Vineyard Park at Queen Anne Manor.

Findings included... Record review, on 09/16/2025, showed the DOS noted in Section 3C titled “Intermittent Nursing Services”, stated the facility typically had a registered nurse in the building for five days per week totaling 40 hours per week. During a meeting with Staff A (Administrator) on 09/16/2025 at 12:45 PM, Staff A confirmed the facility did not have a licensed nurse in the building 40 hours per week as stated in the DOS, and the registered nurse was in the facility usually one day per week. When Department Representative pointed out the DOS stated the facility had an RN in the building 40 hours per . Statement of Deficiencies License #: 2745 Compliance Determination # 65716 Plan of Correction Vineyard Park at Queen Anne Manor Completion Date week, Staff A stated she was currently working on updating the DOS. Review of an email, dated 09/17/2025, Staff A stated the DOS had been updated and a copy was attached. The updated DOS, signed by Staff A, showed in Section 3C titled “Intermittent Nursing Services”, the facility did not have a licensed nurse in the building. Review of an email, dated 09/18/2025, Staff A confirmed the reduction in having a licensed nurse in the building had occurred when the facility changed ownership on 04/01/2025. Staff A stated the new DOS would be sent to the legal representatives and a copy given to the residents now. In interview, on 10/02/2025 at 2:10 PM, Staff A confirmed that if the nursing care in the building was reduced prior to the DOS distributed to residents that stated the building typically had a registered nurse five days per week totaling 40 hours per week, that did not meet the requirement of notifying the resident of a reduction in care with a 30 day notice. . Statement of Deficiencies License #: 2745 Compliance Determination # 65716 Plan of Correction Vineyard Park at Queen Anne Manor Completion Date Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Vineyard Park at Queen Anne Manor 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 .

Conclusion / Action: Ii 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 2031152nd Ave W, Suite 100, Lynnwood, WA 91036 Statement of Def1c1enc1es License#. 2745 Co mphance Determin at1on # 60658 Plan of Correction Vineyard Park at Queen Anne Manor Completion Date You are required to be in compliance at all times wrth 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 06/05/2025 of: Vineyard Park at Queen Anne Manor 10 0 Crockett St Seattle, WA 98109 This document references the following complaint number(s): 180731 The following sample was selected for review during the unannounced on-site visit 14 of 80 current residents and Of ormer residents. The department staff that investigated the Assisted Living Facility: Cathy Prentice, Complaint Investigator From: OSHS, Aging and Long-Term Support Administration 20311 52nd Ave W, Suite 100 Lynnwood, WA 98036 . Statement of Defic1enc1es I...Jcense #. 27 45 Compliance Determination #60658 Plan of Correction Vineyard Park at Queen Anne Manor 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 regulabons as stated in the cited deficiencies in the enclosed report. 06/30/2025 Date I un rstand that to maintain an Assisted l.Jving Facility license, the facility must be in com liance with all the licensing laws and regulations at all times. / Date WAC 388-78A-2710 Disclosure of services. (1) The assisted living facility must disclose to residents, the resident's representative, if any, and interested consumers upon request. the scope of care and services it offers, on the department's approved disclosure forms. The disclosure form shall not be construed as an implied or express contract between the assisted living tacilrty and the resident. but is intended to assist consumers in selecting assisted living facility services. (2) The assisted living facility must provide the services disclosed. This requirement was not met as evidenced by: Based on interview and record review the Assisted Living Facility (ALF) failed to develop or provide a Disclosure of Services form that described the scope of care provided by the facility. This resulted in 80 residents not kno...ving the level of care and services available. Findings included ... Record review. on 06/05/2025. showed a Disclosure of Services (DoS) form that was written for a different ALF. Record review showed the ALF did not have a completed DoS form. In a telephone interview. on 06/05/2025 at 12:45 PM, Staff B (Administrator) stated the ALF had not developed their own Dos. Staff B stated that because the ALF had not developed a Dos, none of the residents received a copy of the scope of care and services the facility provided. . Statement of Deficiencies l..Jcense # 27 45 Compliance Determination #60658 Plan of Correction Vineyard Park at Queen Anne Manor Completion Date Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Vineyard Park at Queen Anne Manor is or wIill be in compliance with this law and I or regulation on jl ~S" . fr (Date) I addition, I will implement a system to monitor and ensure continued compliance with t s r qu1rement. entative) WAC 388-78A-2090 Full assessmenttopics. 