Greenlake Emerald City.

Conclusion/ Action: ~ Failed Provider Practice Identified/ Citation(s) Written D Failed Provider Practice Not Identified / No Citation Written D N/A . Investigation Summary Report Provider/Facility: Greenlake Emerald City Provider Type: Assisted Living Facility License/Cert.#: 2696 Intake ID: 193217 Compliance Determination#: 65114 Region/Unit#: RCS Region 2 / Unit J Investigator: Cathy Prentice Investigation Date(s): 09/04/2025 through 10/31/2025 Complainant Contact Date(s): Allegation(s): 1. The Named Resident (NR) had a bruise on the forehead that was self inflicted with a hammer in an attempt to harm self. 2. The NR was found on the floor with a self inflicted injury to the head with an axe. 3. The NR had stopped eating, gave away possessions before harming himself. Investigation Methods: Sample: Total residents: 99 Resident sample size: 14 Closed records sample size: 4 Observations: Observed ALF residents, delivery of care and services; staff interactions with residents; residents' appearance; environment. Interviews: Named Resident not available: closed record review, 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: According to interview and record review: 1. The NR hit his head with a hammer in a suicide attempt. The facility failed to implement their Accidents, Incidents, and Unusual Occurrences, Ambulance (Emergency) Transport, Emergencies-Major Medical Emergency and Documentation, Mental Health Deterioration, Mental Health/Psychiatric Crisis, and Suicide Precautions policies. See Statement of Deficiency dated 10/31/2025. 2. The NR had suicidal ideation and plans from 10/27/2025 to /2025 when he self inflicted injuries in a suicide attempt with an axe. The facility failed to implement their Accidents, Incidents, and Unusual Occurrences, Ambulance (Emergency) Transport, Emergencies-Major Medical Emergency and Documentation, Mental Health Deterioration, Mental Health/Psychiatric Crisis, and Suicide Precautions policies. See Statement of Deficiency dated 10/31/2025. 3. The NR had suicidal ideation with behaviors and plans from 10/27/2025 to . /2025 including a suicide attempt on 09/02/2025. The facility failed to implement their Accidents, Incidents, and Unusual Occurrences, Ambulance (Emergency) Transport, Emergencies-Major Medical Emergency and Documentation, Mental Health Deterioration, Mental Health/Psychiatric Crisis, and Suicide Precautions policies. See Statement of Deficiency dated 10/31/2025. Conclusion/ Action: Ii Failed Provider Practice Identified/ Citation(s) Written D Failed Provider Practice Not Identified / No Citation Written 0 N/A . ~ · ...,%1~ STATE OF WASl-!J!NG,TON DEPARTMENT OF SOCIAL AND HEALTH SERV!ICES AGING AND LONG-TERM' SUPPORT ADMINISTRATION 16311 51.ndAve W, Si,he 10,(JI, Lynnwood, WA 9'1036 Statement of Def1c1enc1es license #. 2696 Compliance, Determ1n-atmn # 65114 Plan of Correction Green!ake Emerald City Completion Date 'r ou are required to be in compl'.iance at aH fones with aH licensing jaws and rng.ulatJons to maintain your Assisted Living Fadlity license_ Tlle department completed data collection for an unannounced on-site c0mplaintinvestigati,on on 09/04/2025 of: Greenlake Emerald City 9001 Lake City \Nay rN'E Seattle, WA 98 15 This document references the following complaint number(s): 193217, 19 '165 7, 194 64, 194321, 195584, 196668 The following sample was selected for review during the unannounced on-site visit 14 of 99 current residents an 4 former residents. Toe department staff that investigated the Assisted Living Facility: Cathy Prentice, Complaint Investigator From: DSHS, Aging and Long-Term Support Administration R,esi ential Care Serviices, Region 2 , Unit J 203:1 t 52nd Ave W, Suite 100 Lynnwood, WA 98036 . 01/30/2013 22:45 2057292700 GREENLAKE EMERALD PAGE 07/18 S'fa.ttmentof Deficiencies License'#: 2696 CQmpllance Detarminat,on #~114 Plan of-CorrectiQn Gn~enlak~ Emerald Git¥ Completi(rn D-at.e P;9e.2 • cf10 . Licans0a: Gref¼nla!k.e Seniof . Services LLC 10/3112025 . As a result of the on-site v1sit(s) the department found that you· are not in compliance with the 1 hcensing'faws· and regulations as stated in the cited..defitiendes in the ,enclosed repo.rt ~s.