires medication assistance and his or her negotiated service agreement indicates the assisted living facility will provide medication assistance; and (b) If the assisted living facility provides medication administration services, each resident who requires medication administration and his or her negotiated service agreement indicates the assisted living facility will provide medication administration. This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to implement a system that supported and promoted safe medication services for 2 of 2 sampled residents (Residents 1 and 5) who required staff to administer or assist with medications. This failure resulted in Residents 1 and 5 not receiving medications as prescribed and placed Residents 1 and 5 at risk for compromised health conditions. Findings included… Review of the ALF’s policy titled Documentation Standards of Medication, revised 04/12/2021, under the section of New Orders and Medication Order Changes, showed, “New order and medication order changes are faxed to the pharmacy for processing and entry into the computer system.” Review of the ALF’s policy titled Documentation Standard Medication, revised 04/12/2024, under the section of Omitted Medication showed, “It is not acceptable to omit a medication because it is not available.” This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2381 Compliance Determination # 47206 Plan of Correction Aegis of Queen Anne at Rodgers Park Completion Date Page 9 of 26 Licensee: Aegis Senior Communities LLC 10/14/2024 Review of the ALF’s policy titled Limited Supply Ordering Back Up Medication Supply, revised 03/27/2015, under the section of Obtaining Medications showed “that the Medication Care Manager (MCM) will call the ALF’s preferred pharmacy and determine why the medication has not arrived and determine if it will arrive on time.” “Convey this information to the next shift and the Licensed Nurse so that they can continue to follow up.” RESIDENT 1 Record review showed that the ALF admitted Resident 1 on /2021 with multiple diagnoses including . Review of Resident 1’s Individual Service Plan (ISP - equivalent to a Full Assessment and a Negotiated Service Agreement), dated 07/18/2024, showed that trained staff would manages skin irritations, including application of creams as ordered. Records review showed that Resident 1 developed an open skin wound on their buttock on 06/11/2024. Review of a Progress Note (PN), dated 08/15/2024, showed that Resident 1’s physician, ordered silver sulfate cream (used to skin issues) to be applied to Resident 1’s wound twice a day for seven days. Review of the August 2024 electronic Medication Administration Records (eMARs) showed that Medication Care Managers (MCM) put their initials in a column for applying the silver sulfate cream to Resident 1’s wound from 08/16/2024 until 08/29/2024. Resident 1 received applications of the silver sulfate cream for 13 days, not seven days as ordered. RESIDENT 5 Record review showed that the ALF admitted Resident 5 on /2017 with multiple diagnoses, including Review of Resident 5’s ISP, dated 07/25/2024, showed that Resident 5 required staff assistance with medication services. The ISP showed that Resident 5 had been using the ALF’s preferred pharmacy, and that staff had been responsible for the timely reordering of all medications. Review of the July, August, and September 2024 eMARs showed that Resident 5 had been prescribed multiple medications, including ferrous sulfate (iron supplement). Review of the eMARs showed that a physician had ordered Resident 5 to take ferrous sulfate once every three days. The eMARs showed that the ALF was giving Resident 5 ferrous sulfate three times a week on Sundays, Mondays, and Thursdays instead every three days as prescribed. In an interview, on 09/13/2024 at 2:30 PM, Staff J (Regional Registered Nurse) confirmed the ferrous sulfate had been given incorrectly. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2381 Compliance Determination # 47206 Plan of Correction Aegis of Queen Anne at Rodgers Park Completion Date Page 10 of 26 Licensee: Aegis Senior Communities LLC 10/14/2024 In an interview, on 09/13/2024 at 2:40 PM, Staff A (Health Services Director) acknowledged that MCMs had not given ferrous sulfate to Resident 5 as prescribed. Records review showed that Resident 5 had been prescribed Jantoven (an anticoagulant used to prevent blood clots from forming or growing larger in a person’s blood and blood vessels) for their A- Fib. Record review showed that the dosage of the Jantoven was controlled by an anticoagulation clinic (a clinic to manage anticoagulation therapy). Review of a Progress Note (PN), dated 08/02/2024, showed that the anticoagulation clinic called the ALF and instructed Resident 5 to take Jantoven 1.5 milligrams (mg) on that day. Review of the August 2024 eMARs showed that on 08/02/2024, a MCM put their initials in a column for Jantoven 2.0 mg, indicating Resident 5 received 2.0 mg instead 1.5 mg. Review of an order from the anticoagulation clinic, dated 08/03/2024, showed that the anticoagulation clinic instructed Resident 5 to take Jantoven 3.0 mg on 08/03/2024. This order was faxed to the ALF on 08/03/2024 at 10:17 AM. Review of the August 2024 eMARs showed the 08/03/2024 the order was not transcribed into the eMARs, and Resident 5 did not receive any dose of Jantoven on 08/03/2024. Review of a PN, dated 08/05/2024, showed that the anticoagulation clinic called the ALF and instructed Resident 5 to take Jantoven 1.5 mg that evening. The August 2024 eMARs showed that a MCM put their initials in a column for the 2.0 mg of Jantoven, indicating Resident 5 received 2.0 mg instead of 1.5 mg. Review of a PN, dated 08/30/2024, showed that the anticoagulation clinic instructed Resident 5 to take 1.5 mg of Jantoven on 08/30/2024. However, review of the August 2024 eMARs showed that on 08/30/2024, Resident 5 did not receive any dose of Jantoven. Review of PNs, dated 07/28/2024 and 08/27/2024, showed that an anticoagulation clinic instructed Resident 5 to take Jantoven on those days. Review of the July and August 2024 eMARs showed that on 07/28/2024 at 8:00 PM and 08/27/2024 at 5:00 PM, the MCMs documented in the eMARs that Jantoven was unavailable, and waiting for the pharmacy to deliver, indicating Resident 5 did not received Jantoven on those days. In an interview, on 09/13/2024 at 2:30 PM, Staff J (Regional Registered Nurse) stated that the ALF’s preferred pharmacy could deliver a medication at around 10:00 PM if necessary. Staff J stated that even with a late delivery, a MCM should have given the medication to Resident 5. On 10/07/2024, the Department received additional documents from Staff H, including This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. 10.18.2024 15:09:14 State of Washington 11/27 Stat~,w~nt cf Deficiencies ~•Jan ,;f Corrn~tir.<n Aegis Gf ChiBsn-.A.:ins ii!. Rodg,ns Patk Cr,rnp/.stiu1 bat., Lic~n~t?~: ..4 e.gis .s~nior-CQ inn1tH1ities lLC W/14/20::4 the pharrnacy's rn:<=dicatim1 d<::livt,y rec;m:ls. Hev1ew of me phan-nac\_.,S records. dati:d G7i2Bi202'-1 and GB/2712024 .. s1·wwe:j that Uk Alf had re(:£:\'ed Resident 5's .Jarito':/en on thms.e days. Ho\r'ie-./er, records !\€..- ie-vv shvv\ted nc~ do.::urnfntati0n to ir1d~~:.afe that R=s1.de1~t ~2.r~.:::e·~\''ed .jar,toven ~Jn thost davs. There-'+"'ias aiso ;1:1 documei-,tafam to shcv1./that n,.Hsin~ ~~rnff h~d r;:;pertd foe. ornissicn of -.J. · a " t·1 ' ~ I..~ ·· . . , .. • ): , - - . . : .. ,• 1. 1 • , •. ' H " ! t .. · • I 1,- ., ,; ~ :, . : . . _ :. 1_.,·..•..·J:~.,, ; . c J . :.. . ' , -~ t w ." : t. : . . - , ~ < 1'\ i ,J . .. , ,. ~ ;~ t - t; ., ; 1 · .. c ; . 1 ~ .,) l" 1 ' : / " . I ;, · · • · . . ' .. : ~ . t - ." , i, , . I . - R1::-...1ie\-'V of an ernaii dOCLH1~F. nt fn:im Staff A. dated int08/2.J2ti. sh,;.iwed tl,at Resii:~ent 5 :j;°d noHke t,} be dlsturbed uurin•l iate ho;_Jrs. and 1--vouio n'ot take tr1efr rnedh:atiD:11 late. The ernag doi:.:ument sn,:,vved . a ., s - ~ ..1 , :< . .. t \ " ., ·rr1 , e• .r 1 ~ ·" · h ~ ,- . - v -. . , . 1 . · . i R::., , . . ,. , . " .> ·1 d· " - ' . t l ' t ~ .,_, " .: " :J . r·; . : , . . , ~ < • 1· , . _ .- . , •_ ~ ~ _. " .. ' " , 't·· (. ~ , r' . · . 1 . _ . , , " . . ' ... • . " .- ' • -' ' I > ' n . f : i - , , - > ,, .: . - . . , :, . ,,n :2 " 1 f .. i : - -. P -(. ~ ., t . H' .1 ., - \ , ' · ' i I • I . , , . . , · \ · . . , .t :. ' . ,. _ , r . e . " y • . · . " . ' . ' . ~ ., , . · ' . - . . > . f l R•. . , . . , · s:,··d-. '- :; -" ,- ' ~ ~ t . , ', : J ; . ·c .:: · J 1, ,. , _ : _ : .~ : :i did rwt address this inh:mnation about i~,te refusal at' ,1,edicatiort · · R€co rd~ 1:1:::vi~vv shdwed that f~t:!siiJent 5-vv~s adrnitted t<:r the hnspital bi" an acutf medical con,jificn, and , r- .. ; .. : . , ,, > ,.__, 1 . a ,: r , • , 'et1 l'- \. i , 1 ~ h l e _. . A \ '- · F ~ - . • . ,ri , '\ -: ) - '}. .. . . : .. ! . . · , R ;: . , ., . :vi ' " - ' ' V \ ' ' of a , u + .~ s \ " .. h -.~ ·· G -, r ! " :.~ " t · > , l" ,., ' ,, ' , " ..,. P _ " . a'1 \., , • 1 . ,,. r·1 I v .., , ,. -" _ j;: , , , i· . ~ f, - ., . _ . . , .. . . , ,, , tt·· 1 · , · : · : · l·l,'.·l-·".J'·tr1· j-f...r\.~t , . • :i , " ,: ~ _. ted " - ): ~ ~· - }4 ; d :.h - s .. r ,. , , . ....., -.,,.>~ t.t n C t ., , R ec ;. : ) - . - \.. l : < ... " . n . t _ . ; . : . ; _ ) ' . t ' - i • i '.:P ~ ' . : ns~ :i.: , , · v- " -.. • ... ' ted t" ,. .1 · ' t- i: 0 . , . . 1 , , · . . a _ . 