Alpine Way Retirement Apartments.

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

allegations of sexual abuse. Investigation Methods: Sample: Total residents: 87 Resident sample size: 2 Closed records sample size: 0 Observations: Identified resident Residents Dining Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Identified resident Nursing staff Management Record Reviews: Facility policies Progress Notes Negotiated Service Agreements Temporary Service Plans Investigation Summary: Quality of Care/Treatment: Facility failed to conduct follow facility policy, and conduct investigation into incident once they became aware of incident. Failed Practice Identified. 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 800 NE 136th Ave Ste 200, Vancouver, WA 98684 Statement of Deficiencies License #: 2141 Compliance Determination # 64415 Plan of Correction Alpine Way Retirement Apartments 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 08/20/2025 of: Alpine Way Retirement Apartments 900 W Alpine Way Shelton, WA 98584 This document references the following complaint number(s): 191095 The following sample was selected for review during the unannounced on-site visit: 2 of 87 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Paul Aube, ALF NCI From: DSHS, Aging and Long-Term Support Administration 800 NE 136th Ave Ste 200 Vancouver, WA 98684 . . Statement of Deficiencies License #: 2141 Compliance Determination # 64415 Plan of Correction Alpine Way Retirement Apartments 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. 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-2371 Investigations. The assisted living facility must: (1) Investigate and document investigative actions and findings for any alleged or suspected abuse, neglect, or financial exploitation; or accident or incident jeopardizing or affecting a resident health or life; (2) Determine the circumstances of the event; This requirement was not met as evidenced by: Based on record review and interview, the memory care facility failed to investigate, and document investigative actions/findings after becoming aware of an allegation of potential sexual abuse involving 2 of 2 residents reviewed, (Resident 1 [R1] and Resident 2 [R2]). This failure placed R1 at risk for ongoing sexual abuse. Findings Included… Review of the facility policy titled, “Abuse & Neglect” last reviewed on 09/2017, stated, “All alleged/suspected abandonment, abuse or neglect is investigated by the executive director or designee.” Under “Definitions and Examples” it stated, “SEXUAL ABUSE is any form of non- consensual contact, including but not Iimited to unwanted or inappropriate touching, rape, sodomy, sexual coercion, sexually explicit photographing, and sexual harassment.” Under “Procedure” it stated, “The associate initiates an Alleged Abuse Investigation Summary documenting the facts of the alleged incident and forwards it to the nurse on duty for resident assessment, completion of investigation and preventative measures… The executive director or designee determines the type of incident and: • Immediately investigates the alleged/suspected abuse using the following guidelines: • Conducts an interview with the wellness director or other manager. • Conducts all interviews individually and in a private place. . Statement of Deficiencies License #: 2141 Compliance Determination # 64415 Plan of Correction Alpine Way Retirement Apartments Completion Date • Interviews the individual alleging the abuse, the resident, and other associates who were on duty at the time of the alleged/suspected abuse. • Expands interviews as indicated to identify others who were potentially affected by the alleged event. • Documents the interviews and maintains confidentiality of the information at all times.” Review of R1’s face sheet showed that R1 was admitted to the facility on /2025. Review of R1’s progress notes, dated 08/16/2025 at 4:35PM, documented “[R1] asked staff member, ‘What do I do if my [spouse/R2] demands sex and I do not want to?’… Staff member reported this to nurse, which prompted the need to file a state report. State report filed…” During an interview with Staff A, the Executive Director, and Staff B, on 08/20/2025 at 9:51AM, Staff A and Staff B were asked to discuss the outcome/progress of the investigation into the allegations/concerns made by R1 against R2. Staff A stated that they were not aware of the allegations. Staff B stated that they were aware of the statements made by R1 and stated that R1 was placed on alert monitoring by the facility. At this time, Staff A and Staff B were requested to provide incident reports, and all documents that were part of the investigation. On 08/20/2025 at10:23AM, Staff A stated that they were unable to locate any incident reports for this incident, for both R1 and R2. During an interview with Staff B on 08/20/2025 at 10:45AM, Staff B was asked if it was part of the facility process to complete Incident Reports for allegations of abuse made by any resident. Staff B stated, “Yes, we usually do an incident report. There should be incident reports for both residents, and a behavioral incident report for the [aggressor], and a Temporary Service Plan for both residents. We also have a binder at the desk; the state reports that are time sensitive go straight to the ED and [they go] through that every day.” Staff B was asked if it was a normal part of the investigation process to interview residents and staff. Staff B confirmed that interviews with staff and residents were a normal part of the investigation. Staff B was asked if there was any investigation into this incident conducted by the facility, such as resident interviews, or staff interviews, etc. Staff B stated that they were unsure and would have to ask the nurse who filed the report. Staff B was asked if they were able to locate or provide any documentation of the investigation including resident interviews, staff interviews, a summary of investigation, or any other parts of the investigation into this incident. Staff B stated, “No, just the chart notes.” This is a recurring deficiency previously cited on 05/02/2024. . . Statement of Deficiencies License #: 2141 Compliance Determination # 64415 Plan of Correction Alpine Way Retirement Apartments 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, Alpine Way Retirement Apartments 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 .