· • 11/13/2025 esidential cbrvic.es Date I under:stand ttiat to maintain an Assisted Living Facility license, tne facility must be in compliance. '1-Jith alt the lkensjng ·1aws and.r ·egulationi at all times·. • • • • • I D'ate W.AC 388-18A-2600 P.oltc1es a.nd procedures. (1) The assisted living facillty. must develop and implement policies and p.rocequres in support.of . services t11at are-provfd.ed a_nd are necessary.to: • • • • (a) ~aint~in or 1.nhence tht•q uality of life for r1s1dents including r:eside.nt 'deai~ion-m~king righ~; on (2) The ~s~isted living faciliLY must d@velop, impleme.nt-and train sta1'1' p~rsons pqlii:ie-sand prac~dures to address what staff persons must do: • (f) In response to medical emergencies; . . (g) 1/'V'hen there are urgent situations in the assisted.living facility requlring addition31.staff s.upport; (p) To coordinate-services and share resident information with outside·resources, con:sistent with WAC 388-76.A:-2350; • WAC·388•78Aoo2600 Policie~ and p"'cedurt1s. ( 1) The assJsted living facility must develop and implement policies-and procedure,s in support of services that are pfovided and are n_ecessary to; (_b) Provide the netessary care and services for residents, including those with special needs; Thi5 r■quirament wa$· not met as eviden11:ed by; Based on intervii:w and reC□rd review, the Assi:sted Living Facility {ALF) failed to irnpleri1ent their ,Atclcte.nt!i, lncld~nts, and Unusµ:al occurrences,.An1lulance (Em~rgenty) Transprirtr Emerge_hctes-: M~jor Medical Emergency .and Documentation, Meneal Health t)eter/oranon, Mem~I: • • Health/Psychiatric Crisis, arrd Suicide Pre'.calltions policies for 1 of 1 resident (ReSident 1~ who exhibited suitidat ideations and plansi and a·suic;ide a~mpt. This failure resulted in Resident t .not receiving iie.cessaty mental • • • • . Statement of Deficiencies License#:. 2696 Compliance Determination #65114 Plan of Correction Greenlake Emerald City C!lmpletion Date As a result of the on-site visit(s), tne department found that you are not in compliance with tlle licensing laws and regulations as stated in the cited deficiencies in the enclosed report_ ~ s· 11/13/2025 ~ ial cArvices I understand that to maintain an Assisted Living Facility license, the facility must be n compliance with all the licensjng laws and regulations at all times. Administrator {or Repre5en.ative) WAC 388-1.SA-2600 P0Hcies and procedures. 1 (1} The assisted living fadlity must develop and fmplement policies and procedures 111 support of services that are provided and are necessary to: (a) Maintain or enhance the qua~ity of lite for residents including resident decision-making rights; (2} The assisted Hving facllity must develop, implement and train staff pe sons on policies and 1 procedures to address what staff ersons must do: (f) In response · o medical emergenc;ies; (g} \f\ihen there are urgent situations in the assisted living facility requiring additional staff support; (p} To coordinate services and shaire ,resident information wi,th outside resources, consistent wil:h WAC 388~7BA-2350 ~ W.AC 388-78A-2600 1P0Hcies and procedures. 1 (1) The assisted living facility must develop and implement pol'lcies and procedures in support ot seNJees that are provided and are necessary to: (b) Pr-ovide bhe necessary care and services for residents, including those wroh special needs; This requirement was not m-et as evidenced by: Based on interviiew and record review, tlhe Assisted Living Faci1lity (ALF~ failed to implement their Acddents, Incidents, and Unusual Occurrences, Ambulance (Eme:rgency) Transport, Eme.rgencies M ajor Medical Emergency and Oo,cumentation, Mental Health Deterioration, Mental. Health/Psychiatric Crisis, an Suicide !Precautions pollc1es for 1 of 1 residen (Resident 'I~w ho exhibited suiddal ideations and plans, and a suicide attempt. This failure resulted in Resident 1 not receiving necessary mental . Statement of Heficiencies License#_2 696 Compliance- Determination# 65114 Plan of Correction Grnenlake Emerald City Ciimpletion Date Page 3 o{ 10 Licensee: Greenlaike-Se-ni<tr Services LLC 10131f 2025 hea(th servie:es and interventions which eontt1ibuted to a second :suicide attempt reqrnrmg hospitalization. F·indings included ... NOTE. Washington Administrative Code 388-78A-2120-Monitoring residents' welt-being_T he assiste living facility must (3) Evaluate, in order to d:€te :rmine if there is a 0e€ d for further action: b} Each resident when an accident or incident fhat is likely to adversely affect the resident's well-being, is observed by or reported to staff persons_( 4) Take appropriate- actron in response to each resident's changing needs.. Review cf the ALF policy,. "Accjdents, Incidents, and Unusual Occurrences~, dated 02/15/2024, sta. e,d on page 22, for r~sident acc1idents or unusual occurrences e facility were o immediately prnvide for safety and administer ffrst aide or call 9 1 if indicated. 1 Review of the ALF policy, "'Ambulance (Emergency) Transport', dated 02/15/2024, stated on page 28, ''When a res1dent dis-plays symptoms of a potentiaJly serious or lite-tihreatemng illness or sustains 1 a potentially senous or lifo-thre.atening injury, the supervisor or designee will ca I 911. Review of the ALIF poli{;y, "Emerge des-Major Medical Er"llergem::y and Documentation•, dated 02/15/2024, stated on p:age 55, ''V\llhen a resident shows any si-gns or Bymptoms of a riledkal crisis, 91 must b € summoned immediately_!