1 • ·' - )- •,t , . :: . ; n-:":'::iI _' · . · .: · f = ~ ~ u . a ..., . t: '~ ·- '! s - n -' j- t ~ i ~ -..,, - \ :' , : . - .I - ~ ·; - ,,j t , · _ , . t.re",tthe symptoms afschlzf:phenia {{a mental Wnass that ,::auses d,sturb-e:j or unus,.,cJI t·11nki,~g_ los-:; of interest in life. and strong or inappropriate erntltons)} at bedtirne. · Revif.it<i aHhe ._iuty 2024 eMARs shav,•ed that the quet1apine onier v-;as not !t'i.HlS-cribed into the f.M.A.Rs. Record;; ;-e,Ai?.Vi shovved no documentati;Jn ,ndi,:ating tt~e .AL.F had faxed the rv::w order to the p\1.arTnacy for processing per the .l!;_Lf"s potcy. Thei'i: ;,-vas ;_~isQ n::1-docuri1tntatian 1nd1eatnq triat the. A.LF 1·12,d c:ontaJ:td Resident s:·s phisidcm a~•:Jut the hospital q;;etiapine. ,:;rder. · In a telephone inte,viev-i date H}/07i2iJ:2-4 at 1_: )7 PM, Staff H stated th:at n:;rse.s we.re responsible for rev\t,•\1\ng phys1ciarni' order·s nr r.:i:s:Jrnrge: instrw:tion frnrn the hospital:. Plan/Attestation Statement i h€reby certify t'-iat I ha'/e rev\e:wed this H:~~ort snd h:;Ne fa~:.-::n or ~Nill tak£t ,:1Ct!ve rneasur-1::s to ccne-:.::t U11s cefr.::iency. By tar;in~1 this Bcti,:m. Aeg=s ot Que~n ,A/int: at Rod9e1s ?ari<: is {>f ,-\1 iH be ir. cornpli,an::e. v-iit!1 this i:avv .and l or regulation r.n {Date1./J/$f:/._#__ ___ . h1 add1t1;::n. I ,,.-~1H imp!et'!"lent a system to m::w,ito; ;y,;j ensure contr~ued soi-r,phance v.iu·i ~;N:t:/1£,e)' /Dk!/24 Statement of Deficiencies License #: 2381 Compliance Determination # 47206 Plan of Correction Aegis of Queen Anne at Rodgers Park Completion Date Page 11 of 26 Licensee: Aegis Senior Communities LLC 10/14/2024 the pharmacy’s medication delivery records. Review of the pharmacy’s records, dated 07/28/2024 and 08/27/2024, showed that the ALF had received Resident 5’s Jantoven on those days. However, records review showed no documentation to indicate that Resident 5 received Jantoven on those days. There was also no documentation to show that nursing staff had reported the omission of Jantoven on those days to Resident 5’s physician. Review of an email document from Staff A, dated 10/08/2024, showed that Resident 5 did not like to be disturbed during late hours and would not take their medication late. The email document showed a statement from Resident 5’s representative confirming that. However, review of Resident 5’s ISP did not address this information about late refusal of medication. Records review showed that Resident 5 was admitted to the hospital for an acute medical condition, and returned to the ALF on /2024. Review of a discharge medication order from the hospital, dated /2024, showed that Resident 5 was instructed to take 12.5 mg of quetiapine (used to treat the symptoms of schizophrenia ((a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions)) at bedtime. Review of the July 2024 eMARs showed that the quetiapine order was not transcribed into the eMARs. Records review showed no documentation indicating the ALF had faxed the new order to the pharmacy for processing per the ALF’s policy. There was also no documentation indicating that the ALF had contacted Resident 5’s physician about the hospital quetiapine order. In a telephone interview, date 10/07/2024 at 1:37 PM, Staff H stated that nurses were responsible for reviewing physicians’ orders or discharge instruction from the hospital. 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, Aegis of Queen Anne at Rodgers Park 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. Statement of Deficiencies License #: 2381 Compliance Determination # 47206 Plan of Correction Aegis of Queen Anne at Rodgers Park Completion Date Page 12 of 26 Licensee: Aegis Senior Communities LLC 10/14/2024 WAC 388-78A-2230 Medication refusal. (1) When a resident who is receiving medication assistance or medication administration services from the assisted living facility chooses to not take his or her medications, the assisted living facility must: (c) Notify the physician of the refusal and follow any instructions provided, unless there is a staff person available who, acting within his or her scope of practice, is able to evaluate the significance of the resident not getting his or her medication, and such staff person; (i) Conducts an evaluation; and (ii) Takes the appropriate action, including notifying the prescriber or primary care practitioner when there is a consistent pattern of the resident choosing to not take his or her medications. (2) The assisted living facility must comply with subsection (1) of this section, unless the prescriber or primary care practitioner has provided the assisted living facility with: (a) Specific directions for addressing the refusal of the identified medication; (b) The assisted living facility documents such directions; and This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to notify the physician or evaluate for any negative outcomes when 3 of 3 sampled residents (Resident 5, 8, and 10) refused their medication. This placed Residents 5, 8, and 10 at risk for a compromised health condition. Findings included... Review of the ALF’s policy titled Resident Refusal of Medication, dated 04/12/2021, showed, “The Health Services Director (HSD) or Wellness Nurse will follow-up on the refusal of a medication, particularly if this is a pattern of refusal.” “The HSD or Wellness Nurse will contact the resident’s prescribing practitioner if the medication refusal is repetitive. This conversation will be documented in the Health Record.” RESIDENT 5 Records review showed that the ALF admitted Resident 5 on /2017 with multiple diagnoses. Review of Resident 5’s Individual Service Plan (ISP - equivalent to a Full Assessment and a Negotiated Service Agreement), dated 07/25/2024, showed Resident 5 required staff assistance with medications. Review of the July and August 2024 electronic Medication Administration Records (eMARs) showed that on 06/22/2024, Resident 5’s physician had ordered Resident 5 to apply an Aspercreme patch (lidocaine patch, used to relieve minor pain in shoulders, arms, neck and legs) to their left leg and back daily. Review of the eMARs showed that This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2381 Compliance Determination # 47206 Plan of Correction Aegis of Queen Anne at Rodgers Park Completion Date Page 13 of 26 Licensee: Aegis Senior Communities LLC 10/14/2024 in July 2024, Resident 5 had refused the Aspercreme patch for three days and in August 2024 Resident 5 refused the Aspercreme patch for seven days. Review of Resident 5's active records showed no documentation as to whether a Medication Care Manager (a non-licensed caregiver) had notified the HSD or Wellness nurse about Resident 5’s Aspercreme patch refusal. There was no documentation to indicate that the HSD or Wellness nurse evaluated Resident 5's condition for negative outcomes. There was no documentation showing the ALF had notified the physician about Resident 5's continued pattern of refusing Aspercreme per the ALF’s policy. In an interview, on 09/13/2024 at 2:40 PM, Staff A (Health Services Director) acknowledged that there was no documentation to show the ALF notified the physician or evaluated Resident 5 for negative outcomes following the Resident 5’s medication refusal. RESIDENT 8 Record review showed the ALF admitted Resident 8 on /2024 with multiple medically disabling diagnoses. Review of Resident 8’s combined Assessment/Individual Service Plan (A/ISP – ISP is equivalent to Negotiated Service Agreement), dated 08/28/2024, showed Resident 8 required assistance with medication services. Review of the September 2024 electronic Medication Administration Records (eMAR) showed Resident 8 refused to take the 10:00 AM dose ordered medications on 09/03/2024 and 09/04/2024 for polyethylene glycol powder (prevents and treats occasional constipation). Record review showed no documentation as to whether the ALF notified the physician about Resident 8’s refusing her medication. RESIDENT 10 Record review showed the ALF admitted Resident 10 on /2024 with multiple medically disabling diagnoses. Review of Resident 10's A/ISP, dated 09/04/2024, showed Resident 10 required assistance with medication services. Review of a Progress Note (PN), dated 08/15/2024, showed Resident 10 tested positive for COVID 19 (is an infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death). Review of the August 2024 eMAR, showed Resident 10 was prescribed Paxlovid (a medication used to treat mild-to-moderate COVID-19) for five days. The eMAR showed Resident 10 refused to take two morning doses and three evening doses of Paxlovid, because it made her feel worse. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. 10.18.2024 15:09:14 State of Washington 14/27 Statern8nl cf Defid;:-ncies Pian d Corrnctic,n Aegis Gf Ch:i~sn .A:ins ;;1 Rodg,Hs Pa!k Crn,p!stic,n Oat;; Pa-;,rs ·14 of 2£ Lic~nse>;,~ .Aegis S!=r1ior. C ornrnunfties LLC W/14/2024 R~vi<'::l.·'>i c.t t.he .}un£c 2014 <?.MAf.~, sh1}:-,•~--=d Res1d<ent i O refused to taf<e Refre~h Tedrs 1?.ye drops (us,;;d fo treat d,y etts} on 06iL'.:i2024, GB/13/2024, ami 06i14l2024. F:f,,ji-"w o• e Pf':i s1~av-.,;,,,..; i~,, dor: ,m,.,·1:;:1tion ,B ta .-vhdh-":- :_ 1 "· M =~ ;:. ~ . :· t .,1 · - F rv ,. i ti:1 ': i · ., ·- ,·! th ,~ " ... ' .. i· · < '' 1 , ·1 - y< '" :. " i · ,~ ··. i - :" · " " at· - ,.- ' , - ,u " i ' ., R .-.- t . : . : J s _ , . d .... en . t ' 1 ,: t 1 . . .. s . ra · u .: s ' W · iQ .. t . H .... :'r - - P ~ axw .--- V -~ t - i1 .. - ~J·.. .:. 