Statement of Deficiencies License #: 2141 Compliance .Determination # 5 7103 Plan of Correction Alpine Way Retirement Apartments 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 complete.d data collection for the unannounced on-site full inspection on 03/28/2025 and 04/02/2025 of: Alpine Way Retirement Apartments 900 W Alpine Way Shelton, WA 98584 The following sample was selected for review during the unannounced on-site visit: 9 of 78 current residents and 1 former residents. The department staff that inspected the Assisted Living Facility; Anissa Bearden, Licensor Celeste Vashey, ALF LTC Licensor From: DSHS, Aging and Long-Term Support Administration 800 NE 136thAve Ste 200 Vancouver, WA 98684 . 04/2~/2025 TUE 15, 51 FAX ~003/053 04.24,20'lb lb:bll:43 ~tate or washlngton l I/ Statement of Deficiencies License#: 2141 Compliance DetermiMtion # 57103 Plan of Correction Alpine Way Relireme11t Apartmenls Completion Date As a result of the on-site visit(s), the department found that you are not in compliance witl1 the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. ~ ~ 04/24/2025 Resffiential Care Services Date I understand that to mair1tain an Assisted Living Facility license. the facility must be in compliance with all the licensing laws and regulations at all times. 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: (a) Develop and implement systems that support and promote the safe practice of nursing for each resident; and (b) Ensure the req~1irements of chapters 18. 79 RCW and 246-840 WAC are met. (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: (d) Chapter 246-841 WAC, Nursing assistants; and (e) Chapter 246-888 WAC, Medication assistance. This requirement was not met as evidenced by; Based on observation, interview, and record review, tl1e facility failed to ensure that 4 of 4 residents (Resident 6 [R6], Resident 4 [R4), Resident 1 [R1], and Resident 12 [R12]) received medication administration from medication technicians within their scope of practice. This failure placeq all four residents at risk of receiving unsupervised nursing services by unqualified and untrained medication technicians. Findings included ... Revised Code of Washington (RCW) 18.79260, "Registered Nurse- activities allowed- delegation of tasks ... (3) A registered nurse may delegate tasks of nursing care to other individuals where the registered nurse determines that it is in the best interest of the patient (a) The delegating nurse shall: (i) Determine the competency of the individual to perform the tasks; (ii) Evaluate the appropriateness of the delegation; . Statement of Deficiencies License #: 2141 Compliance Determination# 57103 Plan of Correction Alpine Way Retirement Apartments 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. 0 ~4, 04/24/2025 Reslential 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. 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: (a) Develop and implement systems that support and promote the safe practice of nursing for each resident; and (b) Ensure the requirements of chapters 18.79 RCW and 246-840 WAC are met. (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: (d) Chapter 246-841 WAC, Nursing assistants; and (e) Chapter 246-888 WAC, Medication assistance. This requirement was not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that 4 of 4 residents (Resident 6 [R6], Resident 4 [R4], Resident 1 [R1], and Resident 12 [R12]) received medication administration from medication technicians within their scope of practice. This failure placed all four residents at risk of receiving unsupervised nursing services by unqualified and untrained medication technicians. Findings included ... Revised Code of Washington (RCW) 18.79.260, "Registered Nurse- activities allowed- delegation of tasks ... (3) A registered nurse may delegate tasks of nursing care to other individuals where the registered nurse determines that it is in the best interest of the patient (a) The delegating nurse shall: (i) Determine the