Statement of Deficiencies License #: 2696 Compliance Determination# 63313 Plan of Correction Greenlake Emerald City Completion Date You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for an unannounced on-site follow-up on 07/31/2025 of: Greenlake Emerald City 9001 Lake City Way NE Seattle, WA 98115 This document references the following SOD dated: 08/07/2025 The following sample was selected for review during the unannounced on-site visit: 19 of 90 current residents and O former residents. The department staff that inspected the Assisted Living Facility: Erin Steinbrenner, Nursing Consultant Institutional Faith Le, NCI From: DSHS, Aging and Long-Term Support Administration 20311 52nd Ave W, Suite 100 Lynnwood, WA 98036 . AUG/25/2025/MON 01 :38 PM Emerald City Seni~:_ __ FAX No. 206 P. 005 v, nu.nllll;:f\oVll 4/17 :;,t-.1fP r\'lPnt nf nPfiriPntiP'i I il'Pn'if' ~· 7AijR rnmrili.nrP. n,.t,.rmin'rltinn i R1'\1" Pl-an o·f Correction Greenlske Emerald Cily Cornpletion Date .Page 2 of 12 Liceo~ee: GreeniaKe senior Se.rvlees LLC 08/07i2025 As a result or ttie on-sI~e vIsIt(s) the aepartmem ~ound ttmt you are not in compliance with tt)e llcensin;g laws and regu1ations 3-s stated in-th~ cited deficiencies fn the enclos~d report, 08/19/2025 Date I understand that to maintatn an Asslsted Livl·ng Facility license, the facility must be :in compliance w[th all Hw licensing 'laws and regulations at .all times. Date WAC 38$-78A-2474 Training and home care aid~ certification requireme.nts. (2) The assiste-d livln9, facility must eosure all assisted livinQ facility administra~ors, or their designees·, and .caregivers hired en ,or after January 7, 2012 meet the long-te,n1 care.worker training r&Cjuirements Of chapter 388s112A WAC,•includin•g b.ut not limited to: · (d) Cardiopulmonary resuscitation and first aid; a11d (e) Contln.uing education. (3j The assisted li\/.ing facility must ensure that all staff receive appropriate training and orientation to perform their specific.job dutie·s and responsibilities. This req_uiremen:t was not met as evidenced by": Ba.sad on interview and record review, the .Assisted Living FaGility (ALF) failed ~o ensure 2 of 6 sti:\ff (Staff 8 and C) complete.d the required facility orientation. . Thi.!:\ placed the ALF>s 90 residents at risk of narm 1;1nd injmy from care staff who were unfam_il~rwith the fai;ility. Findings included ... NOTE: Washington Administrative Coda (WAC} 388-112A-0200 - VVnafis orient~tion training, who .should complE;?t~ it, and when -should it be completed? The~ are -two types of orientation training: Facility orientation training and long--term care worker orientation training. (1) Facility ori'entation .. lndlvid4als who are exempt from certlfica·Hon as des-crihed, in Revised Code of Washington 18.88B.041 and volunteers are r:equ1red to complete facil.ity orientation training before having routine Interaction with rs_sidents. Tni.s trainjng provid~s. _basic introquctqry information appropriate to th.e r~sidenti.al care setting and . Statement of Deficiencies License #: 2696 Compliance Determination# 63313 Plan of Correction Greenlake Emerald City Completion Date As a result of the on-site visit(s) the department found that you are not in compliance with the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. ~ s. 08/19/2025 esidential Car~s Date I understand that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. Administrator (or Representative) Date WAC 388-78A-2474 Training and home care aide certification requirements. (2) The assisted living facility must ensure all assisted living facility administrators, or their designees, and caregivers hired on or after January 7, 2012 meet the long-term care worker training requirements of chapter 388-112A WAC, including but not limited to: (d) Cardiopulmonary resuscitation and first aid; and (e) Continuing education. (3) The assisted living facility must ensure that all staff receive appropriate training and orientation to perform their specific job duties and responsibilities. This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure 2 of 6 staff (Staff B and C) completed the required facility orientation. This placed the ALF's 90 residents at risk of harm and injury from care staff who were unfamiliar with the facility. Findings included ... NOTE: Washington Administrative Code (WAC) 388-112A-0200 - What is orientation training, who should complete it, and when should it be completed? There are two types of orientation training: Facility orientation training and long-term care worker orientation training. (1) Facility orientation. Individuals who are exempt from certification as described in Revised Code of Washington 18.88B.041 and volunteers are required to complete facility orientation training before having routine interaction with residents. This training provides basic introductory