North Point Village, Assisted Living & Memory Care.

NOTICE OF CONDITIONS ON LICENSE June 30, 2025 ELECTRONIC-FACSIMILE Based on the Statement of Deficiencies dated June 16, 2025, the Department of Social and Health Services imposes the following conditions on the license of North Point Village, Assisted Living & Memory Care, License # 2479, located at 1110 E Westview Ct, Spokane, Washington. • The licensee must hire, at their own expense, a Registered Nurse Consultant (RNC) not currently or previously associated with the facility no later than July 22, 2025, who is familiar with assisted living facility regulations, to assist with the following: o Assess the current medication system and if necessary, develop a new system or modify the existing system to comply with all applicable medication regulations for assisted living facilities to include but not limited to WAC 388-78A-2210. o Train all current staff performing as medication technicians in the new or updated medication system to ensure a clear understanding of safe medication delivery and to ensure residents receive medications as prescribed. o Audit the medication delivery system weekly until such a time as the facility can demonstrate sustained compliance with WAC 388-78A-2210. • The licensee will provide the RNC with a copy of September 6, 2023, June 24, 2024, August 27, 2024, October 4, 2024, April 15, 2025, and June 16, 2025, Statement of Deficiencies reports. • The licensee will provide the Residential Care Services (RCS) Field Manager with the RNC contact information as soon as the RNC is hired. • The licensee must coordinate a meeting with the RCS Field Manager and Regional Administrator to discuss continued non-compliance and Department expectations by August 4, 2025. • The RNC will be available to the Department for questions. • The RNC will send weekly progress reports to the RCS Field Manager for review. • The licensee must post this Notice of Conditions of Operation, with the license, in a visible location in a common use area accessible to residents and visitors. • The licensee must post this Notice of Conditions of Operation, with the license, in a visible location in a common use area accessible to residents and visitors. Notice of Conditions of Operation Page 2 These conditions are effective on June 30, 2025, and remain in effect until lifted by formal Department of Social and Health Services notice. Matt Hauser Compliance Specialist Residential Care Services

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 June 4, 2025 ELECTRONIC-FACSIMILE Administrator North Point Village, Assisted Living & Memory Care 1110 E Westview Ct Spokane, WA 99218 Assisted Living Facility License # 2479 Licensee: PSL Associates, LLC IMPOSITION OF CIVIL FINES Dear Administrator: On May 23, 2025, the Department of Social and Health Services (DSHS), Residential Care Services completed a Complaint Investigation at your facility. This letter constitutes formal notice of civil fines on the license for your assisted living facility, also known as North Point Village, Assisted Living & Memory Care, located at 1110 E Westview Ct, Spokane, 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 fines on the license are based on the following violation of the RCW and/or WAC as described in the attached Statement of Deficiencies (SOD) report dated May 23, 2025. Civil Fines RCW 70.129.140 (1) Quality of life -- Rights. $1,000.00 WAC 388-78A-2660 (1)(7) Resident rights. The licensee failed to provide care in a manner which promoted health and well-being for one resident. This failed practice resulted in resident pain and discomfort and a lack of wound assessment and treatment of the resident's wounds, contributed to wound infection and the need for surgical interventions, and placed the resident at risk for health complications. Administrator North Point Village, Assisted Living & Memory Care License # 2479 June 4, 2025 Page 2 WAC 388-78A-2120 (3)(b)(4) Monitoring residents' well-being. $1,000.00 The licensee failed to ensure that staff evaluated and took appropriate action for wounds sustained by one resident. These failures resulted in resident pain due to a lack of wound assessment and treatment, contributed to ongoing wounds with the need for surgical repair, and placed the resident at risk of ongoing skin breakdown. This is a recurring deficiency previously cited on December 5, 2023, and on January 4, 2023, for subsections (3) and (4). NOTE: These are the violations, which resulted in the fines; see the attached Statement of Deficiencies for any additional violations. 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: Stephanie Jenks, Field Manager Region 1, Unit B 8517 E Trent Ave, Suite 102 Spokane Valley, WA 99212-2329 Phone: (509) 993-7821/ Fax: 509-921-2426 rcsregion1email@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). Administrator North Point Village, Assisted Living & Memory Care License # 2479 June 4, 2025 Page 3 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. Please email your request(s) and supporting documentation to: RCSIDR@dshs.wa.gov OR FAX to: 360-725-3225 Formal Administrative Hearing You may contest the civil fines by requesting a formal administrative hearing to challenge the deficiency, which resulted in the civil fines. 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 fines are due to the Office of Financial Recovery twenty-eight (28) calendar days after receipt of this letter. Mail a check for $2,000.00 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, WA 98507-9501 (360) 664-5919 / FAX: (360) 664-8401 OFRMMISVendor@dshs.wa.gov Administrator North Point Village, Assisted Living & Memory Care License # 2479 June 4, 2025 Page 4 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. NOTICE: State and federal law provide protections to defendants who are in military service, and to their dependents. Dependents of a service member are the service member’s spouse, the service member’s minor child, or and individual for whom the service member provided more than one-half of the individual’s support for one hundred eight days immediately preceding an application for relief. One protection provided is the protection against the entry of a default judgment in certain circumstances. This notice pertains only to a defendant who is a dependent of a member of the National Guard or a military reserve component under a call to active service, or a National Guard member under a call to service authorized by the governor of the state of Washington, for a period of more than thirty consecutive days. Other defendants in military service also have protections against default judgments not covered by this notice. If you are the dependent of a member of the national guard or a military reserve component under a call to active service, or a national guard member under a call to service authorized by the governor of the state of Washington, for a period of more than thirty consecutive days, you should notify the Department in writing of your status as such within twenty days of the receipt of this notice. If you fail to do so, then a court or an administrative tribunal may presume that you are not a dependent of an active duty member of the national guard or reserves, or a national guard member under a call to service authorized by the governor of the state of Washington, and proceed with the entry of an order of default and/or a default judgment without further proof of your status. Your response to the Department about your status does not constitute an appearance for jurisdictional purposes in any pending litigation nor a waiver of your rights. If you have any questions, please contact Stephanie Jenks, Field Manager, at (509) 993-7821. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 1, Unit B RCS Regional Administrator, Region 1 HCS Regional Administrator, Region 1 DDA Regional Administrator, Region 1 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW HP

