Pine Ridge Alzheimer's Special Care Center.

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 8517 E Trent Ave, Ste 102, Spokane Valley, WA 99212 Statement of Deficiencies License #: 2513 Compliance Determination # 66600 Plan of Correction Pine Ridge Alzheimer's Special Care Center 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 10/02/2025 of: Pine Ridge Alzheimer's Special Care Center 12009 E Mission Ave Spokane Valley, WA 99206 This document references the following complaint number(s): 195327, 194809 The following sample was selected for review during the unannounced on-site visit: 4 of 46 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Amy Wright, NCI Complain Investigator From: DSHS, Aging and Long-Term Support Administration 8517 E Trent Ave, Ste 102 Spokane Valley, WA 99212 . Statement of Deficiencies License #: 2513 Compliance Determination # 66600 Plan of Correction Pine Ridge Alzheimer's Special Care Center 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-2140 Negotiated service agreement contents. The assisted living facility must develop, and document in the resident's record, the agreed upon plan to address and support each resident's assessed capabilities, needs and preferences, including the following: (1) The care and services necessary to meet the resident's needs, including: (a) The plan to monitor the resident and address interventions for current risks to the resident's health and safety that were identified in one or more of the following: (iii) On-going assessments of the resident; This requirement was not met as evidenced by: Based on interview and record review, the facility failed to document in the negotiated service agreement, interventions to prevent falls for residents identified as being at risk for falls for 2 of 2 residents (Residents 1 and 2). This failed practice placed residents at risk of falls, pain, injury, hospital visits, and decreased quality of life. Findings included… <Resident 1> Review of an incident report for Resident 1, dated 09/11/2025, showed that the resident had a fall on that day. The incident report showed that Resident 1’s fall resulted in a lump above their left eye, an abrasion to their nose, and knee pain. Review of the incident report showed that after their fall, Resident 1 cried and stated, “Oh I hurt.” Further review of the incident report showed that the resident was sent to the hospital for evaluation after their fall. . Statement of Deficiencies License #: 2513 Compliance Determination # 66600 Plan of Correction Pine Ridge Alzheimer's Special Care Center Completion Date Review of an incident report for Resident 1, dated 09/16/2025, showed that the resident had a fall on that day. The incident report showed that after their fall, Resident 1 complained of breast and knee pain. The incident report showed that a bruise developed on Resident 1’s left breast, redness developed on their right breast, and they had scrapes to both knees. Review of a Falls Management Evaluation for Resident 1, dated 09/17/2025, showed that the resident had two falls within the last 90 days and that they were at average risk for falls. In an interview on 10/02/2025 at 12:19, Staff A, Executive Director, stated that Resident 1 had two falls since 09/11/2025. Staff A stated that if a resident had a history of falls or a risk for falls, their care plan should reflect that and it should include interventions to prevent falls. Review of a Negotiated Service Agreement (NSA) for Resident 1, dated 07/16/2025, showed there were no fall interventions listed for Resident 1. <Resident 2> Review of a Quarterly Assessment for Resident 2, dated 07/16/2025, showed that the resident was at a low risk for falls. Review of an incident report for Resident 2, dated 09/28/2025, showed that the resident had a fall on that day. The incident report showed that the resident hit their face on the floor and received a skin tear to their elbow. Review of an incident report for Resident 2, dated 10/01/2025, showed that the resident had a fall on that day at 1:15 AM. The incident report showed that after the resident’s fall, they grimaced while trying to move or walk. The incident report showed that the resident was recently started on a new pain medication due to a previous fall with pain. Review of an incident report for Resident 2, dated 10/01/2025, showed that the resident had a fall on that day at 1:47 PM. In an interview on 10/10/2025 at 8:47 AM, Collateral Contact 1 (CC1), Resident Representative, stated that staff had been providing the resident with a lot of care due to a recent fall. Review of an NSA for Resident 2, dated 07/16/2025, showed there were no fall . Statement of Deficiencies License #: 2513 Compliance Determination # 66600 Plan of Correction Pine Ridge Alzheimer's Special Care Center Completion Date interventions listed for Resident 2. This is a recurring citation previously cited on 08/06/2025. 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, Pine Ridge Alzheimer's Special Care Center 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 . . . . .