competency of the individual to perform the tasks; (ii) Evaluate the appropriateness of the delegation; . Statement of Deficiencies License #: 2141 Compliance Determination #57103 Plan of Correction Alpine Way Retirement Apartments Completion Date Page 3 of5.2 Licensee: Cascade Living Group -Shelton, LLC 04/16/2025 (iii) Supervise the actions of the person performing the delegated task; and Ov) Delegate only those tasks that are within the registered nurse's scape of practice. {b) A registered nurse, working for a home health or hospice agency regulated under chapter 70.127 RCW, may delegate the application, instillation, or insertion of medications ta a registered or certified nursing assistant under a plan of care. (c) Except as authorized in {b) or {e) of this subsection, a registered nurse may not delegate the administration of medications. Except as authorized in (e) or {f) of this subsection, a registered nurse may not delegate acts requiring substantial skill, and may not delegate piercing or severing of tissues. Acts that require nursing judgment shall not be delegated. Record review of the Washington State Department of Social and Health Services document titled, "Community Nurse Delegation Orientation 2025", undated under the section titled, "medication 1 assistance vs [versus] medication administration", showed the distinction between these two ways for individuals to receive medication was critical in determining to delegate to long term care workers or not. Medication assistance described ways to help an individual take their medication and. does not need delegation. Medication administration was the way an individual received their medication from an authorized person. The task must be delegated if it was for a long-term care worker to complete. Under the section titled, "what is medication administration'', showed when the client or resident was not functionally able and/or not cognitively aware they receive medication, the long term care worker that was authorized with delegation of the medication. The long-term care worker must be delegated for each task to administer. Under the section titled, "medication assistance continued", showed for medication assistance to take place the cUent or resident must be both functionally able. to get the medication where it needs to go {the last step) as in put it in their mouth, or apply the ointment to their own body, and they must be cognitively aware that they receive medications. Raco.rd review of the facil.ity's, "Disclosure of Services Required by Revised Code of Washington 18.20.300", undated, under the section titled, "intermittent nursing services'', showed the facility did not have nursing assistances that provided authorized nursing services under delegation of a registered nurse. Under the section titled, ''help with medications", showed the facility assisted residents with administration of their oral, topicali eye, ear, or nasal medications. The facility did not use nursing assistances under delegation of a registered nurse to administer drops, oral, and topical medications. Ra Record review of R6's Move In Record, dated 03/06/2025, showed R6 moved into the facility on /2019 with multiple medical diagnoses that included and . Record review of R6's customized service plan, dated 10/31/2024, located in the caregiver's service plan binder, under the section titled, "medication management'', showed licensed staff {who were aware of resident's abilities with medications'' were to consult with the pharmacy and health care provider to oversee mediation program. Staff were to order, store, and deliver medications per healthcare providers orders and licensed nurse instructions. Staff were to report any changes in needs or ability to the . Statement of Deficiencies License #: 2141 Compliance Determination #57103 Plan of Correction Alpine Way Retirement Apartments Completion Date Page 4 of5.2 Licensee: Cascade Living Group -Shelton, LLC 04/16/2025 licensed nurse. . R6 had difficulties with speech and required extra time to find words or responded to yes/no questions.