1 .. . . ) , - v ;,-f , - 0 ~ h ~ .. t ..., j . ar R :_,,. t ~ r -: r n ;. . . .. s . :t1 ; f:~n-s eyl': t1n~ps. Jn;:i l'1<3l'.l ::::'/clUat\:d tne s1ornfica1c-e Gf Fesid,:;nt 1O 's rnedii::atio,n refusi:Jls ..A nd the!"e \NUS n;:1 do,::urnentathrn th-at st&ff n,Jtffled R . - ... . .. : , . ... _ .. j ~ , je •. : • ·; ~ t 1 , ( . f < ~ ' ., o • h• --~1 si, - ~ · i , : ._ ' 1 " , , tl1" '- " " , ~ e • , - .;. : t -so I. r I v,41 J '' .c...l, -f,:': ref' U ' S ._ e ,. d th . 4 ...., ~ r v• v:-·C, jj,-s_.s.,t.)j:- .· ,\,_" 1. ,;. ,~ .,. i- ) ~ .. t ~ - at•i to · .~ • _, : . . ., ' . P • a . ~ 0- , IO'•lid ma .._ f~ _: e t- 1 . . ; ... : ,, . ~ , feet vvmse. In interview, ,Jn Olli 13/20:'.4 at 2.05 Hi, Staff l tDirt:,::tor d Operations) and ~:itaff A {He<i!th S.e,victs Dhectof_) acl<nov\il<'=dged the ,'esi.J,:;nts' p1·1ys1dans: 1.-vere t,::; be notified and rne-dP::at1on refusals \'\·ere do-::~urnented (~c,:ordH"'1~~ to .~LF~s pn~~C)'. . This ;s_a defi,,::iency previm.,s!y cited tJn OH27i2023. Plan/Attest3tion State:me-nt In Bdd°itiH~,. I :.-viii imp!erner:t a S-y"stem to monitor and e:ns;3n~ ,::onbnutd ,:cmpiian;_:e i,,,:it~, this r WAC 388-78A-2320 tnt~rmittent nursing services systems. ( ~} VVhen an :::ss:sted iivfr:g fodl1t'( pr·Gvfd;:;s intern~ttent f';urs\r,9 services to any reskient ;:either ('lire,:rly ::i, imi,re,:t1y, t1·1e assisted livh1g f-cKility rnust:. (:?) The) :;issrstt:d living facidy prn:v1d\ng nursing s:e1:-..,'lc~s, eitt11:.:r i:lir0.:.::tly· (,r ,ridir1:,ct(i, rnust ensure trwt the nurs!ng setvkes systems in.:lude· (3) The assisted l1vinJ ~;:i(:itty rn0st <::nsurr:: tl:'mt all rn.Jrnin9 serviGes. incl::.;d1n{1n u~sing suQervis,mi, assess;,11::nts, ::::nd d-e/egati,.:,n. 2ire pro'-.--id-ed in ac,:crdan,::e 'l.-~th app;,c;;.tl\o:, statuto:,S 2nd rul£cs., induding, tut net iirnited ta. Statement of Deficiencies License #: 2381 Compliance Determination # 47206 Plan of Correction Aegis of Queen Anne at Rodgers Park Completion Date Page 14 of 26 Licensee: Aegis Senior Communities LLC 10/14/2024 Review of the June 2024 eMAR, showed Resident 10 refused to take Refresh Tears eye drops (used to treat dry eyes) on 06/12/2024, 06/13/2024, and 06/14/2024. Review of a PN, showed no documentation as to whether the ALF notified the physician about Resident 10’s refusing her Paxlovid [COVID 19] or Refresh Tears eye drops, and had evaluated the significance of Resident 10’s medication refusals. And there was no documentation that staff notified Resident 10’s physician the reason why she refused the medication or that the Paxlovid made her feel worse. In interview, on 09/13/2024 at 2:05 PM, Staff I (Director of Operations) and Staff A (Health Services Director) acknowledged the residents' physicians were to be notified and medication refusals were documented according to ALF’s policy. This is a deficiency previously cited on 01/27/2023. 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, Aegis of Queen Anne at Rodgers Park is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date WAC 388-78A-2320 Intermittent nursing services systems. (1) When an assisted living facility provides intermittent nursing services to any resident, either directly or indirectly, the assisted living facility must: (b) Ensure the requirements of chapters 18.79 RCW and 246-840 WAC are met. (2) The assisted living facility providing nursing services, either directly or indirectly, must ensure that the nursing services systems include: (b) Nurse delegation, if provided; (3) The assisted living facility must ensure that all nursing services, including nursing supervision, assessments, and delegation, are provided in accordance with applicable statutes and rules, including, but not limited to: (c) Chapter 246-840 WAC, Practical and registered nursing; This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2381 Compliance Determination # 47206 Plan of Correction Aegis of Queen Anne at Rodgers Park Completion Date Page 15 of 26 Licensee: Aegis Senior Communities LLC 10/14/2024 This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to follow the criteria for nurse delegation (ND) for 1 of 1 sampled resident (Resident 1). This resulted in non-licensed staff members administering medications without receiving ND training and placed Resident 1 at risk for compromised health conditions. Findings included… NOTE: Washington Administrative Code (WAC) 246-840-930 Criteria for delegation, (1) In community-based and in-home care settings, before delegating a nursing task, the registered nurse delegator shall decide if a task is appropriate to delegate based on the elements of the nursing process: ASSESS, PLAN, IMPLEMENT, EVALUATE. ASSESS (3) Assess the patient's nursing care needs and determine the patient's condition is stable and predictable. A patient may be stable and predictable with an order for sliding scale insulin or terminal condition. (4) Determine the task to be delegated is within the delegating nurse's area of responsibility. (5) Determine the task to be delegated can be properly and safely performed by the nursing assistant or home care aide. The registered nurse delegator assesses the potential risk of harm for the individual patient. Review of the ALF’s policy titled Nurse Delegation, revised 11/14/2018, under the section for Medication Administration showed, “Determine if a resident’s needs administration of medication. If the resident is NOT functionally (physically) able to take medications and cognitively aware he/she is receiving medications, the medication must be administered by a person authorized to do so.” Records review showed the ALF admitted Resident 1 on /2021 with multiple disabling diagnoses, including . Review of Resident 1’s Individual Service Plan (ISP - equivalent to a Full Assessment and a Negotiated Service Agreement), dated 07/17/2024, showed that Resident 1 required staff assistance with medication services. Review of the June, July, and August 2024 electronic Medication Administration Records (eMARs) showed that Resident 1 had multiple prescribed medications. The eMARs showed oral medications might need to be crushed. In an interview, on 09/13/2024 at 12:45 PM, Staff L (Medication Care Manager - MCM) stated that MCMs had been crushing oral medications and mixing them with pudding. When asked whether Resident 1 had been able to put the mixed medication in their mouth, Staff L said, “No”, and stated that MCM had been administering the medications. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. 10.18.2024 15:09:14 State of Washington 16/27 Stat~ni~r:t cf OeficisnGies F•lan 01 Cc:irrnctinn Aegis Gf Ou~sn .A:in~ a1 Rodgern Fark CfilT,pistivn Dat;; ·ion Pag~ ·1G c-f2F. L~c~nse-:e-: ..4 egi_s S~njof C ornrnunities lLC 4/2024 R;;vievv o1 ar, ND docwn-::nt blrid::r s.hc;·,\~d rm dG;:OUtr:£:ntJtjon tiJ indicate me-ALF p,G(H:dy delegated r,_,1.C M s for mirninistennt1 mi::<.iit<~ti;:.ms to Resldent 1 . Ir' 1 ~ :•·1 1 , - n ~• . te . r v; , ~ ... , . , . , ,, . - 'v'!.~• 1 ._ 1 ··8 • ! 1 . •.)._i1'_h. )_'_;! , i ;-~i"t' - > -- :. ~ < ·- (l 0 ~ ~.--,-1 1 . ,S _ f . , , ; _ c _ • ft • • A : , ~ • t . , . ~ ._ . < . C , J f . t . j . -: . - .. ; . : _ : • ; • " _ " . t" - ; t ,, . , ,. . , : _ . . f _ :. □·1r·,.:;.:.,..c....t...,..~. •,·)\ ·· o ~ r .. ' . \ . . . - . n . r .. 1.,.'v- .d. i " _ - . : . · v ~ ~ ;1 e,J , ih ,. l _ ' .. l ,_ \ ! t,ad not ct~bgattd M Cfi..•l s to administer rnedkaU:1ns: io Reslf.tent 1 . Plan/Attestation St:atenient I hereby certify h'lat I have revlc1Ned tl,is report and have taken Gr wiH tal<e -tl•::tive. m~~e~a~ts~u~ri·/e}s 'toJ c~<::~rre:/:t2 th4is e.:~e ficiency. By ta;<:ing ths a(:tion. Aegis of Ouean /vme -at i,:, c;xnpl1'anee. v~~u1 tbs i,w..t antj / or re:'.:Jul2;tion on , , In a,:foit1r;1, I ~-111H in:p(en,s;nta svsternto rnbnitor anr.i ensure contir"<ued tompliance \Nit;--: th.is r&quh~mf.nt. WAC 388-78A-2600 P-oHcJes and procerlures. (\} The. 8'::isfsted living faciH:/ must develop m,d 1mplen1ent poti:.:.ies and pr::1,~edutes in st:,pport of services that are pr,:;.vid;;,J and c1re necessary tc: (2) Tl,-:: assisted living foc:i)it1· n~ust devi?.lop. irr,plement nnJ trarn staff p;;,rsons ::,n p<Jlides .:ind pn:;cedures t(1 ,Hidress v\·hat staff p~rr,,:,;-;,:;·.must do· This requirement was not met-as evidenced by: 8asEd on ob%,\··Jti,0(',, 1nterv;t::\f\', and re,:cmi rev',e~'-,. tJ,i:: .A.ss\ste.J Uv;n,J Faci;ity {t>.Lf) fa=led D irnp/ernent their poiici2s reg:a,Jing s/,. ., n m,;magement for 1 Df '! sarn0!ed nos-lJent (Rcsident 11' ..t,.rw developed a pr-essuie sore, a!)d a!'sc:, fmlf.i:I t;::i m,p[;;t~ent the,f p;)ki<:'s and prccf.,:lures t:i .::onsistentiy monitr}r ,md i:10,:;urrnmt !God ternpe.ratures (FTs) cit reqtutd h{,t [,flti ,:;(}hi FT ~Gntrc-1 prinr ti:.1 S<::l'Ving poter,tially hazardGLi-S food to l2 cf 11 residents in tni:-: Mernory Car,:; Unit (t-lCU). This restdti::d ,n r1.~ ed,,:-atian Care M an:age 1-s {non--h,:ensed st-aff me:ml:icrs) applying prescribed mt dk:at,ons to G:;;:-s.idef\t i's wo:...:nc 8nd piac:ei.1 i~esid::mt 1 at rls\ ford deteriorated healtt', condition. aniJ 12 res.irlents ,·n M(~U .at frsk f,:;r acqu:l(ng fDG;:i bam~ ,llness. Statement of Deficiencies License #: 2381 Compliance Determination # 47206 Plan of Correction Aegis of Queen Anne at Rodgers Park Completion Date Page 16 of 26 Licensee: Aegis Senior Communities LLC 10/14/2024 Review of an ND document binder showed no documentation to indicate the ALF properly delegated MCMs for administering medications to Resident 1. In an interview, on 09/13/2024 at 2:30 PM, Staff A (Health Services Director) acknowledged they had not delegated MCMs to administer medications to Resident 1. 