Cottages of Snohomish.

This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website.

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

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 . I&] □ □ . STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALT H SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20425 72nd Avenue S, Suite 400, Kent, WA 98032 Statement of Deficiencies License#: 2740 Compliance Determination # 58982 Plan of Correction Cottages of Snohomish 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 05/02/2025 and 05/08/2025 of: Cottages of Snohomish 1124 Pine Ave Snohomish, WA 98290 This document references the following complaint number(s): 176294, 177141, 176847 The following sample was selected for review during the unannounced on-site visit: 3 of 47 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Wesler Dumecquias, Community Complaint Investigator From: DSHS, Aging and Long-Term Support Administration 20425 72nd Avenue S, Suite 400 Kent, WA 98032 . Statement of Deficiencies License #: 27 40 Compliance Determination # 58982 Plan of Correction Cottages of Snohomish 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. 05/28/2025 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. WAC 388-78A-2090 Full assessment topics. The assisted living facility must obtain sufficient information to be able to assess the capabilities, needs, and preferences for each resident, and must complete a full assessment addressing the following, within fourteen days of the resident's move-in date, unless extended by the department for good cause: (1) Individual's recent medical history, including, but not limited to: (a) A licensed medical or health professional's diagnosis, unless the resident objects for religious reasons; (b) Chronic, current, and potential skin conditions; or (6) Significant known behaviors or symptoms of the individual causing concern or requiring special care, including: (e) Other safety considerations that may pose a danger to the individual or others, such as use of medical devices or the individual's ability to smoke unsupervised, if smoking is permitted in the assisted living facility. WAC 388-78A-2100 Ongoing assessments. (2) The assisted living facility must: (a) Complete a full assessment addressing the elements set forth in WAC 388-78A-2090 for each resident at least annually; (b) Complete an assessment specifically focused on a resident's identified problems and related issues: (iii) When the resident has an injury requiring the intervention of a practitioner. This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to . Statement of Deficiencies License#: 2740 Compliance Determination# 58982 Plan of Correction Cottages of Snohomish Completion Date complete a focused assessment for 1 of 3 residents (Resident 1) who used a knee scooter. This failure placed Resident 1 at risk for potential health complications, harm and injury. Findings included ... Note: WAC 388-?BA-2090- Full assessment topics. The assisted living facility must obtain sufficient information to be able to assess the capabilities, needs, and preferences for each resident, and must complete a full assessment addressing the following, within fourteen days of the resident's move-in date, unless extended by the department for good cause: (1) Individual's recent medical history, including, but not limited to: (a) A licensed medical or health professional's diagnosis, unless the resident objects for religious reasons; (b) Chronic, current, and potential skin conditions; or (6) Significant known behaviors or symptoms of the individual causing concern or requiring special care, including: (e) Other safety considerations that may pose a danger to the individual or others, such as use of medical devices or the individual's ability to smoke unsupervised, if smoking is permitted in the assisted living facility. Review of the ALF's current policy titled "Assessments- Ongoing Focused Assessment" dated 10/01/2020 showed it was the policy of the ALF to complete an assessment specifically focused on a resident's identified problems and related issues as listed which included when the resident had an injury, incident, or illness that required the intervention of a practitioner. Review of Face Sheet dated 05/02/2025 showed Resident 1 was admitted to the ALF on 2024 with multiple diagnoses including and and . Review of Medical record dated 01/27/2025 showed Resident 1 was seen in the Clinic by their Podiatrist due to pain and bump on their right foot. The record showed a prescription for the use of a knee scooter for their right leg. Review of an assessment dated 10/29/2024 did not show any record of Resident 1's assessment for the use of the knee scooter as a medical device was done or added. . Statement of Deficiencies License#: 2740 Compliance Determination # 58982 Plan of Correction Cottages of Snohomish Completion Date Page 4 of4 Licensee: Snohomish ALC LLC 05/22/2025 Review of an Online Incident Report dated 04/25/2025 showed Resident 1 tripped on their knee scooter while using it and had a fall. On 05/08/2025 at 2:48 PM, Collateral Contact 1 (CC1) stated that Resident 1 started using a knee scooter due to their , right foot bunion and wound on their right foot. CC1 stated that Resident 1 used their knee scooter at nighttime to use the bathroom and fell. On 05/02/2025 at 2:01 PM, Staff B, Regional Resident Operations Specialist, stated ttiat they would do an assessment for residents' use of medical devices. Staff B stated that they did not have an assessment of Resident 1 's use of a knee scooter. On 05/15/2025 at 3:37 PM, in an email, Staff A, Executive Director stated that Resident 1 had no records or documentation of any Physical or Occupation Therapy referrals regarding the use of their knee scooter. On 05/22/2025, Staff A stated that any medical device or equipment prescribed for their residents would have an assessment added and the care plan updated. Staff A stated that the previous Licensed nurse should have added and updated the care plan. 