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . I&] □ □ . 12/16/2024 MON 14, 20 FAX ~005/009 12.11.2024 09:54: 16 state oF llashlngton 61 Statement of Deficiencies License#: 2141 Compliance Determination # 51141 Plan of Correction Alpine Way Rellremant Apartments Completion Date Page 2 of4 Llcensea: Casc.ade Living Group. Shelton, LLC 12/0312024 ~ ~ _,,y~ ~ (or Representative) WAC 388-78A.;2305 Food sanitation. The assisted living facility must: (1) Manage food, and maintain any on-!Jite food service facilities in compliance with cha 5 WAC, food service; This requirement was not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure timely disposal of leftover foods for 1 of 1 facility kitchen reviewed. This failure placed 85 of 85 residents at risk for contracting foodborne illness. Findings Included, .. r/i# J 246•215-03526 , "Temperature and time control-Ready-to•eat, time/temperature control for safety food, dateV marking (FDA Food Code 3•501, 17). (1) Except when packaging food using a reduced oxygen packaging method as specified under WAC 246•215-03540, and except as specified in subsections (5) and (6) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than twenty•four hours must be clearly marked to indicate the date or day by which the food must be consumed on the premises, sold, or discarded when held at a temperature of 41°F (5°C) or less for a maximum of seven days. The day of preparation must be counted as day one ... (4) A date marking system that meets the criteria stated in subsections (1) and (2) of this section may include: (a) Using a method approved by the regulatory authority for refrigerated, ready•to•eat, time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for·whlch date marking is impractical, such as soft-serve mix or milk in a dispensing machine; (b) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or disoarded as specified under subsection (1) of this section; (c) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under subsection (2) of this section; or (d) Using calendar dates, days of the week, color-coded marks, or other effective marking methods. provided that the marking system is disclosed to the regulatory authority upon request." . 12/16/2024 MON 14, 21 FAX ~007/009 12. 11. 2024 09, 54: 16 State of Uash In gton 8/ Statement of Deficiencies License#: 2141 Compliance Determination# 51141 Plan of Correction Alpine Way Retirement Apartments Completion Date Page 4 of4 Licensee: Cascade Living Group - Shelton, LLC 12103/2024 In an interview on 12/03/2024 at 12:10 PM. Staff 8, Cook, said left over foods were to be disposed after three days from the prepared date on the container. Staff 8 stated he used the assisted living facility's Refrigerated Storage Guidelines as reference when he was not familiar with how long a leftover food should be kept. Staff B staled dietary staff members were responsible for routinely inspecting the refrigerators and disposing food that had been expired. 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, Alpine Way Retirement 9r Apartme l t / J f t A S · i 8 s ;9r w M ill . be in C0 'J '.1 1 / J r ?li~ n;,e with this law and I or regulation on ,'5~ . /,tlc::J.;;)6 · (Date) In addition, I will implement a system to monitor and ensure continued compliance with this requirement. ~U@L.. ~ - - Administraior (or Representative)