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, Aegis of Queen Anne at Rodgers Park is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date WAC 388-78A-2600 Policies and procedures. (1) The assisted living facility must develop and implement policies and procedures in support of services that are provided and are necessary to: (a) Maintain or enhance the quality of life for residents including resident decision-making rights; (b) Provide the necessary care and services for residents, including those with special needs; (2) The assisted living facility must develop, implement and train staff persons on policies and procedures to address what staff persons must do: (n) Related to food services consistent with chapter 246-215 WAC and WAC 388-78A-2300 ; This requirement was not met as evidenced by: Based on observation, interview, and record review, the Assisted Living Facility (ALF) failed to implement their policies regarding skin management for 1 of 1 sampled resident (Resident 1) who developed a pressure sore, and also failed to implement their policies and procedures to consistently monitor and document food temperatures (FTs) at required hot and cold FT control prior to serving potentially hazardous food to 12 of 12 residents in the Memory Care Unit (MCU). This resulted in Medication Care Managers (non-licensed staff members) applying prescribed medications to Resident 1’s wound and placed Resident 1 at risk for a deteriorated health condition, and 12 residents in MCU at risk for acquiring food borne illness. Findings included…. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2381 Compliance Determination # 47206 Plan of Correction Aegis of Queen Anne at Rodgers Park Completion Date Page 17 of 26 Licensee: Aegis Senior Communities LLC 10/14/2024 SKIN ISSUE Review of the ALF’s policy titled Skin Management Protocol, revised 08/10/2016, under the section on Skin Observation/Wound Observation Record, showed that wound care other than first aid may not be provided in the ALF by anyone other than a licensed nurse or other licensed health care professional. Records review showed the ALF admitted Resident 1 on /2021 with a diagnosis of . Review of Resident 1’s Individualized Service Plan (ISP - equivalent to a Full Assessment and a Negotiated Service Agreement), dated 07/18/2024, showed that nursing staff would complete the “skin irritation treatments” ordered by a physician. The ISP showed that Resident 1 had skin breakdown on their bottom, and trained staff would manage “skin irritation”, including the application of creams as ordered. Review of a Progress Note (PN), dated 06/11/2024, showed that a caregiver reported to nursing about an open area on Resident 1’s buttocks. The PN showed a Wellness nurse assessed the wound and found a 1.5 centimeter (cm) x 1 cm open area. Review of a PN, dated 06/13/2024, showed that the wound had grown to 4.5 cm x 2.5 cm with redness around the edges with broken skin. Review of a PN, dated 06/19/2024, showed that the physician prescribed Silvadene (used to skin breakdown) cream to apply to the pressure sore on buttocks twice a day for seven days. Review of the June 2024 electronic Medication Administration Records (eMARs) showed that starting on 06/21/2024, MCMs, not nurses, documented they applied Silvadene to Resident 1’s open wound twice a day. Review of a faxed note to the physician, dated 07/04/2024, showed that Resident 1 had a wound that had been treated with Silvadene, but had not improved. Records review showed that on 07/05/2024, the physician had ordered Calmoseptine ointment to be applied to the wound. Review of the July 2024 eMARs showed that starting on 07/08/2024, MCMs, not nurses, documented they had applied Calmoseptine ointment to Resident 1’s wound. Review of a Current Skin Issue Observation Form (CSIOF), dated 08/05/2024, showed that a wellness nurse assessed Resident 1’s wound and measured it at being 2 cm x 1.5 cm. A CSIOF, dated 08/12/2024, showed that the wound was measured at 4 cm x 2 cm, having increased its size. Review of a PN, dated 08/15/2024, showed that the physician had ordered Silvadene cream to be applied to the wound. Review of the August 2024 eMARs showed that This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2381 Compliance Determination # 47206 Plan of Correction Aegis of Queen Anne at Rodgers Park Completion Date Page 18 of 26 Licensee: Aegis Senior Communities LLC 10/14/2024 starting on 08/16/2024, MCMs, not nurses, documented they had applied Silvadene cream to Resident 5’s wound. Review of a PN, dated 08/29/2024, showed that a Wellness nurse assessed the wound on Resident 1’s buttock. The PN showed that the wound appeared to be stage 3 (stage 3 ulcers have progressed to breaking completely through the top two layers of the skin and into the fatty tissue below), possible stage 4 (stage 4 pressure ulcers are the most serious and extend below the subcutaneous fat into the deep tissues, including muscle, tendons, and ligaments and can extend as far down as the cartilage or bone.) Another PN, dated 08/29/2024, showed that Resident 1 was sent to an emergency room for wound treatment. In an interview, on 09/13/2024 at 12:45 PM, Staff L (MCM) stated that she had applied the prescribed creams to the wound on Resident 1’s buttocks. In an interview, on 09/13/2024 at 2:30 PM, Staff J (Regional Registered Nurse) stated that once a resident had an open skin wound, the wound care should have been conducted only by licensed nurses, as stated in the ALF’s policy. FOOD SANITATION NOTE: Washington Administrative Code 388-78A-2305 Food sanitation. The assisted living facility must: Manage food, and maintain any on-site food service facilities in compliance with chapter 246- 215 WAC, Food service; NOTE: WAC 246-215-03525 Temperature and time control—Time/temperature control for safety food, hot and cold holding (FDA Food Code 3-501.16). (1) Except during active preparation for up to two hours, cooking, or cooling or when time is used as the public health control as specified under WAC 246-215-03530, and except as specified in subsections (2) and (3) of this section, time/temperature control for safety food must be maintained: (a) At 135°F (57°C) or above, except that roasts cooked to a temperature and for a time specified under WAC 246-215-03400(2) or reheated as specified under WAC 246-215-03440 may be held at a temperature of 130°F (54°C) or above; or NOTE: Washington Administrative Code 246-215-03515 - Temperature and time control—Cooling (FDA Food Code 3-501.14). (1) Cooked time/temperature control for safety food must be cooled, uncovered, protected from contamination, in equipment that maintains an ambient air temperature of 41°F (5°C) or less and: (a) In a shallow, uncovered, layer of two inches or less; or Review of the ALF’s Policy and Procedure (P/P), Time & Temp Guidelines for Foods Transferred from Main Kitchen, revised on 05/07/2024, showed, “The facility followed the state and federal guidelines on maintaining accurate food temperature records for potentially hazardous foods that have been transferred from the main kitchen to other This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2381 Compliance Determination # 47206 Plan of Correction Aegis of Queen Anne at Rodgers Park Completion Date Page 19 of 26 Licensee: Aegis Senior Communities LLC 10/14/2024 areas of a community for consumption.” The P/P included “A food temperature log shall be maintained daily for all meals served to the residents (breakfast, lunch, and dinner) and kept in the main Kitchen. A second temperature/time log will travel with the food to assure the time is being monitored throughout the process… The temperature/time logs shall be kept for a period of 12 months and destroyed thereafter.” In interview, on 09/13/2024 at 9:30 AM, Staff K (Assistant Care Director) stated FT were supposed to be taken and logged for breakfast, lunch, and dinner. Review of a FT logs, posted in Life’s Neighborhood (Memory Care Unit) showed that the log would be maintained at each meal period to record appropriate FTs. The log included instructions such as, “Hot foods should be kept at an internal temperature of 135 degrees F (°F) or warmer. Cold food should be 41°F or colder. Keep cold foods refrigerated or on ice until serving time” and “Minimum Internal temperatures: Beef, Pork, Lamb steaks, chops and roasts: 145 °F; Ground meats: 160 °F; All poultry: 165 °F; Ham: 145 °F; Eggs: °F; Fish and shellfish: 145 °F; Casserole: 165 °F; Vegetables, grains and legumes: 135°F.” Review of the FT log in dining room 2 (DR2), found inconsistent documentation of food temperatures as follows: There was no FTs from 08/26/2024 through 08/29/2024. On 08/30/2024: Only one food temperature was recorded at lunch for the soup. There were no other FTs recorded for breakfast, lunch, and dinner. On 08/31/2024, a serving of fruit at breakfast, showed an out of range temperature recorded at 79°F (cold temperature required 41°F (5°C) or less). There were no FTs recorded at lunch and dinner, except soup. On 09/01/2024, a serving of fruit at breakfast, showed an out-of-range temperature recorded at 80°F, the entrée recorded at 120°F. There were no food temperatures taken (except soup) at lunch and dinner. On 09/02/2024, There were no FTs recorded at lunch and dinner. On 09/03/2024, a serving of fish and shellfish at dinner, showed an out-of-range temperature of 90°F. On 09/04/2024, a serving of fruit at breakfast, showed an out-of-range temperature recorded at 80°F. There were No recorded FTs at dinner. On 09/05/2024 and 09/06/2024, there were no FTs recorded at lunch and dinner. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. 10.18.2024 15:09:14 State of Washington 20/27 Statt!m~nt of Deficien,:ies Uc.ens~ #. 238T FiJan ;,f Cmrn-ction .Aegis Gf Qi.i8Srl Anns «1 Rodg.e-ts Park CnmpistiGn Dati:i Page '20 of2f L;c~nsee-~ l,egi_s S!=nior. C orn~1~nfti~-~ lLC 'i 0/14/2024 On G::!i'l 2i2G.'.::'.4, a serying of fish and shelifish Jt dinnef., sha,N1;cl 8n out-ot-rangt tetnpf.rat;.J!'e ~t 126.'?~f'·. In an int~N,e\ 1;;·, 0n 08/'l 3/2024 at 1 'i: lO AM. Staff M (lnterir-n Food ServK•?.S rnredor) ad,;nowlt::dged the faiiur~ -:)r staff to monit!}f f;)Dd temperatu/l?.S and their pb[L'.'y' ar,d procedur'='s. Pl.in/Attest~tion Statement In additfo1. l ',">11H irnp!ernent a s;;stem to manitor and ens,}re ,:·ontinued ,:ampfian,:::e wit~, this requir€rnent. WAC 388-78A-3100 Safe sto.rage· of supplies and eqµipment. The assisted living fatiHty must secure potentially hazardous suppf:ies and equipment commensurate with the assessed needs ofresid:ents and their functional and cognitive abtlities. In determining what s.upptles and equipment mav be aecess:ible to residents, the assi.sted livfog facility must eonsider at a minimum: (2} The dt:gre-e of hazardousness Gr tc.1xicity posed ty H1 e- supplies or cqulp-rnent: This reqt.Jirement was not met as evidenced by: Based nn r:,bsw\,.1ati£in, inte,v,f1;\i, and ,e:.:,:,rd rc:v·ievi. the Assi:_,te-d L}vin~1 F ac.i!ity" (ALF) faded tG ~ect..::re toxk. ,J1,;:rni;:::,!s ,n c.1n area oCCf:S£itle t,:i ri:sidentr,_ T:1is faik,re plai:ed 34 ;:,f 34 t?31de11ts in th.:-, .ALF at ,·,sk k,r in:dvertent in~-;esti:::in of a tGxk: sub-srnnte that. Statement of Deficiencies License #: 2381 Compliance Determination # 47206 Plan of Correction Aegis of Queen Anne at Rodgers Park Completion Date Page 20 of 26 Licensee: Aegis Senior Communities LLC 10/14/2024 On 09/07/2024, there were no FTs recorder for breakfast, lunch, and dinner. On 09/10/2024, a serving of cold salad at dinner, showed an out-of-range temperature at 54 °F. On 09/12/2024, a serving of fish and shellfish at dinner, showed an out-of-range temperature at 126.7°F. In an interview, on 09/13/2024 at 11:10 AM, Staff M (Interim Food Services Director) acknowledged the failure of staff to monitor food temperatures and their policy and procedures. This is a deficiency previously cited on 02/27/2024. 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, Aegis of Queen Anne at Rodgers Park is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date WAC 388-78A-3100 Safe storage of supplies and equipment. The assisted living facility must secure potentially hazardous supplies and equipment commensurate with the assessed needs of residents and their functional and cognitive abilities. In determining what supplies and equipment may be accessible to residents, the 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 met as evidenced by: Based on observation, interview, and record review, the Assisted Living Facility (ALF) failed to secure toxic chemicals in an area accessible to residents. This failure placed 34 of 34 residents in the ALF at risk for inadvertent ingestion of a toxic substance 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. 10.18.2024 15:09:14 State of Washington 21/27 Stiitt'm8nt cf Deficiencies U,.:.ense: # 2381 Cornpliar,c.e Oete;min,ihm # 4i'206 Pian d Corrnction Aegis d iJt,1?.sn .A.:ins <i1 RodgeH Pa!k CnrnpistiI:<r1 boit& Pags "2'f d2f Findings \nduderJ ... r,( ~ ,ij., .. , . . ,. . ,- -.. , , o• \ f -. r . , ,, , . , .. . , t• , nda~ , . : • - . ., , ., - ., i . t'<; J r .Si . d< -.. > ..~ q . • ,. ('. ~ h . , , , .. . ., , , · - a ., - ~ ·-. t . < .. > ., fr; ... : .· l t i ~ "' s R '· ', ~ ,e ·- ;t - e . · r ' t . R . C •.. P . \ ,,' ~ ~ hO , ' ' " ir '" : ' : d • '-1'~ ,a • ·- • - · : ) -- , - ~ -- re- . s , • de -.t ·1 , 1s W" ,_ '- ,., " ... " _ ' . . ide,ltiff~,j as having i11:,'nt::riili~ (a woup cf symptonis th8t. affects memory. foinhing ant~ interferes vAJ--1 dail:..-Hre} or other togn,tve Impairment and t,at eight res.dents \•vere. 1oentit1ed as re,:e:iving.M ent.:il H- .. > ..... a1 ) fr t s ... ~ _-~ • 'lk .~ " c; " ... " > a,y · ~ '-'" /,- - . > .r h •' a v'' ~ ' J 1 -. a .., · a n,. , . , .. , . n , tal' ._ ; ., , . . . , . , ., ,. c: . :s • : It . h " ..., · ,i ~ :;:. s • " _ ' ..n~1..a-~r1A'1 ·.stnJ,.e.-,..r' • The A.LF's envirorvnent observatiocs with S'tai~ l (Qj;-,~dor of Opf.rati0ns) and $'tart H (l\>ts,ntcnarice, C;recMr), on D9i11/1G24 at rn:!38 AM. sho.ved a duoi fo the SalQG morn in the bi:.isement .vas uniock~.d. CbsHvati~;11 m the Sa!on HJ G,n1 shc~Ned Uue1:: bottes of ,:Jie(rn,:::alt:, 1ndudi1::g F-'eo.xde 1',,ti_,fa $utfacc:;; undei U1c sink in a bathroom. The: l8beis on these ct1::.n11::c:il t;:::;ttli::s sho~,wd.. ''Oang1::r'' ;:.1nd "f<eep ()ut nf R1c:a,:::;h of Ct,ilcktrt • The b2s:::1T1e..nt vv:::s: cISCes~,ibie t:J residents 1:-i the k,sisted Uvir:g units. In an tntef\.'ie\,\' o,; 09/1. tr?024 zit 11: 10 Afvl, Sta!f I stati=:cl t.har;.1 re,:e·pt10n¥st had ,mlock~d the door for the Sa!nn at around 8. 00 AM for a pe,'si:m wna W1Juld t,e using the Salon that aftemo;:ii'i. Staff I st,1ted that t.he· recel"t:on1st sMu!d n-:1t ~1ave opened trie Salon ,mt,r thi:: pe.rscr} arrived. PlanJAttestation St.atement I 1 t 1 . . . _ ,, , · , . .. , . ,t, · ' } 1 ~ · . · . · ... - ... " , I i t i ; ) " • , • ,~ h , • 0 s 1 , . I J '1 : · < • " n .A • '.J e r.; , . 1'·;: o ,. ? ·, V ,, ~ , ' , l. . - , , . \: ,, < . I = - , ~ ,, < i ' ~ \. 1 °1i ~ <· 1 . ' . . .. a .. > :,.. . .: " - ,Ol't - C ~ :, 1•1,-.-.>i . ~ ~ ~· O ·n. Y .-. ' : . : - . ~ '" , ~ -, · ; " . ' 0 -· . I , : 1 ~ ·~ , \, r \,< ';( d ~ : . t,.~,-r,t- .\... ,,,, · ~ · ' • - • . f J · ~ . 'e nwasures tn co;-rect t11is ct2f,.cienty. By t:al~ing this a,:tion ..~ egis GI Quei2.r: .Anne at Rod,.,-~e-,= rs Pz· ·t· is or i ? NlH ! ! tie . in rnmc·s li'afl::·e vvith · r · n ,s i'aw and i or re- · ;i uit'ition en •o·•· .. \ ~.~ -'-I-.J-I-J,-=G~""~=-1-- . In dd1jition, I vviH irnµlernent d 5'y-StenYto monitof i.t,ci ensvr~ :.:Dntinued sqrnpimnce ._,:;ith this recquii·~ment. Cate WAC 388-78A-2t20 Monitoring residents' well-being. The assisted living facility must: ( ~; Observe cash res.dent sons,stent with his Dr hi::r ~issesse,'.l needs and ne-gotiaa.c:d S'::fYic:~ a:J·eetYi~N; (2) ltient\fy :any chan~1es in tr,e resident's· physk:aL emononal. and mental fUf';Ct1on;ng tn~tt are a·. Statement of Deficiencies License #: 2381 Compliance Determination # 47206 Plan of Correction Aegis of Queen Anne at Rodgers Park Completion Date Page 21 of 26 Licensee: Aegis Senior Communities LLC 10/14/2024 could cause harm and compromise health. Findings included… Review of the undated Resident Characteristics Roster (RCR) showed that 26 residents were identified as having dementia (a group of symptoms that affects memory, thinking and interferes with daily life) or other cognitive Impairment and that eight residents were identified as receiving Mental Health services and/or having a mental health case manager. The ALF's environment observations with Staff I (Director of Operations) and Staff N (Maintenance Director), on 09/11/2024 at 10:58 AM, showed a door to the Salon room in the basement was unlocked. Observation in the Salon room showed three bottles of chemicals, including Peroxide Multi Surface, under the sink in a bathroom. The labels on these chemical bottles showed, "Danger" and "Keep Out of Reach of Children." The basement was accessible to residents in the Assisted Living units. In an interview, on 09/11/2024 at 11:10 AM, Staff I stated that a receptionist had unlocked the door for the Salon at around 8:00 AM for a person who would be using the Salon that afternoon. Staff I stated that the receptionist should not have opened the Salon until the person arrived. 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, Aegis of Queen Anne at Rodgers Park is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date WAC 388-78A-2120 Monitoring residents' well-being. The assisted living facility must: (1) Observe each resident consistent with his or her assessed needs and negotiated service agreement; (2) Identify any changes in the resident's physical, emotional, and mental functioning that are a: (a) Departure from the resident's customary range of functioning; or (b) Recurring condition in a resident's physical, emotional, or mental functioning 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. 10.18.2024 15:09: 14 State of Washington 22/27 Stat~rn~nt of Defici;,rn:ies Uc~nse #: 2381 Pian 0f C c,rrni:.tion Aegis d. iJi,~sn .A:ins a1 Rodg-Ns Park C r,mpistic,n b.o1tii L~c~nsi?:e-: ..l :,.agis S~njor. Co :nrnun~i~s LLC 10/14/2024 This requirem:ent was not met as evidenced by: 8;:,s:ed G:1 i11tervie'N, ar.d fe.<::Grd t'i:Vit::\N, u-;~ .As-s\sii::d Living F~Kility (A.LF} b il<::d tc mantor aod evaluate 1 of 1· sarrx,i€d fi'::sident"s {Res.tiff1t. I G} pain \ssue" Ti,isfaHure placcf.i R-esidem ·, 0 at risl< for dwninrshed quality Gt hfo i:iut: to c:.::peri-encmg pain. P:e:::ord review s1·1ov,-ed thatthe .ALF admitted Resident rn on /2024 witr, multiple dlaqn<}ses. F- . ; . ' . f ,. : , v·1 .. c ... . - s . , ~ ,' of ~ , f: , .,) .. ; . , ~ ;: • :, - i . , , - • i - c ~ . nt· '1 . i •J v -- ~ . _ _ . , 1 . ,: , , , - , L , , , ~ ~ .J -, . 1' , · _ ~ ,. ~ ,.. ; .