information appropriate to the residential care setting and . AUG/25/2025/M0N 01 :38 PM Emerald City Senior FAX No. 206 P. 006 "'""°"''" :J/17 UI rtUJlttll::floVII Statement of Deficlencies License #: 26!;16 CornpJian_ce Determination-# 63313 Plan of Correction Graenlake Emerald City Completioti Date Page 3: ot 12 Lic~nsee: G~e,nla.ke Senio( Se_rvjee.s LLC 08(07/2025 population serve~. The depa_rtme.nt does not approve this specific orientation prograrn, rryateri'als, or -trainers. No t~st ls required for tt,rs qrientatian. Review of staff re.cards .showed the ALF hired Staff B (Caregiver) an 01/10/20-25 .. Record review o.f Staff' ffs record .showed no facility orientation training. Review of staff records. showed the ALF hired Staff C (Caregiver) on 05/26/2024. Record review of Staff C's rec0rd showed no facility orientci!lion training. e In an interview, oi, 07131/2025 at 3:30 PM, -Staff J (Business Office Manager) confirmed Staff and Staff C were stil_l employed and had not completed facllity orientation. S.taff J stated they are working pn new systems for onpoarding. This is an uncorrected deti:ciency under subsection (3) previo.usly cited on 06/05/2.025. Plan/Attestation Statement I hereby ce_rtify that I have reviewef;l this report c;1n_d have talc.en or will take aciive measures. to correct this deficiency, By taking this action, Greenlake Emerald City is or will be in complian:ce with this I.aw and/ or re-gl!l.a~ion on (Date) 'j ~ t 5 - Z,..F .. In: addition, I will implement a system to-mon.itor and ensure continued coropliance wit_h this requirement. Date WAC 388-78A-3100 Sa.fa storage of sup-plies ahd equipment. The assisted living .fac-ll_ity must secure potentially hazardous supplle.s and equt·pment commensurate with the assessed ne.eds of residents and their functional a.nd cognitive abilitres, In determining what supplies anq equipment rnay l,e "'<:cessrble to re.si.dents th~ assis.t~d liVin~ faciJlty must c;.on~h:Jer ftt a 1 minimum; (1). The re~idenis' characterist_ics and needs; (2) The-degree of hazardousness or toxicity p¢sed by the swppii~~ or equipment; ihis requirement was not met as evidenced by·: . Statement of Deficiencies License #: 2696 Compliance Determination #63313 Plan of Correction Greenlake Emerald City Completion Date population served, The department does not approve this spec.ific orientation program, materials, or trainers, No test is required for this orientation. Review of staff records showed the ALF hired Staff B (Caregiver} on 01/10/2025. Record review of Staff B's record showed no facility orientation training. Review of staff records showed the ALF hired Staff C (Caregiver) on 05/26/2024. Record review of Staff C's record showed no facility orientation training. In an interview, on 07/31/2025 at 3:30 PM, Staff J (Business Office Manager) confirmed Staff Band Staff C were still employed and had not completed facility orientation. Staff J stated they are working on new systems for onboarding. This is an uncorrected deficiency under subsection (3) previously cited on 06/05/2025. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Greenlake Emerald City 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 res'ldents' characteristics and needs; (2) The degree of hazardousness or toxicity posed by the supplies or equipment; This requirement was not met as evidenced by: . Statement of Deficiencies License #: 2696 Compliance Determination #63313 Plan of Correction Greenlake Emerald City Completion Date Based on observation, record review and interview, the Assi.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: Greenlake Emerald City Provider Type: Assisted Living Facility License/Cert.#: 2696 Intake ID: 158573 Compliance Determination #: 51554 Region/Unit #: RCS Region 2 / Unit J Investigator: Cathy Prentice Investigation Date(s): 12/11/2024 through 02/12/2025 Complainant Contact Date(s): Allegation(s): 1. The Assisted Living Facility (ALF) nurse neglected the Named Resident (NR) resulting in skin breakdown when he was left in bed for 1.5 months without treatment. 2. The ALF did not notify the family or physician of the NRs skin issues. Investigation Methods: Sample: Total residents: 91 Resident sample size: 20 Closed records sample size: 6 Observations: Named Resident (NR); 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: 1. Record review and interview showed the NR had an assessment and care plan that was appropriate to care needs. The NR had a significant decline in condition, was admitted to and receiving care from home health/hospice. Interview, with home health/hospice representatives showed no concerns his decline and subsequent wounds were a result of neglect in the ALF. The ALF failed to implement the facility skin care management policy see Statement of Deficiencies dated 02/12/2025. 