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 . . STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 800 NE 136th Ave Ste 200, Vancouver, WA 98684 Statement of Deficiencies License #: 2141 Compliance Determination # 43051 Plan of Correction Alpine Way Retirement Apartments 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 06/24/2024 and 07/08/2024 of: Alpine Way Retirement Apartments 900 W Alpine Way Shelton, WA 98584 This document references the following complaint number(s): 135340, 135964 The following sample was selected for review during the unannounced on-site visit: 3 of 72 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Pamela Horlick, NCI RN Complaint Investigator From: DSHS, Aging and Long-Term Support Administration 800 NE 136th Ave Ste 200 Vancouver, WA 98684 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. 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. . . Statement of Deficiencies License #: 2141 Compliance Determination # 43051 Plan of Correction Alpine Way Retirement Apartments Completion Date Administrator (or Representative) Date WAC 388-78A-2630 Reporting abuse and neglect. (1) The assisted living facility must ensure that each staff person: (a) Makes a report to the department's Aging and Disability Services Administration Complaint Resolution Unit hotline consistent with chapter 74.34 RCW in all cases where the staff person has reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred; and This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure that staff immediately reported neglect to the department’s Complaint Resolution Unit for 1 of 3 residents (Residents 1 [R1]) reviewed. This failure placed 72 of 72 residents at risk for neglect and unmet care needs. Findings included… “RCW 74.34.035 Reports—Mandated and Permissive—Contents—Confidentiality. (1) When there is reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred, mandated reporters shall immediately report to the department. Record review of Assisted Living Facility Guidebook, dated February 2018, showed to report to the department when there was reasonable cause to believe violations had occurred involving abuse, neglect, abandonment, significant injuries of unknown source, or personal and/or financial exploitation. Record review of the facility policy, titled, “Abuse and Neglect,” revised 09/2017, stated, “All alleged/suspected abandonment, abuse, or neglect is investigated by the executive director or designee and timely reported following the Washington Reporting Requirements for Assisted Living…The executive director or designee investigates all cases of alleged/suspected abuse or neglect. All associates are educated on abuse and neglect. Any associate hearing or witnessing any abandonment, abuse, or neglect in the community and has reasonable cause to believe the incident is reportable, must report, without fear of reprisal, as follows: 1.) Notify the Washington State Complaint Resolution Unit (CRU:1-800-562-6078) as soon as the resident is protected from further harm. . Statement of Deficiencies License #: 2141 Compliance Determination # 43051 Plan of Correction Alpine Way Retirement Apartments Completion Date 2.) Notify their immediate supervisor, manager on duty, or executive director of the alleged incident." Under “Definitions and Examples,” it stated, “Neglect is a pattern of conduct or inaction of a care provider that fails to provide goods or services that maintain physical or mental health; or that fails to avoid or prevent physical or mental harm or pain; or an act of omission that constitute a clear and present danger to health, welfare, or safety of a resident." Review of R1’s face sheet, dated 06/24/2024, showed that R1 was admitted to the facility on /2024. Record review of Residential Care Services Online Incident Report, dated 06/19/2024, showed a report was received to the Complaint Resolution Unit (CRU) regarding R1 not being afforded the opportunity to use the restroom and being instructed to use their brief. There was no report from the facility regarding this incident. Record review of a witness statement provided to the department, dated 06/26/2024, Staff B, Medication Technician, wrote that Staff C, Caregiver, told them that R1 wanted to get up and use the toilet. Staff C explained that they told R1 they must go to the bathroom in their brief due to them not having the ability to walk or stand on their own. Staff B explained to Staff C that there was a way to get R1 to the restroom by using a toilet sling and a hoyer lift. In an interview on 06/24/2024 at 11:25 