- 't . _ , ~ \ ._ " .: " J " ; ' ; " > , , . - ,, c .. - •; · ·1·1 ; .. : . , . , ~ ., . ~ ·'L 1 i 1 t)l'i-,', ' . ' / : , f _ J ti · u ~, , l C ....~ ~ . . . . : r - - r r , J ,; t _ - , , .. , .r . F1 i" - a x 1 , . , .: l , . ; r- \ , , ii i ._ :p , -· - " c "q•u·1· , , t ,- : . . , . , . 1. • , • , 1 . 1 .; .. .. r· . u -, ['~eg;:it1:ated Se-rvice AgreerntntL ifa"te:d O;JiDGt2024_ shzwved Resident ·1i J t"t.HjLi1,ed assistance V'lith mi::dication servi•:es. R~,:ord re\.:~ev·t. Qate(l 0:2/'i 4.l2014: shnv·-. 1 -=d Resident: 1{ )'5 p~~y·sf~!an :Jn.ier.ed t~upr,:;ter: (used t:J: help reli;;ve rniid to rnoderat? prnn) tvvG tablets ev·':!ry six twu~s as ne:.eded. Review or the Ju!,-, .August, 2nd Septc,-nt,o::r 1024 ele<::tronk M,5Ji,<::;3t1<Jn A-::!ministratinn Rec•3rds (dvlAR,;} show-.;;d Residerit Hi requ~sted the as neederi 1buprden on ?3 r.:ic::,::2rn:lcns for pain. ·rh~ eM.AR.b shm-v:::d that st:af! rt,::m:Jed r~esident 10 tHitt some or no rti\ef"of t,dr pain from the lbuprofe:n. R;:;:ord r>:ovie\·.-er tl1t A.s-sessment, tiated 0S/W}/2U24 .-shoiNed n;:i intormatltJn rnii:lted tG u·ie n·mn_irnrlng c-r EV'aluation of the kicaticn of 'tht pain, v..-h2ff triggered the pai~•,, vvhat relie-sie.d the pain r, •. , - ,r R . " ._ 'S ..,_ .1 . j-e . r . l . t iI U . Gt • " 1 l -vh I = , /; , t ' , - " !. " . l " fH.iF ·' " · · ~ v· t .. h . < , > _ l~ ~~ ' ·. " . e . -: . :C . _ < .~ ''': .. b e-r •,·o, • · ; - :, · f +, . : , . _ ,_ ... , .. , _ r ~ , ·v< " > • n "' ; " . ' - : , - o .. ;, , : . , C ~ J' r ~,d-" .._ ' " • ' " L "' , IL:1 ; ; . : A ;t •- ::> v , fh >" .. p . l' . - :: - > '. ' I > >-- ' ~ i tL··, , . .J " " ,u l' ; " t I 'g v " her pain mei:k:arion. In an int.er--.;;i;w, G!~ IJS/13/2024 at "L20 PM_. Staff A H ealth Se1v1~:►.;s Oirecbt) achn,w..-i'=dged !h,rc had be en a iad--: i}f inon/roring for ReSident l D for pa,!"l. This ,s a recurnnq defi,:;iency pre\1fot~sty ,)ted uwter 2(a){t) 0n 02i2"!ll024. 2(a} en 01/2}/2023. ,ff1d 2(bj on·; 1/:Jlt:2021 Plan/A ttestatlon Statem e-l'lt I iH.:rttv sertify· that I ha~-'e r-e-,',•N~ed this n;·p,:irt ani_l hav-:: tah.:n ~w ',\lit take acuv 1 :i t~~~t~r117W:iit me.ar.,ures to C{lrred tt1is fieficiew:y. By t::.xing this a~:tian. Aegis of Oueen .A,·ir:e at in be c<:1m011:ancc v~~th tt,;S la,.•.. { and.:' Of" re-gu~2,tion (i!: In adciitk,-i. I '/1,il! in:pterntr'it a svstern to rnGnitor ani:i ensure contir"<ueJ -:Gmp!ian~e \Nit:, tl-1is requi~ernent. Statement of Deficiencies License #: 2381 Compliance Determination # 47206 Plan of Correction Aegis of Queen Anne at Rodgers Park Completion Date Page 22 of 26 Licensee: Aegis Senior Communities LLC 10/14/2024 has previously required intervention by others. This requirement was not met as evidenced by: Based on interview, and record review, the Assisted Living Facility (ALF) failed to monitor and evaluate 1 of 1 sampled resident’s (Resident 10) pain issue. This failure placed Resident 10 at risk for diminished quality of life due to experiencing pain. Findings included… Record review showed that the ALF admitted Resident 10 on /2024 with multiple diagnoses. Review of Resident 10’s combined Assessment/Individual Service Plan (A/ISP - equivalent to Negotiated Service Agreement), dated 09/06/2024, showed Resident 10 required assistance with medication services. Record review, dated 02/14/2024, showed Resident 10’s physician ordered ibuprofen (used to help relieve mild to moderate pain) two tablets every six hours as needed. Review of the July, August, and September 2024 electronic Medication Administration Records (eMARs) showed Resident 10 requested the as needed ibuprofen on 23 occasions for pain. The eMARs showed that staff recorded Resident 10 had some or no relief of their pain from the Ibuprofen. Record review of the Assessment, dated 09/06/2024, showed no information related to the monitoring or evaluation of the location of the pain, what triggered the pain, what relieved the pain for Resident 10, or when to notify the prescriber for effectiveness and evaluate the need to change her pain medication. In an interview, on 09/13/2024 at 1:20 PM, Staff A (Health Services Director) acknowledged there had been a lack of monitoring for Resident 10 for pain. This is a recurring deficiency previously cited under 2(a)(b) on 02/27/2024, 2(a) on 01/27/2023, and 2(b) on 11/01/2022. 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, Aegis of Queen Anne at Rodgers Park 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. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. 10.18.2024 15:09:14 State of Washington 23/27 Stat~m~nt ::::f Deficiencies F'Jan ,:;! Corrn;:.tiDn .Aegis Gf iJ1.,1?.sn A:ins <il Rodgern t-'atk Cr:rnp\.;,tiDn O.. it& Pa~t'=' "23 of2£ bc:lnsi:&: Aegis Seroio, C ornmunltic;s LLG ·\0/14/2[1'.?:4 Date WAC 388-78A-2240 Nona.vaUabitity of rn ed1eati<'ns. When th~ assi.sted IMng facility has a assumed r-esp.onsibility for obtaining resident's. prescribed medica.tions. th~ assi.sted Hvin9 b~IHty must obtain them in .i com~ct and tlmety manner. This require-numt was not met as evidenced by: Based n:n iritervie•.vs and record review. the Assist'3d Livir,9 Fadlrty (,t;,Lf} tailed to ensure p(t?.s;;(bfd s IT t > ' a E ~ , f ! : f j : , , . a - -_ - ,.( · s . 3 s t; 1- i , ,. s . . , , . t · . w a . ;.:) n V c •-; e ·e . r v . , - . " . v , i a th ,- '/ ~ Ii , r :; : n , 1 . a e • d ·>1- n ::P : "." a h ti • c · - .t m · · ... · _ i s ,.... e . i: , ~ f rv ,; : i 0 _· c e , :: - :l s . ~ ..J . , ' " .- T 1 ._ P h .1 ' i e s , · \ · _ j c . r a · x o :; , u , c .... , s . j ~ j e » . d . > .,.., : " ,. F ,. < _ • . .. : ' ,. · c _ ; ~ : R s : 1 : " '" - d '. < _ e . - ,: n i - • ._ t j s . ; . : , . . n ., 3 , t , s 8 ' ' . - i - . , :, ; • , : J . n ~ d a r n , n 1 d to 1 • ( · ; 9 \ l 1 : J v v , \ ,, ~ , ., , , , - ,. . t , , . h . f c - " 4 - u " • t 1 : iu . i • : -e -. ' . l r n -• ,- : 2 -. , • . . - .; . ) - .. , _ : , , ,, i k .. • , C ., - , . j . · '· , n , ~ 1 : .t s ; • 1 ~ .,. cl " '' • : • : ' J -' ,t 1··, .. . . . ., , , , , 7· ,; • : •, . 0 \: ~ ., r11 . ~ J , t . ' , ~ , C .~ ,, . , . . .. . . , . . . , ,. : . :! . . t .. • , ) , I' · :; · r> 1 " 1 'l : ~ « . t .. , , . ,w ,,, - , K , ~ -~ ~ ~ .. e ·'- A ~ ,· L ,- -10: - ,l , . l)_ "'t ; ; . A , ~ ,; • : - h ~· , ; . .. _ ,.o , J ~ -• , ! . 1 . - - ~ .. - . • .. - 1·,: ·' . - . • . t J , > ~ t: l · \ - . 1 : • :O 1 , s • Findings included .. f~;:;viev,1 ofthe .ALf-'.'s revised policy "Limited Supply C,dering Ba,:k-·up Medic~t!ons Process {.AH states):· dated DJinrnn S s!a'.ed, ''Ai! rnedications (i:yc:ed and mm-<;;/dti:iJ are k.1 ba re-0,·ctered v. ..- ~1<::n si::ven-d:ay supply rtrnair;s Tlv,~ M edi::atJ:ar:: (:;ye M,.rn:aJe1· (M CM} ls ;-espons,bie for foili:i•.-'.dng up ,rn a daily bas,s that the n1el'.i1catan ls receive~. imp[;:;rnerits the emerjency bac.~;.:!.ip rnedi,:ak,n proci:ss·i·vhen tte se;::cnci to last dost:-. of -a n,i:di:::atkin has t,~~n adrnin1stertd 21nd there is not a r· C · ' p - , · 1 ' , " , ". 1 . - ,· - - · " :- '1" l ·1 · < - = - > • - · ,1 • ' " ' l n•tH _ ' 1 U ' - " -'': " " ' fn _ - ( · , t.h- , > ,_,. i ~ ast ~ ~. . h , G .. c ... e . 1 . ')-~i~"= · = · di . · . · .. · . , ~ es t : 1 . t • in , s • , .. - , oni~ '" , ' . W ,,j ' ·h l jrn " ,.;.~ r' ) c - ! n-p -\ :·_ " , ' $ '- _ - ,.r • , .< - " · d · 1 ., n I ; iai: . L , r ~ . :- r . d ..,, l ' - , · r· e · d pt1am1tK\i. Th,;, Aeis ,:orr;m~mity' is ;-e-sporis1b:e fo, ordering tt,c rr,eo:k:ation The MCM cGntacts the P• h ar•f > l' ' : - i ' • - ~ -. , _ .. - - ;::~. ~ .... . . .> ;d ~. e -~ •1r -1~ f ~ v " I ' ' ·V .• " ~ '·' ] ' t - i " '\ ' ~ '- ' , • - ' ~ : ·•e , d ,~ f• _ · . · · at } ·. V .- . H .- _ , • , ~ , ' q ' , O ~ - ' .. a- . - .. · ~ : . .1.w i : ' c ·7. , ,. r ~ • I! 'f -:- ' · ;:ir- 1 · ~ · - J \t' • ' i l -1 . < -1 ''; ! _ , ~ , ._ . , ' : ) . l'fiv~ ._ ~ .... ,c · :: - l - t , . - ~ , -<->~-~"~i',~.. ..<,_>•~"h1 t , 1 ·• ' .~ C • V . f .. '· . f . ' . ' y ' f 1 ~ / J 'I pkt up tb:: med1cath:in to bring the medict1fan t~ the community. Ii' th:: nan- prefe~reJ pharmacy ·is unabie. to prnvid<?. the rne,i\catioi, in tir~r:;-, the MCM v,;,JI {1rder a 7-oay emer!JflEV ba.:il-up suppl~, or enough until thi:: m=dication is du2. ta bt deliv<::reu _f f m1i.kat\1::!i i::2nJ1ot t;;:, ootain2d, send a fax to the pres::rib;ng physic!an infGrming tncm tt1at tl1e medication ~s n-:it a\,·1,1\able " F~ESIDE!".!T 3 F:.:;;:-;:ord rtvie\\.' shovv,:,d that the ALF adinitted Ri:-s-ldent ~I en r2019 ..-~itn ,n.Jtipk dla9n-nes induding . Revie1,v 0f Resident 3's con~bined Assessrnentiindi'/d::.rnl S,;;r,1ice Plan (A.ii SP - the /SP is equi\'alent to f'..i e9otkned Servke ,t..greement). date;~i Q7 !'22i2.fr24, si·ie:v.