2. Record review and interview showed the family were aware of the NR’s decline, skin issues and changes in conditions. The NR’s physician was aware and ordering appropriate home health/hospice care due to end of life process. No failed practice identified. Conclusion / Action: . Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: Greenlake Emerald City Provider Type: Assisted Living Facility License/Cert.#: 2696 Intake ID: 158569 Compliance Determination #: 51554 Region/Unit #: RCS Region 2 / Unit J Investigator: Cathy Prentice Investigation Date(s): 12/11/2024 through 02/12/2025 Complainant Contact Date(s): Allegation(s): 1. The Assisted Living Facility (ALF) nurse neglected the Named Resident (NR) resulting in skin breakdown when he was left in bed for 1.5 months without treatment. The nurse was not aware the NR had skin breakdown. 2. The ALF did not notify the family or physician of the NRs skin issues. Investigation Methods: Sample: Total residents: 91 Resident sample size: 20 Closed records sample size: 6 Observations: Named Resident (NR); 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: 1. Record review and interview showed the NR had an assessment and care plan that was appropriate to care needs. The NR had a significant decline in condition, was admitted to and receiving care from home health/hospice. Interview, with home health/hospice representatives showed no concerns his decline and subsequent wounds were a result of neglect in the ALF. In interview, the ALF nurse stated she was newly employed and in training while the NR had skin breakdown and not aware of many of the care needs of the residents at the time. The ALF failed to implement the facility skin care management policy see Statement of Deficiencies dated 02/12/2025. 2. Record review and interview showed the family were aware of the NR’s decline, skin issues and changes in conditions. The NR’s physician was aware and ordering appropriate home health/hospice care due to end of life process. No failed practice identified. . Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: Greenlake Emerald City Provider Type: Assisted Living Facility License/Cert.#: 2696 Intake ID: 159966 Compliance Determination #: 51554 Region/Unit #: RCS Region 2 / Unit J Investigator: Cathy Prentice Investigation Date(s): 12/11/2024 through 02/12/2025 Complainant Contact Date(s): Allegation(s): 1. The residents are being abused and neglected. 2. An Unnamed Resident (UR) was found dead on the bathroom floor and had no care plan. 3. Staff are diverting narcotics and other medications, and residents are not getting their medications as ordered. The Named Resident 1 was not getting medications as ordered. Staff are not getting training to pass medications. 4. Staff are being told to lie to the Department. 5. No one cleans resident rooms. 6. The Named Resident 2 (NR2) was not getting showered and has feces in apartment. Investigation Methods: Sample: Total residents: 91 Resident sample size: 20 Closed records sample size: 6 Observations: 2 Named Residents (NR); delivery of care and services; staff interactions with residents; residents' appearance; environment. Interviews: 2 NR's, 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: 1. Observation showed the residents were clean, comfortable and interacting easily with staff. Record review and interview showed the residents had appropriate care plans, appropriate staffing ratios, the ALF had an abuse and neglect policy in place and staff new how to identify abuse/neglect. In interview, sampled residents denied any issues with abuse and neglect and felt safe in the facility. No failed practice identified. 2. Record review and interview, showed the NR was assessed and care planned to . be checked by care staff four times per shift. The ALF failed to implement the care plan when they did not conduct safety checks as required. See Statement of Deficiencies dated 02/12/2025. 3. Observation and interview showed no concerns regarding medication diversion. The facility conducted an investigation and were unable to substantiate medication diversion. In interview, resident and the NR 1 denied any issues with receiving medications. Record review showed residents received medications as ordered. Record review showed staff were trained and had delegation in place to pass medications. No failed practice identified. 4. In interview, staff denied being told to lie to the department. No failed practice identified. 5. Observation showed resident apartments were clean. In interview, sampled residents denied any issues with environmental concerns. No failed practice identified. 6. Observation showed the NR2’s room was clean without feces. Record showed the NR2 had a care plan to be showered. In interview, NR2 denied any issues with showers, environment, care or services. No failed practice identified. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A .