AM, R1 was asked if staff helped them with their toileting needs, R1 stated “yes, sort of. They told me to go in bed. They put diapers on me and I am supposed to go in them.” R1 was asked if they call for help from the caregivers to assist with toileting, R1 stated, yes, I am supposed to call them after I go in my brief. Record review of R1’s Negotiated Service agreement, last reviewed on 02/22/2024, under the “Toileting” category stated, “Resident requires total assistance for toileting with 2 person assist with hoyer and incontinence care AM/PM and PRN (as needed). Resident does use the toilet and will require a split leg hoyer sling for toileting.” In an interview on 07/08/2024 at 10:54AM, Staff A, Health and Wellness Director, was asked when Staff B was first made aware of Staff C telling R1 to use his brief, Staff A stated, not until he was cleaned up that day when it happened, when R1 first arrived to the facility. Staff A was asked if Staff B should have reported it to Staff A when they learned of what happened. Staff A stated, yes Staff B should have reported it. Staff A was asked if the facility would have reported the incident to the Complaint Resolution Unit (CRU), they stated, yes, it would have absolutely been reported to CRU at that time we were aware of it. . . Statement of Deficiencies License #: 2141 Compliance Determination # 43051 Plan of Correction Alpine Way Retirement Apartments 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, Alpine Way Retirement Apartments 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: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . . 05/0~/2024 THU 16, 56 FAX ~003/011 05,08.2024 15:10:49 State or Uashington 41 Sl~1Ht'(l!!lll. i:il OM1.~rwi~s. Llcerili~ #.; 21,lt .G qmpliam:;e D~IJ!lff!lin!ltl{l11 # 40251) ri~tij Pfan ~.f b•ori~~tiort .i>Jpinit Wiy l-<~!11~;),,m t\pat.h1>1ltll$, . . :b,mp!$ti-Oi'I P$!J1i; .. ' 4 of a Li,,.u,ii.1,e: Ga$,;a(i.e Lililhg Gn:ii,ip , Shelt~ri;, u.c 04/151.2024 WAC·38848A-21.20 M"'nltotll'ltresi<li•ffltt' W&ll,J)tlng" Tht &!1$1$.ted llvlngfaclilty mu!it: . ' ' ' . . . . . ' . . (2) . Jdeni!ify . . !lrr, cha11ge11 ln tt ' re re.'! . lldi! . t llfi, physlr.:al, ~mciion"11, l;lr . ui 1r1ertta . liu11,:;tib!lirl.(,l tti!lt lj . l r ' ~ . • . F (,1!] f.Jeµaitt1ri'!-.fr1m1 U'le reskl~M't"lS Cti!ll~miuy r~rige tffun$lidl'lh'1f!; 1lll' (3)1:vii!ll!at11, in im:feftll de!~~l'l'li1~e if th~re ls.a needt1Jrf1.1rtt1l!r at;ticin'. (a) ·hie d1,!il'ige1Hi1eriiified in .tha resklentp.er :i;uh:.e:G!lcn (:tl of!his stction: and . ' . ' . . . . This requirtffl'l/litt WH ,iot m R'IUi 'l!IIGl!ftll!'d by; B~i!ed·offinrewiew and ret:.imlreview, me fadlityfaiied t~ 1de:11tify chang!i.s in condition am'l. ~valuate th'il\ r,eed fill'1ltrltler J:ction after $1'$'1.idente)(tierrenced abusa for ·r .an reside1~t (filesidenl 1 [Rl]) riiviewe.d. TfiiJslaH,lf~ r-esultecd in R1. hot ~eir).9 mor.ittwed for h1S Jl'rMtional dist/:i!S.!l.afteran inttdent, l'lrfd i:f!ai::e,j RJ et risk fi:irJurt;ti!'Jr ,iHstrest., Llnidl:itJtifieiJ ;:are iwedi./aMIJ dac1'eils.~JJ qlia!itf df llffi. R;,11iew 6t a fl'F.:Hit;y i:,-0li.¢y titl~d, 'Atmse &.Negletf, ci,,ite:d EHl/20·1 i, at!lted /'Tli<! Executive Dir.it:ilof or d1isl9nee 1nv,e,m:i.ga1':;,.lJlil q1s~1l o! .a1l;,gi,;d/s~rsp.e<::te;d abtJ!le or neg!t:.ct Ali lilss!ldates <ir;II\ edµcl!lt,:;d on qbll!>ll .ind negted:Any aswdatl\< h~aring <ln'l'ltnes;;;ing lilflY abandonment, ab,1:;;e .or neglect kl the c-,rrtnuriliy, er.d has reasi)nilble 1:a1..1~e to believe tfai inc;idl!nt is 111,pnrrarota, ITTtlfk 1'6pQJt, without fe'ar of replis~L " · · · · ·· · · · · R~vliaw of a tacillr:,1 /'.l!iil.~y titlieci, "lnc:h:leht1Acdderit Management", dated. m:it:2i:Hr,.1Mm.d,.' For Re:sfdet1tEvents: To l!IS'ii,e$$the n!i~1dr,H1t stiitws,. Welltless Notes ¼ill t.ev<iriitsi:n as indicated/ lnw'I inter.titw oo 04125/20::14 .m! lil'l.'ilit\M, Staff AJ:he Executive .. .Diie,~tor, JNa1>asKed wlnattypes ot thh:1.i;is residents Wl!fe µ1.icit!l (;,t1 'l!terl: fv\/ellness N9te$} !pr. StllffA !.iatet!, "Resi!'