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: (10) Individual's personal identity and lifestyle, to the extent the individual is willing to share the information. and the manner in which they are expressed, including preferences regarding food, community contacts, hobbies. spiritual preferences, or other sources of pleasure and comfort. This requirement was not met as evidenced by: Based on observation, interview and record review, the Assisted Living Facility (ALF) failed to ensure Assessments, for 11 of 11 residents (Residents 1, 2. 3, 4, 5. 6, 7, 8. 9. 10, 11) living on two Memory Care Units (MCU}, included preferences for hobbies and activities. This placed Residents 1, 2. 3, 4, 5. 6, 7, B, 9, 1O , 11 at nsk of not having an activity program that was tailored to their interests. Findings included ... NOTE: Washington Administrative Code 388-78A-2180 - Activities. The assisted living facility must: ( 1) Provide space and staff support necessary for: (a) Each resident to engage m independent or self-directed activities that are appropriate to the setting, consistent with the resident's assessed interests, functional abilities, preferences, and negotiated service agreement; and (b) Group activities at least three times per week that may be planned and facilitated by caregivers consistent with the collective interests of a group of residents. (2) Make available routine supplies and equipment necessary for activities described m subsection (1) of this section. . Statement of Deficiencies License #. 274 5 Compliance Determination #60658 Plan of Correction Vineyard Park at Queen Anne Manor Completion Date Page 4 of6 Licensee: Queen Anne ALC LLC 06/25/2025 Observation in the first floor of the Memory Care Unit (MCU), on 06/05/2025 at 1.00 PM, showed no group activities taking place, no individual activities taking place and no activity schedule available for the residents. Residents were observed either sleeping or sitting in their chairs in the dining area with no activ,ties or engagement. Record review showed the ALF admitted Resident 1 on /2024, with a diagnosis of . Review of an Assessment. dated 04/09/2025, showed a section titled. Hobbies/Interests/Activities wtth a note that stated ·see below" however there was nothing listed below. The Assessment had no preferences or interests tor activities listed for Resident 1. Record review showed the ALF admitted Resident 2 on /2023, with a diagnosis of . Review of an Assessment, dated 04/25/2025. showed a section titled, Hobbies/Interests/Activities with a note that stated ·see below however there was nothing listed below. The Assessment had no preferences or interests for activities llsted for Resident 2. Record review showed the ALF admitted Resident 3 on /2021, with a diagnosis of . Review of an Assessment, dated 04/25/2025, showed a section titled. Hobbies/Interests/Activities with a note that stated "see below" however there was nothing hsted below. The Assessment had no preferences or interests tor activities listed for Resident 3. Record review showed the ALF admitted Resident 4 on 11023, w,th a diagnosis of . Review of an Assessment dated 04/09/2025, showed a section trtled. Hobb1es/lnterests/Activ1ties with a note that stated ·see below" however there was nothing listed below. The Assessment had no preferences or interests for activities listed for Resident 4. Record review showed the ALF admitted Resident 5 on /2024, with a diagnosis of . Review of an Assessment, dated 04/25/2025. showed a section titled, Hobbies/Interests/Activities with a note that stated ~see below however there was nothing listed below. The Assessment had no preferences or interests for activities hsted for Resident 5. Record review showed the ALF admitted Resident 6 on /2024, with a diagnosis of . Review of an Assessment, dated 04/09/2025. showed a section titled Hob bies/1 nterests/Activities with a note that stated • see below however there was nothing listed below. The Assessment had no preferences or interests for activities listed for Resident 6. . Statement of Deficiencies l.Jcense #. 27 45 Compliance Determination #6065B Plan of Correction Vineyard Park at Queen Anne Manor Completion Date Record review showed the ALF admitted Resident 7 on /2023, with a diagnosis of . Review of an Assessment, dated 04/09/2025, showed a section titled. Hobbies/Interests/Activities with a note that stated "see below" however there was nothing listed below. The Assessment had no preferences or interests for activities listed for Resident 7. Record review showed the ALF admitted Resident 8 on /2024, with a diagnosis of . Review of an Assessment, dated 04/09/2025, showed a section titled. Hobbies/Interests/Activities wrth a note that stated ·see below" however there was nothing listed below. The Assessment had no preferences or interests for activities listed for Resident 8. Record review showed the ALF admitted Resident 9 on /2024, with a diagnosis of .