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written . N/A . Investigation Summary Report Provider/Facility: Greenlake Emerald City Provider Type: Assisted Living Facility License/Cert.#: 2696 Intake ID: 166061 Compliance Determination #: 54598 Region/Unit #: RCS Region 2 / Unit J Investigator: Cathy Prentice Investigation Date(s): 02/11/2025 through 02/21/2025 Complainant Contact Date(s): 02/11/2025, 02/21/2025 Allegation(s): 1. The facility missed a prescribed monthly injection for the Named Resident in January and it is uncertain when the February injection was given. 2. The Named Resident (NR) had increased anxiety due to missing the medication injection. Investigation Methods: Sample: Total residents: 85 Resident sample size: 7 Closed records sample size: 1 Observations: Named Resident (NR); 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: 1. The facility failed to administer the injectable medication as ordered by the physician from November 2024 to February 2025. 2. There was no evidence documented of increased anxiety for the NR. The NR stated she felt good and had no concerns. See Statement of Deficiencies dated 02/21/2025. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . 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 #: 2696 Compliance Determination # 54598 Plan of Correction Greenlake Emerald City Completion Date You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for an unannounced on-site complaint investigation on 02/11/2025 of: Greenlake Emerald City 9001 Lake City Way NE Seattle, WA 98115 This document references the following complaint number(s): 166061, 164925, 161273, 167650 The following sample was selected for review during the unannounced on-site visit: 7 of 85 current residents and 1 former residents. The department staff that investigated the Assisted Living Facility: Cathy Prentice, Complaint Investigator From: DSHS, Aging and Long-Term Support Administration 20311 52nd Ave W, Suite 100 Lynnwood, WA 98036 . . Statement of Deficiencies License #: 2696 Compliance Determination # 54598 Plan of Correction Greenlake Emerald City Completion Date medication name, dose, and route of administration; (ii) The time and date of any medication assistance or administration; (iii) The signature or initials of the person providing any medication assistance or administration. NOTE- Medlineplus.gov stated the medication haloperidol was used to treat psychotic disorders (conditions that cause difficulty telling the difference between things and things or ideas that are not real). Do not stop taking haloperidol without talking to your doctor. Record review of a Face Sheet, showed the ALF admitted Resident 2 on 2024 with a diagnosis of . Review of an Assessment/Negotiated Service Agreement (NSA), dated 10/22/2024, showed Resident 2 required ALF staff assistance with some medications. Record review of the October, November, and December 2024 and January and February 2025 Medication Administration Records (MAR) showed a physician’s order, dated 10/04/2024, for a haloperidol injection 100 milligrams/milliliter, inject 50 milligrams (0.5milliter) intramuscularly every 30 days. Review of the October MAR showed haloperidol was administered to Resident 2 on 10/18/2024. Review of the November MAR, showed no documentation that the haloperidol injection was administered. Review of the December MAR, showed the haloperidol injection was administered on 12/28/2024. Review of the January MAR, showed the haloperidol injection was not administered. Review of the February MAR, showed haloperidol was administered to Resident 2 on 02/11/2025 with a note that stated the haloperidol was actually given, but not documented, on 02/03/2025. Review of the MARs showed the time between the haloperidol administration documented in October of 2024 and the next documented injection in December of 2024 was 51 days. The time between the haloperidol administration documented December of 2024 and the next documented injection in February of 2025 was 37 days. In an interview, on 02/11/2025 at 11:55 AM, Staff A (Health Services Director and Licensed Nurse) stated Resident 2 had a significant history of psychosis and the monthly haloperidol injection helped Resident 2. Staff A stated Resident 2 had behaviors such as yelling at invisible people when the psychosis was not controlled. Staff A stated she did not recall if the November of 2024 haloperidol injection was given. Staff A confirmed the December of 2024 injection was late. Staff A stated the January of 2025 injection late on 02/03/2025. In an interview, on 02/18/2025 at 9:20 AM, Collateral Contact 1 (CC1 – Resident 2’s Representative) stated Resident 2 was prescribed the haloperidol injections monthly to ensure psychosis treatment was on a regular time frame and blood levels of the . Statement of Deficiencies License #: 2696 Compliance Determination # 54598 Plan of Correction Greenlake Emerald City Completion Date medication could be maintained for optimal effect. CC1 stated Resident 2 had more behaviors and psychosis when the medication was not given on time every 30 days and the facility had not administered the medication as ordered since October 2024. This deficiency was previously cited on 08/09/2024. 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, Greenlake Emerald City 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-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. 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 conduct an evaluation when 1 of 7 residents (Resident 1) refused their . Statement of Deficiencies License #: 2696 Compliance Determination # 54598 Plan of Correction Greenlake Emerald City Completion Date medication. This failure placed Resident 1 at risk for a decline in health status. Findings included... Review of the ALF’s Resident Refusal of Medication policy, dated 02/15/2024, showed if a resident refused medication, continued refusal and potential effect would be evaluated and documented by a licensed nurse and the primary care provider would be notified. Record review showed the ALF admitted Resident 1 on 2024 with dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and Parkinson’s disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). The Negotiated Service Agreement (NSA), dated 11/12/2024, showed staff were to assist Resident 1 with medications. Review of the November and December 2024, and January 2025 Medication Administration Record (MAR), showed Resident 1 had a physician’s order for Carbidopa/Levodopa (C/L) (used to treat Parkinson’s symptoms) Immediate Release 25/100 milligrams (mg) three times daily, and Certivite Tab Senior (a supplement) once daily. Review of the MAR showed Resident 1 refused their C/L 28 times in November, 87 times in December and 70 times in January 2025. Review of the MAR, showed Resident 1 refused the Certivite 16 times in December and 25 times in January 2025. Review of a Progress Note, dated 01/14/2025, showed Resident 1 had been refusing medications and did not want medications to be offered everyday anymore. Record review showed the ALF had no documentation in Resident 1’s record of any licensed nurse evaluating the outcome of Resident 1’s medication refusals or notification to the physician about Resident 1’s pattern of refusals of the medications.