.leirt.-trHes\de.rit inciqelitll, new mov!!Hns, faHs,.Qther lniut'ies such as sldnteers, t)!:/W.rn<1dl,~ation111, m-om rt11:tV¢S, de3tl1!1 in l:ar1'l!1¥, othl'i, Mgr'1lfi(;ant life,events/ St$Jf A W3<illlsked i:t rllsklenti: were p\aced l:in .iilii;rt ~~er; ai1;.lleg;:atior1 ofabU\'le; Staff A stl!ti:.:lS"Y!!$, ~ residei1t would bi! pll'IC!ht QI) ::;l!ert fortl!lll,li:itit.111$ Gf a~>uae-.. ' •s t~ff A was asked what !!ltilff Wl!lfe 1nstrud'ed to moti;trtr th,f '/esidem for a•tld .ddtUl1rierif for all~r;iatk1n11c tiri,lmse .. 5111ft A \staberl, 'Veihafoirid roon-i.ieJb::iJsigi.JS ai.ld 1,,ympturi1" ol d!stJ"!,SS, ci1ii!nge itr ri"l\'.i·CI ct. ttian g~ ii . · · . . 05/0~/2024 THU 16, 57 FAX ~005/011 05.08.2024 15,10,49 State of Washington 6/ &'t!ll<;f'11~/il "' D.efi~iirn9l$S Otei'i~i;i #; _21 ~T . Cqfi¥1hmi;e lJ~l#fl'U~l;t,M # 40°f~-l Pl~n M C:~rrtttirin- •A lpiM V\'ay R~tirem,:,m ~:nlfrt#.lllS. ti,rnp1atfon D~te, Pa!_llii 4. of l'J U~irn . i i: . i ie' C~~~ . ji.Livlhl) Sro1jp, Si:i,;ilt~n. ~LC { . )4 "' {.)!5/2024 D11tmg. ~r, inh!l'\l,eWWith R1 <11'.104i24i:'.W24 af 11:2aAM, R1 1/)(i!IS•al.keli if th~y f$rrlf.!'tni.l!;lt'!.lil an alt~rc;atl.~n IMth ~ i.taff pi!iri.on rec>llo!ly. R1. liti'it.e-d, "Y¢~h; !i"l~'/}(r~f"irced me. f.ioWti :' R1 Wilt asked wl1~thppp;1m.ed. R'I stat-eu, ''Yi,:a they h1t me'.,, They hit rn<:i l1;1'1.!'i11;,b,11~k·ofthe hei.td/ R1 1/1(.!JlasK~d n•J\!'f this.miiide fuem fiiH!L Rt ~tated( 'j w.isiscarfd. I w;;inted to ¢!1/'did at1i,>thirig,thtit.w~s/4ausing ~ ~irpble,:i,.'' R1 \/)'.<JS aski,d if tney_ rep,1l~u n?twmiting fo i;ni'!wer :t111tevernn1l R1 t,ti·ite:il. '.l wa.11 wotrie'd tht'ltmat1 Waii goihg to !:le tl1ert _,. _liiieview 61 Pt:o:9re$$ Notes i<llr RI, d!i!ted 04/13/2024 at t I i22AM. i_t statt'!.1 1 • AM carn:gi11er t>:tPJJfl:!lci. to this. otic-se that [ti:ieyJ r!i!t~ived rep-01ttn:iri1 [Staff Cj .llt.iting.tt:,at reti'il'irnt was .tton.batlve with cart ·am:! kidlkl{l c11i-e:g1;,,~r: AM c~reghier:;fate1; ~\>het:1 [th~yJ !lfltl!rl!ct'ie:.klsint'iii ieoin, [Rt} w.ii.~1ying Jod st.ilt.ict, 'ls.that guy g(mi'!?'A.M lli;lf&!Jlli'iif !!Skii~ reslcli'mfif (they] W~tfO~ .. R!i1'.Etf.1'e11tstatil"1, 'lrrat guy w4)} pulling iln and rfpplng rri;, underwei;lr_,_,o t kkked at hirn; .and he swrted hlttlrig ma" Reiitl!!nt i\.itiid [th$)1JWne!l. ms !ic)weir tn.it ditiNt Wahtfl strd)ll/tt in the evi!inrtll,l b!.taui;;e-''l'mwiiiriei:.t tr~t guy v@I come l:iactk 'AM i:artfgiver'o:!lmfo1ted residenta/\iii l!iilked !I [RH wouid like,[!hem]'to c:omNMe [theit1 i!,hqwe1:, AM .pategivei 1:9me fa nipilrttti thi~ i1u0te and fui~ iJLI/1/ie "imp1et~-0;l1eaiHo tM . ass.erssmtrnt d1m11{1 residl!!nt's shower., Bruise nailed fo le'ft side. et hrc~ 3cm x :i!cm, Wi!Jlntisl(.□ire.ctor notifo:;d, Executiv!i Dlttdr;rNoti!!ed, PCP (Primary C.im, Pruvicter) l'!otilied.,. Monitt.if lnJilace,.il!l;;r\o •f2-hoi11~:: Thistiot!!- ;\\ddressil'd R·!'i b!'Uili,e but did ri!'lt.addr\:ss Rh, P!:iYCl:l!)!liJd1,1! W!!l!b.eing re!at!iid lo. the incidtnt Fwther revle1•</ ofR'l '-s ~1rogril!l!l,>"nQ:te,s i,h.;:;wed lh<:1re.wa:. no alert .drnrting kdhe n11.1idi!itl:t r·ettlrd docum~\ntlng rnqr,itQJ'\pg tif'!h~ rtslcl,mtfor syrnpt11rns bf dis!;rel!ls, i:,bangl?S\ ii\ rr.mod:, .or·.~hangiM 1.M bd-r,wlor:. rii,r amy document~ti"oh ~I a.tti◊nsfaken afterthe. facility bec~m~ .aw?irn of the.a!legath:m.: · · · · · · · .Plan/Attestation St1tt.m11U. i Mi!!!'eby !iettify that I_ ha\'~ r/!:ii!ii\,;;ed thi~ f!lp!J,it .in!) hiiy; fakiif1 tlf.Wlil t.ili:e \i(,.iive rne:;:,suri,i<; tei 1.;:'.'irrect this. . detfdt:,.ncy .. By tii\'l\ing tr'lilii actton, Al:pi11V€ iiay Rellinm~tnt Ap.i:rtryien0l!t J.1 wll! be JM compliahr.fi With tbill; law and /.or iei;!1il,ati,Jn m:1 GJ.4 •.• GP ~6?0 (Dati!i) In .:itdi:ilmcim, 1·1'iiil! implerni1111t .a 1,yst.emto n:1rmililr;;1nd enli'..ir.<l .c·ontinued compfian,:ij with this r~.q,tirein~nL . . .. . . . .. . . WAC 3M-78A-2fi1} Rii!1•1dWttt tt~ts;'The a1n1i1t.ed livin;Jacl{lty must: (1) Ci~mp.ly~"iiili-d1npt~r 10,129 RG\IY; Lj;ih~-tann q1Ji!1! re-sltkmf. riybta: (2) Ensure an 1ttifl pl!!i:si:ms prqvide .cap'! af'ld s~r111t~s tg ecicH resident ,:iimmstilm \!