-'>={1 ttiat Res.i:i::.,nt 3 rtquirei:1 a de.l:€ Jpt,:;d -staff and/ or li,;::er1-s;;:d nurse {LN;1 tu rdniirnsti::r their m1;;1fo::2ih0rss, inCllidfng fr1a special nutrition a! suppfen1ent Ens,Jrc ev~ry rr,eaL Feview of the .)unt,. julv .. and August ~024 e:l=dron,,: Medrc:JhD·n .t..;jrnini,strati"-n R~;:Grds {eM.ARs} shiJWed En&ffe H:rE-e tirrie.s ctai!y \N;:is: presuibed by a pt·iysldan since Statement of Deficiencies License #: 2381 Compliance Determination # 47206 Plan of Correction Aegis of Queen Anne at Rodgers Park Completion Date Page 23 of 26 Licensee: Aegis Senior Communities LLC 10/14/2024 Administrator (or Representative) Date WAC 388-78A-2240 Nonavailability of medications. When the assisted living facility has assumed responsibility for obtaining a resident's prescribed medications, the assisted living facility must obtain them in a correct and timely manner. This requirement was not met as evidenced by: Based on interviews and record review, the Assisted Living Facility (ALF) failed to ensure prescribed medications were available for 3 of 10 sampled residents (Residents 3, 8, and 10), who required staff assistance with medication services. This caused Residents 3, 8, and 10 to go without prescribed medications and placed them at risk medical health complications. Findings included... Review of the ALF's revised policy, “Limited Supply Ordering Back-up Medications Process (All states),” dated 03/27/2015 stated, “All medications (cycled and non-cycled) are to be re-ordered when seven-day supply remains. The Medication Care Manager (MCM) is responsible for following up on a daily basis that the medication is received, implements the emergency back-up medication process when the second to last dose of a medication has been administered and there is not a replacement in-house for the last those. Medications coming from a non-preferred / mail-ordered pharmacy: The Aegis community is responsible for ordering the medication. The MCM contacts the pharmacy to identify why the medication is not available and when it arrives, an Aegis employee will pick up the medication to bring the medication to the community. If the non- preferred pharmacy is unable to provide the medication in time, the MCM will order a 7-day emergency back-up supply or enough until the medication is due to be delivered. If medication cannot be obtained, send a fax to the prescribing physician informing them that the medication is not available.” RESIDENT 3 Record review showed that the ALF admitted Resident 3 on /2019 with multiple diagnoses including Review of Resident 3’s combined Assessment/Individual Service Plan (A/ISP – the ISP is equivalent to Negotiated Service Agreement), dated 07/22/2024, showed that Resident 3 required a delegated staff and / or licensed nurse (LN) to administer their medications, including the special nutritional supplement Ensure every meal. Review of the June, July, and August 2024 electronic Medication Administration Records (eMARs) showed Ensure three times daily was prescribed by a physician since This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. 10.18.2024 15:09:14 State of Washington 24/27 Stat~rnBnl cf Defidsncies license #. 2381 i=-"•ian d Ccmectic,n Aegis Gf Oti<?.sn A:ins a! Rodgets Park Cr;mpistion D.ite F'a~t<z 2-i ◊f 2f L~c~nsi;--e-: ,~i::gis Ser.1jor C 0:-nmuniti~s lLC ·\ 0/1 4/2024 ·12/ I·; /2020. Tht er-..JJ AR s s.hc-..l-J~d that an D£f}7.i20'24 at 6·. :30 F.:!,,~. O'"'/'t06t1.014 at ti30 Pr,.1 ~ 07/07/202~ at 6.3{) F-~M, 08/02/2024 at~ 2 00 PM, n:n 08/03/20::,\l m H.00 AM. LtOO PM and i3.3G f-lM. and 08.i0.4/2D2il at S:00 .AJ\11 and 12~Ch) F'~~1. :En.s.ure ~"vas not g}ven to Res~d~nt 3 bcca:Js.e it v~·c1s docutr:tnted as be!ng ui,avaifatle .. In an intetvl~•N_. c~ 09/'I 3/1024 ~it L20 f'M Srnft I (D\!·ector of Operati:::ins) an1 Staff .A. (Hea'th Sen1i<::es Director} ~E'.knG\·\'l=dgtd tt,£1t Resid".:nt '.3 tiad n•::lt rectNed Ensure- supplernem.s on th.: J;_:ys noted rn tr1e eMP8s beca,.,rn:e of supply i:SSU<=S. RESIDENTS F-~w:ord re-,Aew showed t!Ht· the: .ALF adrn;tted Re-sldentH on /2024 v,.,cth :-i,u!titile Jiagrwsis. R~vi<:.'N of R.es\di:x1t i;··s:A/ISP ciated 08/28/2024, shov,•ed Peside,'lt ~ re.qui.red assistan:co;; ~'\l'lU-1 me.:J;,:.:ahn:1 setvic'i:5. ReviB~-v of the Sepl,;;rnber 2014 eMARs showed that H physip.n prest.ribc::d R~sidentB ti} take minc;cyciin:., (us.eti ti:i: treat <l cert:3in type of skin condition s.~Hed rG:sace:c~) ev,£;iy rne:m1n:;i onct claily. Tf;e September 2024 e-M.A.Rs SllO\'Ved tnat the MC M doi::urnentf.d, ')£; D}.liH/2024 and D9i1Di2G24 at 1O J)i) PM,. minG-::yct,ne was rwt admmistered rE:cause-;t. ,\•as unavaiic~ble RESIDENT ·10 rn R:e:~0rd r~v\evv sh0vved that th;;; .ALF adrr1ltted Pe-side;nt 0n 2024 V;·\t-; mu1t1pi~ (Jiagn,Jses 1r1<::iLH:iiivJ Ri::view of Rf.Sident i Ts .A/ISP, dated C19/06!2024, s~1ovved R;;:side,1t 10 re:qufred assistan;:.e wiU, rTte(k:,Jtio:1 serv\c.es. rn Review of Phy-sk.:ian's Orders, dated 0:.?/'14/2014, sho',Ned R-es,dent vva-s prescribed a daily dose Gf Ap.ipr,.12.cie {Ust:d t;) trc :~t schzophre ni.a. tiipt,i;}r, and depressfon). Revie:1N ,:1f th,:; .. \t,gust 1024 e-M.AR sf'rn·~·ved that tt1e ApipVi.izol.:;, nn OB/2t3/2024 .. ,..-..a~ n,:,t g,ven b-eca..ise ;tv,as unav::idatile I1 1 an lntt::iVievli mi OBil 31'2024 at L :OP M, Staff I (Di!e;::t,::.r of Operatbns) and Staff A (Hi::.:dh Services O:re.cfor) acknc,.Ntedged r<:::sidents-sh(H..tii:l not run out M ,-r,edk:aticms. Pl.in/Attestation Statement I !1erety <:e!tif,{ tiwt I have r~view-ed H1is report and r1&ve tai-<en or \·\•Ui ta!<e Jct.\,:e rr:nge~a~s~u~r7e/s /tolf )•c;a :1,7--::{ this dd;.-::ii::n<.:y. By tal,ing ttns adion ..A eg;s ct G·ueen .Ar:ne at Ir: is ,◊')}J_n;t- ,::onrpltan;::e ~-vitl7 this law and/ or r.a::;1ui~t1on CG \ ,_ 2-<?.. --·-·'=+- in addition: l v\f:di Hnp;et~sent a systern t.::.i rnonrtor Hnd ens:u:·.e i.::.ontinued c;:.:rnp;j;)nce ·.t.~ith this requir;::rnent. Statement of Deficiencies License #: 2381 Compliance Determination # 47206 Plan of Correction Aegis of Queen Anne at Rodgers Park Completion Date Page 24 of 26 Licensee: Aegis Senior Communities LLC 10/14/2024 12/11/2020. The eMARs showed that on 06/27/2024 at 6:30 PM, 07/06/2024 at 6:30 PM, 07/07/2024 at 6:30 PM, 08/02/2024 at 12:00 PM, on 08/03/2024 at 8:00 AM, 12:00 PM and 6:30 PM, and 08/04/2024 at 8:00 AM and 12:00 PM, Ensure was not given to Resident 3 because it was documented as being unavailable. In an interview, on 09/13/2024 at 1:20 PM, Staff I (Director of Operations) and Staff A (Health Services Director) acknowledged that Resident 3 had not received Ensure supplements on the days noted in the eMARs because of supply issues. RESIDENT 8 Record review showed that the ALF admitted Resident 8 on /2024 with multiple diagnoses. Review of Resident 8’s A/ISP, dated 08/28/2024, showed Resident 8 required assistance with medication services. Review of the September 2024 eMARs showed that a physician prescribed Resident 8 to take minocycline (used to treat a certain type of skin condition called rosacea) every morning once daily. The September 2024 eMARs showed that the MCM documented, on 09/09/2024 and 09/10/2024 at 10:00 PM, minocycline was not administered because it was unavailable. RESIDENT 10 Record review showed that the ALF admitted Resident 10 on /2024 with multiple diagnoses including . Review of Resident 10’s A/ISP, dated 09/06/2024, showed Resident 10 required assistance with medication services. Review of Physician’s Orders, dated 02/14/2024, showed Resident 10 was prescribed a daily dose of Apiprazole (used to treat schizophrenia, bipolar, and depression). Review of the August 2024 eMAR showed that the Apiprazole, on 08/26/2024, was not given because it was unavailable. In an interview, on 09/13/2024 at 1:20 PM, Staff I (Director of Operations) and Staff A (Health Services Director) acknowledged residents should not run out of medications. 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, Aegis of Queen Anne at Rodgers Park 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. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. 10.18.2024 15:09:14 State of Washington 25/27 St.itt<m~nt cf Deficiencies Aegis d Ot,Bsri A:ini:: <i! Rodg.ets t'ark Cr,rT,ptsfa,n D..ite Page 2S of2l3 L~c~nst?~: ~l\.egi_s S~njor Cornrnuniti~s LLC iOtl 4/2CC4 WAC 388-78A-2305 Food sanitation. The assisted living fadlity must: ( 1} l1,1arr.::ige food •. cmd rna,ntain any on-site foGd service fm:.ifares in ;::ampbmce llVith chapter j4;3_2·1 s \/\(Al~. FO(ld sr::rv~ce; This requirement was not n1et-as evidenced by: Based ;:m ob-S-e!V2ihGns and intervievv. it;e .Assisted livh9 Faciity (.<\LF) failed li) ensuri:: i of 1 staff (Staff I<) properl,t \>\'ashed the=r hands. during food prep;;,rnton and before serving r-nc ::~ls tn resid-ents This fc1ih. . rt rfKed 'l 2 of i 2 residents in the Memory c~rr-e Unit 3t_ hsk for ·fKqulring fo,::dbome H!n'=ss . . 1,J(.iTE. \.-'Jashington Adrninistrar\;,~ Gode .24G-215-01.3D:.~ Hands and auns-"Clet,ri!n~1 prncedure. (Fcod and Drug Atitnirwstration Food Code 2-301. l 2). (1) Except as specified ir, sut;se:::ton {4) of this sccti•:in. frh:Sd e1T~1ioye.e·s shall dean tb:if 1·1tmds and txpose-ci p{,rtir:i=1s d tn>::·if arms, inchniing sum:;guhi prosthetic devi,.::es for hands oi a:rr-ns fur at \~ast 20 ser:omls. us;n,:i a deaning ,::orn<p-ound It " t o ,, ~ ,,, , ~ u ,. ; r-1 d, v A < , 1 -~ d c -- /1· ' i · -t '' ' ; f $ ' s• , r , · " ,i . ' : · tM ~• - ~ ~ t ~ L 1· .<~· 1,e_;,,.--.t:- . - f 1· - " • p. ·.. , .. U -~ o ., , .. _ ,_ -:~:>·>:~'"<-.>... ,~ .. , , . f , , . t :'-- -t.i. ~'v",,u'. - - ·~ - < .: > ; - r· , ¥ ,,, v _. . < ..., ,':,;_,'' .·:_;.:,1•;~ 1 J . - . '~> .i> ;•'-.-·, _i L ) : ; - ; . ~ . ) .. : l . .:,'.IJ - . o ., ,1d F) , , :. , . , ~ . t , - !; ' : '-•U. ': - V ... '< t} , ) • U -s 11· C. [kmng ob·;3.ervatin,1 at breakfast_ nn 09.h 3;'2024 at 8:55 AM, Staff t< (Ass;stant Cc1re Ccon:iinatGr). rr.~lltci hot_fo~H~ c..1rt fr,:im tr1e rnain ktd1en c~n the '2M lfaor into the iv1GU ;:lining ,t.l=::-rn 2 (DR2; f,:itt1en-.::tie \/Alrt£H..it handvvash,n9 or dunr,ing glcv1: s, Staff~-;: pulled nut loud ,::ontBinc:rs frorn fo~ hat c2irt (,nto ·tt1e steam table . .t ..t 9.03 .4M. ~vitf!1:rut ;,-vnsf·iing l1tt· l1ands or dcnnin9 gioves, Stsff \·( opened a ,::if;sv-.