Findings included… <Resident 1> Review of Resident 1’s Negotiated Service Agreement (NSA), dated 07/08/2025, showed the resident was admitted to the facility on /2025, had a diagnosis of , required staff to provide standby or physical assistance with bathing, and was care planned for a bathing frequency of twice a week. Review of the facility’s Recorded Care Report, dated 7/11/2025, showed no shower sheet documentation to indicate that Resident 1 had received any showers from 06/29/2025 to 07/11/2025. . Statement of Deficiencies License #: 2513 Compliance Determination # 62449 Plan of Correction Pine Ridge Alzheimer's Special Care Center Completion Date <Resident 2> Review of Resident 2’s NSA, dated 04/10/2025, showed the resident was admitted to the facility on /2023, had a diagnosis of , required staff to provide standby or physical assistance with bathing, and was care planned for a bathing frequency of twice a week. Review of the facility’s Recorded Care Report, dated 7/11/2025, showed no shower sheet documentation to indicate that Resident 2 had received any showers from 06/29/2025 to 07/11/2025. <Resident 3> Review of Resident 3’s NSA, dated 07/10/2025, showed the resident was admitted to the facility on /2024, had a diagnosis of , required staff to provide standby or physical assistance with bathing, and was care planned for a bathing frequency of twice a week. Review of the facility’s Recorded Care Report, dated 7/11/2025, showed no shower sheet documentation to indicate that Resident 3 had received any showers from 06/29/2025 to 07/11/2025. <Resident 4> Review of Resident 4’s NSA, dated 03/27/2025, showed the resident was admitted to the facility on /2024, had a diagnosis of , required staff to provide standby or physical assistance with bathing, and was care planned for a bathing frequency of twice a week. Review of the facility’s Recorded Care Report, dated 7/11/2025, showed no shower sheet documentation to indicate that Resident 4 had received any showers from 06/29/2025 to 07/11/2025. <Resident 5> Review of Resident 5’s NSA, dated 04/18/2025, showed the resident was admitted to the facility on /2024, had a diagnosis of , required staff to provide prompting and cueing for the duration of bathing task, and was care planned for a bathing frequency of twice a week. . Statement of Deficiencies License #: 2513 Compliance Determination # 62449 Plan of Correction Pine Ridge Alzheimer's Special Care Center Completion Date Review of the facility’s Recorded Care Report, dated 7/11/2025, showed no shower sheet documentation to indicate that Resident 5 had received any showers from 06/29/2025 to 07/11/2025. <Resident 6> Review of Resident 6’s NSA, dated 04/18/2025, showed the resident was admitted to the facility on /2023, had a diagnosis of , required staff to provide standby or physical assistance with bathing, and was care planned for a bathing frequency of twice a week. Review of the facility’s Recorded Care Report, dated 7/11/2025, showed no shower sheet documentation to indicate that Resident 6 had received any showers from 06/29/2025 to 07/11/2025. In an interview on 07/11/2025 at 11:55 AM, Staff A, Health and Wellness Director, and Staff B, Resident Care Coordinator, verified that all residents were supposed to have two showers weekly, and that staff were supposed to document resident showers in Care Tracker and complete a shower sheet after assisting residents with care tasks. Staff A and Staff B further stated that if staff hadn’t documented showers on a shower sheet to match the Care Tracker system, it was likely that the showers had not been provided, and that currently the facility was not in compliance with providing all residents with two showers weekly as identified in their NSA. In an interview on 07/11/2025 at 01:10PM, Staff C, Caregiver, stated they did not believe residents were receiving showers if there was no supporting shower sheet turned in by care staff by the end of the staff’s daily shift. This is an uncorrected deficiency previously cited on 05/15/2025 and a recurring deficiency previously cited on 03/20/2025 and 02/23/2023. . Stat;e of Ui!shington 718 St~t~t'(lantof Defi¢ienpies Uc:eris~ #: 25i 3 Cpmpliam::e D~tiarrninit~on.