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, Cottag s of nohomish is or will 9'- be in compliance with this law and / or regulation on (Date)_ G:, ~ ·-: , In addition, I will implement a system to monitor and ensure continued compliance with this requirement.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: Cottages of Snohomish Provider Type: Assisted Living Facility License/Cert.#: 2740 Intake ID: 162376 Compliance Determination #: 54780 Region/Unit #: RCS Region 2 / Unit A Investigator: Wesler Dumecquias Investigation Date(s): 11/27/2024 through 03/07/2025 Complainant Contact Date(s): Allegation(s): 1. Residents were not getting their medications. 2. There was an unexpected death. A Med Tech was informed to check on a resident. The resident passed away the next day. 3. There was only one caregiver working at the memory care unit which had 8-9 residents. The ALF was lying about staffing. 4. A resident had a "Do Not Resuscitate" order and staff took their paperwork off the wall. 5. A Named Resident was DNR. The Staff used the NR like a dummy to practice chest compressions after they were dead. 6. Residents were not getting served with food. One day for a meal they were served mozzarella sticks, croutons and a roll. Investigation Methods: Sample: Total residents: 46 Resident sample size: 8 Closed records sample size: 1 Observations: Identified resident Residents Medication administration Activities Dining Resident care equipment Resident rooms Interviews: Nursing staff Residents Family members administrator Nurse delagator Record Reviews: Facility policies care plans progress notes MAR Schedule . Shower Logs Investigation Summary: 1. There were three sampled residents who did not receive their medications as ordered. Failed practice was identified. A citation was issued for non compliance with WAC 388-78A-2210. Medication services. 2. The Assisted Living Facility (ALF) investigated the incident. Records showed the Named resident (NR) was on a "Do not resuscitate" order. The ALF staff monitored and the NR and was on alert charting. The NR passed away and the ALF followed their protocol. The law enforcement was notified and cleared the NR's body to be released. 3. The ALF increased their staffing for the memory care unit (MC) by maintaining two staff for the morning and evening shifts. For the night shifts, the care staff would call help from the assisted living units through their radio as needed. The MC unit was observed with two staff working for the morning and evening shifts. Review of schedule showed the ALF had two care staff scheduled to work each for the day and evening shifts. The Families reported being happy the MC unit was staffed with two care staff. 4. The Named Resident (NR) was found unresponsive by the Assisted Living Facility (ALF) staff. The ALF staff followed their protocol and called 911. The 911 instructed the ALF staff to perform cardio-pulmonary resuscitation. The Paramedics arrived, took over and pronounced the NR dead. The Snohomish County Sheriff was notified, arrived at the ALF and cleared the incident for any foul play. The ALF conducted an in-service and ensured that all Physicians Order for Life sustaining Treatment forms (POLST) for residents were easily accessible for staff. The ALF had the "Do not Resuscitate" or POLST forms in their Emergency binder and Resident charts. The charts were located in each of the cottages laundry cabinet areas. The ALF stated that they would include in their system placing the forms on the back of residents' doors for easy access. 5. The ALF followed their protocol in responding to medical emergencies. The ALF staff Called 911 and 911 instructed them to perform chest compression or cardiopulmonary resuscitation (CPR). The Paramedics arrived and assessed the NR. CPR was stopped. The ALF reviewed with their staff their protocol and devised a new system for their Physician Orders for Life Saving Treatment forms to be posted at the back of residents doors. 6. During the unannounced visit, staff served their lunch. During the unannounced visit on 01/22/2025, the residents were served with chef salad, dinner roll, orange slices, hot beef sandwich with choices of bread, milk, juice, tea or coffee. Review of the menu showed the menu was followed. Interview with the chef showed they prepare the foods in their kitchen and delivered to the cottages. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: Cottages of Snohomish Provider Type: Assisted Living Facility License/Cert.#: 2740 Intake ID: 164171 Compliance Determination #: 54780 Region/Unit #: RCS Region 2 / Unit A Investigator: Wesler Dumecquias Investigation Date(s): 11/27/2024 through 03/07/2025 Complainant Contact Date(s): Allegation(s): 1. The ALF allowed unlicensed staff to pass medications. The staff did not have a MedTech Training or credentials. 2. The ALF had an unsafe staffing ratio, and residents would be left unattended. 3. There were 14 residents that can fit in one cottage. 4. A Named Staff made a few medication errors and was working as a Med tech. Staff were working as Med Techs without the training or credentials of a Med Tech. 5. The ALF’s heating and cooling system was broken. 6. The ALF’s bathrooms and ceilings in the bathroom had mold. 7. A Named Resident complained of not receiving their medication in a timely manner and was feeling dizzy. 8. The ALF’s Regional manager told a staff not to return to the ALF premises after they submitted the report to the State. 9. The ALF had no housekeeping staff. Investigation Methods: Sample: Total residents: 46 Resident sample size: 8 Closed records sample size: 1 Observations: Residents Activities Dining Resident rooms Medication administration Resident to resident interactions Staff to resident interactions room temperature Interviews: Nursing staff Residents Family members administrator Nurse delegator Record Reviews: Personnel files . Staff training records Staff patterns care plans MARs Progress notes Staff schedule Shower logs Investigation Summary: 1. The ALF allowed two staff that were not nurse delegated prior to checking blood sugars and administering insulin. Failed practice identified. A citation was issued for noncompliance with WAC 388-78A-2320- Intermittent nursing services. 