Dungeness Courte Memory Care.

—: WA DSHS report: Investigations (03/2025) —: WA DSHS report: Investigations (03/2025) —: WA DSHS report: Investigations (03/2025)

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. 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. 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 HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 February 13, 2024 ELECTRONIC-FACSIMILE Administrator Dungeness Courte Alzheimers Community 651 N Garry Oak Dr Sequim, WA 98382 Assisted Living Facility License #1328 Licensee: Dungeness Courte Alzheimers Communi IMPOSITION OF CIVIL FINE Dear Administrator: On January 31, 2024, the Department of Social and Health Services (DSHS), Residential Care Services completed a follow-up visit at your facility. This letter constitutes formal notice of a civil fine on the license for your assisted living facility, also known as Dungeness Courte Alzheimers Community, located at 651 N Garry Oak Dr, Sequim, 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 January 31, 2024. Civil Fine WAC 388-78A-2040(1) Other requirements. $400.00 The licensee failed to ensure two staff were fit tested for an N-95 respirator. This failure placed all the residents and staff in the facility at risk of being infected and spreading a communicable disease. This was an uncorrected deficiency previously cited on November 21, 2023. NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Administrator Dungeness Courte Alzheimers Community License #1328 February 13, 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: Cory Cisneros, Field Manager Region 3, Unit E 6639 Capitol Blvd SW Point Plaza West Tumwater, WA 98501 Phone: (253) 254-3190 / Fax: (360) 664-8451 rcsregion3email@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 Dungeness Courte Alzheimers Community License #1328 February 13, 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 $400.00 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 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 Dungeness Courte Alzheimers Community License #1328 February 13, 2024 Page 4 If you have any questions, please contact Cory Cisneros, Field Manager, at (253) 254-3190. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 3, Unit E RCS Regional Administrator, Region 3 HCS Regional Administrator, Region 3 DDA Regional Administrator, Region 3 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW HP

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. Residential Care Services Investigation Summary Report Provider/Facility: DUNGENESS COURTE Provider Type: Assisted Living Facility ALZHEIMERS COMMUNITY License/Cert.#: 1328 Intake ID: 106707 Compliance Determination #: 33092 Region/Unit #: RCS Region 3 / Unit E Investigator: Phan Pham Investigation Date(s): 11/20/2023 through 11/21/2023 Complainant Contact Date(s): Allegation(s): 1) Infection control - Named resident was diagnosed with a . 2) Accidents - Named resident fell and fractured her arm. Investigation Methods: Sample: Total residents: 41 Resident sample size: 3 Closed records sample size: 0 Observations: Residents, environment, staff interactions with residents, staff members providing care and services, infection control practice, and safety measures. Interviews: Residents, staff members, administrative and member not associated with the facility. Record Reviews: Sampled residents and incident reports. Investigation Summary: An on-site investigation was conducted, and the concerns related to 1) Infection control, 2) Accidents/injury and quality of care and treatments were reviewed. 1) The Assisted Living Facility failed to ensure all staff were fit tested for an N-95 respirator. 2) The resident’s care plan had interventions/measures to ensure necessary care and services were being met/keep the resident safe and was being followed at the time of the incident. Additional residents reviewed for care, services and safety had no concerns. 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.