Findings included… NOTE: Washington Administrative Code (WAC) 296-842-12005 stated develop a complete work-site specific written respiratory protection program; 296-842-12010 Keep respirator program records; months after initial testing; 296-842-16005 Provide effective training on use of respirators initially and within twelve months of the previous training; 296-842-22005 Conduct medical evaluations with a medical questionnaire reviewed by a LHCP (Licensed Health Care Professional); 296-842-11010 Keep records of the current written respirator program and the LHCP recommendations. NOTE: A "Dear Administrator" letter, dated 04/30/2021, showed the Department informed ALFs of their responsibility to develop and maintain an RPP. An RPP is defined by DOH as a "federal and state OSHA (Occupational Safety and Health Administration) requirement to protect workers from exposure to respiratory hazards." Review of records showed the ALF’s written RPP, dated 11/09/2024, stated that all staff who use a respirator mask must have a medical evaluation first. In addition, the RPP stated it was mandatory that all staff be fit-tested for the respirators before use. Review of RPP records showed Staff C (Caregiver) did not have a medical evaluation for a respirator mask completed. Records showed Staff D (Caregiver) did not have a medical evaluation for a respirator mask completed. Records showed Staff F (Caregiver) did not have a medical evaluation for a respirator mask completed . 1/10/2025 SB confirmed ammended POC date with provider on 12/18/2024. . 12. 16. 2024 11 :4 5: 16 State of Washington 8/13 St~'t~f1H~ntolDefidenpie.s Ucens~ #'. 2695 .C -Qi11pHanr.;e-q~t#rnin.:eitit<"n #E03&9. F 1i .i~ !)f do!"fMtlor~ . G.t~_,,ml.ike,eme:r~kl Cit) Ct Hnpl~tb11 D-.ite P::igi:3- ·of 5 ln additl~r,, i \~in irnplerne:nt ;:.1 svsteq1 tq n19nitor ):Ind e:q~J,(e contim1ed cm"T}plia,nce Wlth th.i~ r~q~1irenwnL · W:AC-.388-7-8A~1240 Nonaval1ibillt1 of 1:11 edfo~tlo:n~·, When the·a~$l'Sted livtngf~"'mty has ~s~mj1_ed re~p--on$ibHity flj:r obt'.tdning aiejsident$. ·preiseribed-m e4fo-~ti~n.1._; thfl ,~~s;httd Uvh1g fi¢ltlty nfost t>btaJn th~m fn a eorreet11nd timely m,an.n~t\ Btlsed-D:n int~J\iiew t~nd r~Y:nrJ, r~vh~~,.._ th~ .~ti$i~t.~:i.d ·U virig.F"aGUity _(:t1.Lf} 1'aHod tn e ns_me phyttd.an's. oroff~ll m~-dicatfor-1was l'lV81lilble for 1 of. 2 ren'idenls{Rt~iti'ent l), Tht.$ fath.1r~ resulted tr} Rer~:i(ient t l'l)itsirq} ;:§(~~es ~f thfff~ pt1y)~id~rri'S 0fdereJ ·m e·di{atii.:1n$; H!'l!1,.-:r1'a,~ed Resident i at rlsk.-bf hmm .. i>JbTE- Mi1:dlf.ii:l':"plu_*:9lW $liited tht i'nedfo;.:1ti.G:t1 Arnlodf~)1ne is uis~ci ~~kme or iti ,:;_(lmfonatfoh 'w\~th oth::~r r,itdk.athnsto tn~•ffl higr1 blood µ:ressure ,n adults. Take aiplodtplne ex~ctlv c.1S :fattcte<l, Dn rwt-bake rnare ~r !ii:S$ al it or take. it i'nm·e: often th~i.1 prn:-s.cJihEd o,;your do ct.or. - . 1 Statement of Deficiencies License #: 2696 Compliance Determination # 50369 Plan of Correction Greenlake Emerald City Completion Date Review of RPP records showed Staff C did not have a respirator mask fit-test completed. Records showed Staff D did not have a respirator mask fit-test completed. Records showed Staff E (Caregiver) did not have a respirator mask fit-test completed. Records showed Staff F did not have a respirator mask fit-test completed. During an interview, on 11/19/2024 at 11:50 AM, Staff A (Acting Administrator) confirmed that Staff C, D, and F had not had a respirator mask medical evaluation and Staff C, D, E and F had not been fit-tested for a respirator mask. This is an uncorrected deficiency previously cited on 09/24/2024. 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, Greenlake Emerald City 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-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 interview and record review, the Assisted Living Facility (ALF) failed to ensure physician’s ordered medication was available for 1 of 2 residents (Resident 1). This failure resulted in Resident 1 missing doses of three physician’s ordered medications, and placed Resident 1 at risk of harm. Findings included… NOTE- Medlineplus.gov stated the medication Amlodipine is used alone or in combination with other medications to treat high blood pressure in adults. Take amlodipine exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor. . Statement of Deficiencies License #: 2696 Compliance Determination # 50369 Plan of Correction Greenlake Emerald City Completion Date NOTE- Medlineplus.gov stated the medication Eliquis is used to help prevent strokes or blood clots in people who have atrial fibrillation (a condition in which the heart beats irregularly, increasing the chance of clots forming in the body and possibly causing strokes). It works by blocking the action of a certain natural substance that helps blood clots to form. Do not take more or less of it or take it more often than prescribed by your doctor. NOTE: Medlineplus.gov stated Duloxetine is used to treat depression in adults and generalized anxiety disorder (GAD; excessive worry and tension that disrupts daily life and lasts for 6 months or longer) in adults and children 7 years of age and older. Duloxetine is also used to treat pain and tingling caused by diabetic neuropathy (damage to nerves that can develop in people who have diabetes) in adults and fibromyalgia (a long-lasting condition that may cause pain, muscle stiffness and tenderness, tiredness, and difficulty falling asleep or staying asleep) in adults. Take duloxetine exactly as directed. Do not take more or less of it, take it more often, or take it for a longer time than prescribed by your doctor. Review of the ALF’s Plan Of Correction, submitted to the Department for unavailable medications, from citation dated 09/24/2024, showed the facility would conduct audits of all residents’ medication supplies, and monitor bi-weekly for compliance of medication availability on medication administration records. The facility alleged compliance by 11/08/2024. Record review of a Face Sheet, showed the ALF admitted Resident 1 on /2024 with a diagnosis of and and . Review of an Assessment, dated 08/02/2024, showed Resident 1 received total assistance with medications from staff. Review of a Negotiated Service Agreement (NSA), dated 02/22/2024, showed Resident 1 required total assistance with medication management. Record review of a November 2024 Medication Administration Record (MAR) showed Resident 1 had physician’s orders, dated 07/12/2024, for amlodipine 10 milligram (mg) once a day; Eliquis 2.5 mg twice a day; and an order dated 09/30/2024 for duloxetine 30 mg twice daily. Review of the MAR showed Resident 1 missed nine Amlodipine doses from 11/10/2024 through 11/19/2024; missed 20 Eliquis doses from 11/09/2024 through 11/19/2024; and missed 19 doses of duloxetine from 11/09/2024 to 11/19/2024 due to, “medication not on hand.” Record review showed no documentation the ALF contacted the pharmacy or Resident 1’s physician regarding any missing medications in November 2024. In an interview, on 11/25/2024 at 11:30 AM, Staff B (Health Services Director) confirmed the above missed medications due to unavailability and stated she was not aware . 1/10/2025 SB confirmed ammended POC date with provider on 12/18/2024. . 12.16.2024 11:45:16 State of Washington 10/13 Sfa~,f,r11~ntafDefiden9ie.s Ui~ns~ #' 2690 .G pi11plia nr.:e D~l ~tini nati'On #@368 ~)hm of Corr~H,llt:tn Gtii<•rni~ke Ern~r,&! ·city ,C(Hnpl~fi~<fl 0-.Qtij Pagli,, S' nf 5 ·t 'l i'1S/1024 Re,~i:detl;t ·l did fl1)t b:ave m,::dit.~UOtl~: Gl\l'~ilabl~ in November 2-024 St~ff $: stat~d the fac"iHty h;:td i$~ues with .nwdh:atimi avaJt~Mi.ty and they '~,i.Je,n:1 Wt f.iroce_'$s Joi i:orter;ting bLrt. ton'\::i;tiiins \"lieri 11dr ·,it · ·· · · · · · ·· l ' ~ ' • a . ' -rr · t ; ~ ~ .. i , e· • 1 t · V "' ) : , . 1 \ ' '" 'j_.,.-. , PJ~n.JA tt:est~tic:,.n ·st~tti!ment. l herr.:tiv -ce1tif_r' th.3t i. h~w-e t'eV~ewed this rf·port anu 11.ave tirl,en :Qr wlH tak~ .active · mlll·:as:tir~~ to ,,::arr~d thiE defi:deiu~y. 8>r' t~idng,·this sdit,ri., rn~eenlak'°' Em~i'a!d Cltv ts 1.Jf V"liH b~ lfl 5 ,.:amp~i~nce witi~ th1~ la),;¥.a nq l >Jr !'~guia!~on Oil {Dat:~} ,;JJ:g}21x"_, .. l:r1 Addlti·' "~ I ,.in irwlf~,rr~ent a .t~y'· ~·~e.rn l,Hi'Mih'P' ~-i·id ent" 11·~ tt~iritfouhi°''fi'r:l~Jriunf-.. \,-_;\th , . :i: ... . ~t~ ~ f-~~- ,; ·t" :\:.i ~:" _ .'W '°?\ . _, .. ,. _t ,. . , ....l ,. · ·--~'-1 .. .r •., _____ ··"-"'··•":· " <.., ~ . --=~• ~ .. . · ,....., .-.. -.·-.. thi/3 reguiri?.ffteht.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . . . "' 1 .