2. The ALF increased their staffing for the memory care unit (MC) by maintaining two staff for the morning and evening shifts. For the night shifts, the care staff would call help from the assisted living units through their radio as needed. The MC unit was observed to have two staff working for the morning and evening shifts. Review of schedule showed two care staff were scheduled to work each day and evening shifts. Interview with family members confirmed their satisfaction of seeing the MC unit was staffed with two care staff. The Assisted Living had residents that did not need 1:1 supervision. The sampled residents were able to call for help with their call pendant and emergency call buttons. 3. Review of records showed the ALF had Six cottages. Four cottages were occupied by residents. One cottage was occupied by 12 residents. Review of bed capacity showed the ALF had 84 licensed beds. There was no cottage that had 14 residents. The memory care unit was staffed with two care staff each for the day and evening shift, and one for the night shift with a float staff helping coming from the Assisted living cottages. 4. The ALF investigated the medication error and followed their protocol. The ALF determined that the Named Staff (NS) misunderstood reading the order and missed a dose of a Named Residents medication. The NS was not nurse delegated. A citation was issued for noncompliance with WAC 388-78A-2320- Intermittent nursing services. 5. Observation and interview showed the ALF heating system was fixed at the time of the unannounced visit. The ALF's memory care unit where the issue was observed had rooms that were individually equipped with a thermostat. The Room temperatures ranged from 70 to 78 degrees Fahrenheit. Interview indicated that at times there were couple rooms where the temperature would increase to 81 to 84 degrees Fahrenheit. The ALF staff remedy would be opening the doors to maintain an acceptable temperature. The ALF continued to monitor their heating system as it fluctuates. 6. Observation during the unannounced visit showed the common bathrooms and sampled residents bathrooms were clean. There was no observed presence of molds. The ALF staff were required to keep the bathrooms clean and organized. 7. The NR did not received their scheduled insulin injection during the unannounced. Failed practice was identified. A citation was issued for non compliance with WAC 388-78A-2210. Medication services. 8.

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20425 72nd Avenue S, Suite 400, Kent, WA 98032 Snohomish ALC LLC Cottages of Snohomish 1124 Pine Ave Snohomish, WA 98290 RE: Cottages of Snohomish # 2740 Dear Administrator: This document references Compliance Determination 55822 (04/23/2025), which included complaint number(s) 168155, 169638, 168859, 169834, 169433. The Department completed a complaint investigation of your Assisted Living Facility on 04/23/2025 and found that your facility does not meet the Assisted Living Facility requirements. The department staff who did the inspection and provided consultation: Wesler Dumecquias, Community Complaint Investigator Consultation: WAC 388-78A-2930 Communication system. (1) The assisted living facility must: (b) Provide the resident with personal wireless communication devices, such as pendants or wristbands, when a communication device is not installed in the resident's sleeping room, and when wireless communications are used: (i) The system must be designed and installed consistent with industry standards and perform reliably throughout the facility; and . Cottages of Snohomish # 2740 04/23/2025 The Assisted Living Facility (ALF) failed to ensure that pendants were responded to within a reasonable time. The ALF care staff pagers were supposed to be in the possession of the care staff at all times while they are at work. The Pagers were not in the possession of the care staff at this time and were found in the Medication cart drawers. The ALF reminded the care staff and included in their in -service a review of their protocol in responding to pendants. A consultation was done under WAC 388-78A-2930- Communication System. WAC 388-78A-2410 Content of resident records. The assisted living facility must organize and maintain resident records in a format that the assisted living facility determines to be useful and functional to enable the effective provision of care and services to each resident. Active resident records must include the following: (9) Documentation consistent with WAC 388-78A-2120 Monitoring resident well-being. The ALF staff followed the care plan. Staff were doing showers but were not consistently documenting them in their ADL task. The ALF reminded and had an in-service with the care staff regarding the importance of recording their observations, residents refusals and ensuring continuity of care. The ALF fixed their documentation and ensured the care and services provided according to the care plan were documented. You Must: • Begin the process of correcting the deficiency or deficiencies immediately; and • Complete correction as soon as possible. You Are Not: • Required to submit a plan-of-correction for the deficiency or deficiencies found. The Department May: • Inspect the facility to determine if you have corrected all deficiencies. You May: • Contact me for clarification of the deficiency or deficiencies found. In Addition, You May: • Request an Informal Dispute Resolution (IDR) review within 10 working days after you receive this letter. Your IDR request must include: o What specific deficiency or deficiencies you disagree with; o Why you disagree with each deficiency; and o Whether you want an IDR to occur in-person, by telephone or as a paper review. o Send your request to: Email: RCSIDR@dshs.wa.gov; or . Cottages of Snohomish # 2740 04/23/2025 If You Have Any Questions: • Please contact me at (253)281-1245. Sincerely, Anthony Devito, Field Services Administrator Region 2, Unit Z . . . . .