\~th ehapter 'i'O.f.29 RCVV: . ch (3) f,Jcituiie ,estratnt,!'l ~riy re,;ident; (4) Promote arid protet;tthe n!:llid~hts~ ex!?.tdse .:rt all rlght~l;Jrahtfd un;j~r crltapterTOTiQ . . . 05/0~/2024 THU 16, 58 FAX ~o os Io 11 05.08.202q 15,10,qg State of l-lashington 9/ &'tale11:1allt .tfDeficien9i!i\s [i,:;ari~~ #; .21. 41 .G ompham:;a D~l!li'illm~!~@n# 41l2&'.i Pli~ ~iC(Wl'Jt\ion . • Alpl\111 Way R<)Hretiiflrrt A@ailtnent;. C:iHnpleffon Date PMe7 ofS Utensiie• Ca$~~dil> Livl119 Grntip. Shall~ri., LLC (l4,Q5/l02.4 Review .of R 1' s Prh9F!,SS NtihHl; d<1tsicl ll4/23/1tY24 at ·t t 22AM , stilted, "AM care.givi>JI' repotted t1.1 f.lih, nurs,;i th~t [th!'lyj ri.r;e\ved report ticwri[Slag CJ stating tN:1t retllcten{ 'N1lii coi,jbati:\1-t Wit!, t:i'!(e a'li1J kicking carl!i,'iiv~r, AM .c aregivef'St:iltes W'!~i [ths1y) el1t1,red resfdel'lfil !1:)!.)ffi, lR f] WiliS: Crying. l!H10 1,-tateo.: 'fs that guy 9~11.~r• AM caregiver iisked tesldC1,fif (t'he,yJ v,ete ok R~si~ent stated, 'Thatgtt\l wa'!l .puliing on and ripping 1'1'1y unclerwear, so I kicked :iit t1lm, !inq he startet! hittir,g. me/ Riil'sident 1,ta~d [thiiyJ wamei.'l. a stmwer but. chdr.'t vvant·11.1 1,t1!.iwer iirtiie: ev11111~.IJ· bo1;C\\1t!$e ''frn wgrriet! tnat guy w!I came. J:iack.'' · · · · · O\idng an niterview~;ith R·t ◊l'l04124/7024 at. 11 );'.!AM, R) was asl<etl if th<!y 1,erner111H!red at1 ;;ilten:atii.rnwilth m staff' j:ltfrs\in reci:r1ily: Rl :!it!lt<!d, 'Yeah·, th<ilyJu~ t~rcii~ rn!li ik.ic\4n .''' R 1 W!l~ 4u,kf/ct 1/Vhathappenl!tL f>,J $1:M"i:1, "V~11·mey hit me Tt1eyhit1T1:e in u,i; b'acicot th\'! l'H!~d" ~1 we$ l'l'<ked .. hoWthi$.Madt ttrer1ifoe\. R'! st.:.m,·,J, '..l was;seared. I wapt<id fo ~v1)id llt\Ytf1ing1h;itwas taus1n9 a. problen,." R'l li,~s li!Sked ii t!1ey re.called not wantirig tq ellOWiff tt!at .. venmg. RI state•d, 'I was worried that ma-n. V.'tl:S gnin.g. tcr be there .. * In .in klterv)ew till 04l24IW24 aJ.t S:i.iOAM, Stafr B, the V11el!nes11 Oir!lli:tr.ir. w11.!!'. asked l'f trre . ir111s€ tigiticm into.the iri~idefit add iJlfegatiim o! abuse.!}fR1 wai.i. complete. Stsff 8. $ted, "Ths1 inv~·sl:tQ.Jtion is dime .. [Steff CJ ii';i SU$p~nded; \they} qid no! work iasi: night:' St?ff 8 'iitatect.triot th~y $P•~ke Yllltl1 be$ Sta:ff C ;jhd :'>t1lff!') and ~tatedlhilt per Staff O'ti ~~afornennh-,t "(Stt1ffD) . i::orn:iborntad wt,'at {$t;)fl' CJ tcihJ me." $h1lfl' e i,itlil!!:!J. "! peltev~ .½'/latth1a/arf.; telllr1g mi:, Ml;! wia ,viii lef {StlltfC] i:ornil ha<:ln.o. W$1"k wtth aomt\ education " Stliff f.h\<as .rsked ifthei w~r~ aware that physi,;;al!y ri,strainlng 1,1· r'e$iqent.tgair,,rthei(1-.1t1 was cons,iforerl abus1a, St!iff 8 g,ave r,o resjloose. Revie'!'I at D~piartrn!:lnt Recofdi!i show~d. a report mad~ b<•l the l!iit:.i}ity 01104123i2024 or an aliegati,;m of mllll!le .made by Fi: 1, abt\UtSll.'!ff C In ttiisreP,t11:t, St,1ff. El st.1.terl th<iy v,ere "confictent no aliu1e .occum'itf'' Dunn.g an int~!Y!ev..• with &'tlff Bari d4/24/1024 at 12:22PM, .staff B wa-s asl<:ed haw and ¥Vhy tl:n,y t.Jltd µct ~busi in. thtl1(ii1Viastigiltidn whtin Staff C and 'Stiif/1 D,butb c\11,lirmed thiitthe'it restr':lil'1~d am the residehtdp'iiig c.,re. St,1ff B. stated, "t $b.iolutely v>Jr;,1)g ftb,; not e•,',1 h 1-'/h~t t tead1 m~ sm!f:" sfotr 8 vWrui~.fd Wthev wouhi c.o:iside~hddlng di':i~n i;i resid¢rit a~1µii•1sttt1eif Will tiorir1g care, a physic.al restraint .Staff B stilltE"d, ''Y!!!S, and we ~~··rl❖t re,strain resia.ents as ii tt!ir.dard." .P lanlA ttet titiori Stat em (int I hereby certify that I h ,we revii.1wed.1t11s .rt pori: l!md hav. .. taf;ein or ¥,Ii(! tak~ 11!:tlve r11easuie~ to correctthill cieWCi!'!ilCV. t3ytal<ing. this action,, flslpir1e Way Retirement 9r Ap/lrtme~tJ is 'i\il_ll}le ,n complla11,;e with thlj)avv arid! ur ,egt,llltll'.ln\m (Date:)uf¼,,/..a. . ~~------ ....

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