# 62449 Pl11~ -ci601tt1/l.ti0f.'I Pine Ri'dge f..Jthe.lri~~ls SpeGfal Care,:C~nt~f . . C~tnp!~tiQft·D:ate P;ige.5' :of 5 Li,-;~n~,w Pini:i Ridg~ OpC9··U ... c 01l17B.0?5:. P.lal\/A ttest.atlon Stat~tnent ! herebytett\fy t~)~t I have reviel¥ed'lril's T~por-t a11d have rake.n,:or ~vm tak~.'.a ctiVe · ff!(HlSUf~'S lo 'c'oitet.fthl~.J:!eij¢\etH~. By ta~lf~g-tril~ ?i~tibn,.Pin:e-Rl~ge .Alzneir'!'!e..f'$: $p,~ci~l ~~Cen~rli~r 1-l'lh!I be in 6orhplihnce iA1th this-l:aw.and i or·re,gU!aHon i:m H~S:: . .. t .... ) .. ~- . I . In t1ck:iitiM, I vvlH irr1plernent a syste,rnto monitqr arid eri:~r~ c_q(ltltiued cqtnpliijnce-vvitn. thii i•e9uirenieht. . . . . . . . .. · . . . . Statement of Deficiencies License #: 2513 Compliance Determination # 62449 Plan of Correction Pine Ridge Alzheimer's Special Care Center 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, Pine Ridge Alzheimer's Special Care Center 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 deficiency: WAC 388-7A-2160 Implementation of negotiated service agreement. The assisted living facility must provide the care and services as agreed upon in the negotiated service agreement to each resident unless a deviation from the negotiated service agreementis mutually agreed upon between the assisted living facility and the resident or resident representative at the time the care and services are scheduled. This requirement was not met as evidenced by: Based on interviews and record review the facility failed to provide bathing assistance as agreed upon in the negotiated service agreement for 6 of the 6 sampled residents. This failure resulted in the residents not receiving the bathing assistance that was agreed upon and lack of hygiene care and placed residents at risk for unmet care. Facility response: Pine Ridge Alzheimer's Special Care shall immediately implement the following plan of correction: 1. Staff will be educated ori the importance of following the negotiated service plan and scheduled care and services agreed upon unless a deviation is agreed upon by the facility, the resident or the resident representative at the time of service. 2. Administrator and RCC with the help of the Lead Med Tech will monitor documentation and schedule daily to ensure showers are being completed according to schedule and complete documentation is done timely and accurately. 3. Continue current process of all refusals of showers will be brought to the attention of the Med Tech to which will approach resident for 2nd approach, if still refused Med Tech can adjust shower schedule for next shift or next day. 4. Staff will continue to document showers in Electronic Medical Records platform a. At this time is ALIS Care Tracker. 5. Staff will continue to document as well on Skin Sheets and RCC will audit that showers are being documented. a. Ongoing trending and tracking of care refusals to allow leadership and resident/resident representative to make strategic changes to the negotiated service plan. Estimated date of implementation: Will be completed by August 31, 2025 . STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 8517 E Trent Ave, Ste 102, Spokane Valley, WA 99212 Statement of Deficiencies License #: 2513 Compliance Determination # 59237 Plan of Correction Pine Ridge Alzheimer's Special Care Center 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 05/07/2025 of: Pine Ridge Alzheimer's Special Care Center 12009 E Mission Ave Spokane Valley, WA 99206 This document references the following SOD dated: 05/15/2025 The following sample was selected for review during the unannounced on-site visit: 9 of 50 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Anne Sinclair, NCI Community Complaint Investigator From: DSHS, Aging and Long-Term Support Administration 8517 E Trent Ave, Ste 102 Spokane Valley, WA 99212 . 8taternEm1 i)i D13fidenciE1s i::11an of Cortectir:in Pirie ~:id~e, ..1 -\hi--11.?.irne-f's Speck,l (;g:re Ctm!~r Cornple-t/Gn ()ate Pag~ 2 of 5 Utens.se: Piri:e Ridg;s iJpC(1 L.lC 05l1.S/20·25 As -0 re.sutt ot tt-ie on-siti:- vislt(s) thi:- f:iepartrnent found that you :are not ln complian1::e vvltll the licensing hwvS< c!l!ld regulatium; as stated in tht:t c:iteu defo:.

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