-er, ro,:ih· a thermometer. pui!e.d the tt1ern~cim.:;ter cr,ver. and ~\ithout wiping Gf ~anttizing the thernx,meter stern. tooI\ tt,f. t;:-mper~ture 01' a saus;:,ge fn:r,n U-,e steam tah/e, then prcceeded to t:::il<:e an.cfr,er-f'w;ci ti::rnperature ..A t that time Staff i~ vvas 0sr-:e<l v,h;;;n sl1e \.-'.")Uto '/\'c:::s~1 her hands during this pt,J<::es-s (lr if sh-e v~'.:luld s::rnitize thi:: ttemwmf.:ter. In intervie::,,,.,,, on DS/13/202,:l at S.DE, A.M, Staff~-( ~tated. 'I an, in a burr,\ be,::au~e it 1,Yas a/.r--::adv late for U1e n:sid~nts. but usual\· 1 wash tr>!f hat~ds.·' St"'tt }< ~ickn;::wl2:dged h~r i;;iu~ of hanJv,msl'iing ,Jr s-aniti:ring the 1.herrncn-1<::ter pr,m to r,andhng the fo,J,J f::ir re~,if.1i::nts. PI anfA ttestiiilti on Statement Statement of Deficiencies License #: 2381 Compliance Determination # 47206 Plan of Correction Aegis of Queen Anne at Rodgers Park Completion Date Page 25 of 26 Licensee: Aegis Senior Communities LLC 10/14/2024 Administrator (or Representative) Date WAC 388-78A-2305 Food sanitation. The assisted living facility must: (1) Manage food, and maintain any on-site food service facilities in compliance with chapter 246-215 WAC, Food service; This requirement was not met as evidenced by: Based on observations and interview, the Assisted Living Facility (ALF) failed to ensure 1 of 1 staff (Staff K) properly washed their hands during food preparation and before serving meals to residents. This failure placed 12 of 12 residents in the Memory Care Unit at risk for acquiring foodborne illness. Findings included… NOTE: Washington Administrative Code 246-215-02305 Hands and arms—Cleaning procedure (Food and Drug Administration Food Code 2-301.12). (1) Except as specified in subsection (4) of this section, food employees shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a handwashing sink that is equipped as specified under WAC 246-215-05210 and Part 6, Subpart C. During observation at breakfast, on 09/13/2024 at 8:55 AM, Staff K (Assistant Care Coordinator), rolled hot food cart from the main kitchen on the 2nd floor into the MCU dining room 2 (DR2) kitchenette. Without handwashing or donning gloves, Staff K pulled out food containers from the hot cart onto the steam table. At 9:03 AM, without washing her hands or donning gloves, Staff K, opened a drawer, took a thermometer, pulled the thermometer cover, and without wiping or sanitizing the thermometer stem, took the temperature of a sausage from the steam table, then proceeded to take another food temperature. At that time Staff K was asked when she would wash her hands during this process or if she would sanitize the thermometer. In interview, on 09/13/2024, at 9:05 AM, Staff K stated, “I am in a hurry, because it was already late for the residents, but usually I wash my hands.” Staff K acknowledged her lack of handwashing or sanitizing the thermometer prior to handling the food for residents. Plan/Attestation Statement This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. 10.18.2024 15:09:14 State of ~ashington 26127 Staterw~nt of Deficiencies Uc:::mse # 2381 Plan ,:,f Corrn{.tion Aegis Gf OtiB;rn .A.:irrn iit RoJge,s Park Cr; rnpfstic,n D.itt.' Pag~-26 c-f 2€ Lc~ns,;,~: .Aegis S!;!nior Cornmuniti'-'S lLC ·rnr14 !2024 ln aad,ti;:m, I ,",i!H ,rr:p(ernent ..i systr:rn t,J mcinitcr and ensure continued .::ornpirnnce ,1,;it; this ·eqrnremsnt. l Da te Statement of Deficiencies License #: 2381 Compliance Determination # 47206 Plan of Correction Aegis of Queen Anne at Rodgers Park Completion Date Page 26 of 26 Licensee: Aegis Senior Communities LLC 10/14/2024 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, Aegis of Queen Anne at Rodgers Park 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 PO Box 45600, Olympia, WA 98504-5600 October 18, 2024 ELECTRONIC-FACSIMILE Administrator Aegis of Queen Anne at Rodgers Park 2900 3rd Ave W Seattle, WA 98119 Assisted Living Facility License # 2381 Licensee: Aegis Senior Communities LLC IMPOSITION OF CIVIL FINE Dear Administrator: On October 14, 2024, the Department of Social and Health Services (DSHS), Residential Care Services completed a Full and Complaint Investigations at your facility. This letter constitutes formal notice of a civil fine on the license for your assisted living facility, also known as Aegis of Queen Anne at Rodgers Park, located at 2900 3rd Ave W, Seattle, 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 October 14, 2024. Civil Fine WAC 388-78A-2120 Monitoring residents' well-being. $700.00 The licensee failed to monitor and evaluate one resident’s pain issue. This failure placed the resident at risk for diminished quality of life due to experiencing pain. This is a recurring deficiency previously cited under 2(a)(b) on February 27, 2024, 2(a) on January 27, 2023, and 2(b) on November 1, 2022. NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Administrator Aegis of Queen Anne at Rodgers Park License # 2381 October 18, 2024 Page 2 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: Jamie Singer, Field Manager Region 2, Unit J 20311 52nd Avenue West Suite 100 Lynnwood, WA 98036 Phone: (253) 312-1446 / Fax: (206) 971-6971 rcsregion2email@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. Send your written request to: Informal Dispute Resolution Program Manager Residential Care Services PO Box 45600 Olympia, Washington 98504-5600 Administrator Aegis of Queen Anne at Rodgers Park License # 2381 October 18, 2024 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 $700.00 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 Aegis of Queen Anne at Rodgers Park License # 2381 October 18, 2024 Page 4 If you have any questions, please contact Jamie Singer, Field Manager, at (253) 312-1446. Sincerely, For: Matthew Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 2, Unit J RCS Regional Administrator, Region 2 HCS Regional Administrator, Region 2 DDA Regional Administrator, Region 2 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW SN

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 March 7, 2024 ELECTRONIC-FACSIMILE Administrator Aegis of Queen Anne at Rodgers Park 2900 3rd Ave W Seattle, WA 98119 Assisted Living Facility License #2381 Licensee: Aegis Senior Communities LLC IMPOSITION OF CIVIL FINES Dear Administrator: On February 27, 2024, the Department of Social and Health Services (DSHS), Residential Care Services completed a Complaint Investigation at your facility. This letter constitutes formal notice of civil fines on the license for your assisted living facility, also known as Aegis of Queen Anne at Rodgers Park, located at 2900 3rd Ave W, Seattle, 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 fines on the license are based on the following violation of the RCW and/or WAC as described in the attached Statement of Deficiencies (SOD) report dated February 27, 2024. Civil Fines WAC 388-78A-2120(1)(2)(a)(b)(3)(a)(b)(4) Monitoring residents' $2,000.00 well-being. The licensee failed to identify, monitor, evaluate and take action in response to changes in skin condition when one resident developed a wound. These failures resulted in the resident developing a large, infected unstageable wound without monitoring, nursing care or medical treatments. WAC 388-78A-2600(1)(a)(b) Policies and procedures. $500.00 The licensee failed to implement their policies regarding skin management and reporting changes of condition for one resident. These failures contributed to the Administrator Aegis of Queen Anne at Rodgers Park License #2381 March 7, 2024 Page 2 resident developing a large, infected unstageable wound without receiving the necessary care and services. WAC 388-78A-2640(1)(a) Reporting significant change in a $500.00 resident's condition. The licensee failed to report the recurrence of a pressure ulcer to the Primary Care Physician and Resident Representative for one resident. These failures contributed to the resident developing a large, infected unstageable wound, without any authorized medical interventions or treatment after December 21, 2023. NOTE: These are the violations, which resulted in the fines; 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: Jamie Singer, Field Manager Region 2, Unit J 20311 52nd Avenue West Suite 100 Lynnwood, WA 98036 Phone: (253) 312-1446 / Fax: (206) 971-6971 rcsregion2email@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). Administrator Aegis of Queen Anne at Rodgers Park License #2381 March 7, 2024 Page 3 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. Send your written request to: Informal Dispute Resolution Program Manager Residential Care Services PO Box 45600 Olympia, Washington 98504-5600 Formal Administrative Hearing You may contest the civil fines by requesting a formal administrative hearing to challenge the deficiency, which resulted in the civil fines. 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 fines are due to the Office of Financial Recovery twenty-eight (28) calendar days after receipt of this letter. Mail a check for $3,000.00 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, Washington 98507-9501 1-800-562-6114 (extension 45919) OFRMMISVendor@dshs.wa.gov Administrator Aegis of Queen Anne at Rodgers Park License #2381 March 7, 2024 Page 4 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. If you have any questions, please contact Jamie Singer, Field Manager, at (253) 312-1446. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 2, Unit J RCS Regional Administrator, Region 2 HCS Regional Administrator, Region 2 DDA Regional Administrator, Region 2 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW HP