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Health and Community Living Administration PO Box 45600, Olympia, WA 98504-5600 June 30, 2025 ELECTRONIC-FACSIMILE Administrator North Point Village, Assisted Living & Memory Care 1110 E Westview Ct Spokane, WA 99218 Assisted Living Facility License # 2479 Licensee: PSL Associates, LLC IMPOSITION OF CIVIL FINES AND IMPOSITION OF CONDITIONS ON A LICENSE Dear Administrator: On June 16, 2025, 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 civil fines and the imposition of conditions on the license for your assisted living facility, also known as North Point Village, Assisted Living & Memory Care, located at 1110 E Westview Ct, Spokane, 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 and 18.20.520. The civil fines and conditions on the license are based on the following violations of the RCW and/or WAC as described in the attached Statement of Deficiencies (SOD) report dated June 16, 2025. Civil Fines WAC 388-78A-2600 (1)(a)(b) Policies and procedures. $500.00 The licensee failed to follow their fall program policy and procedures for six residents sampled for falls. This failure resulted in the residents’ falls not being tracked to potentially decrease further risk and placed the residents at risk of harm. This is an uncorrected deficiency previously cited on April 15, 2025. Administrator North Point Village, Assisted Living & Memory Care License # 2479 June 30, 2025 Page 2 WAC 388-78A-2120 (1)(2)(b) Monitoring residents' well-being. $500.00 The licensee failed to monitor the need for as needed medications for bowel movements for one resident. This failure placed the resident at risk of health complications. This is an uncorrected deficiency previously cited on April 15, 2025, and a recurring deficiency previously cited on December 5, 2023, for subsection (1). WAC 388-78A-2320 (1)(a)(b)(2)(a)(b)(c) Intermittent nursing $500.00 services systems. The licensee failed to provide safe intermittent nursing service practices for three residents sampled for nurse delegation. This failure resulted in the residents receiving delegated nursing tasks without the oversight of a registered nurse and placed the residents at risk of serious health complications. This is an uncorrected deficiency previously cited on April 15, 2025. Conditions on License WAC 388-78A-2210 (1)(a)(b)(2)(a)(b) Medication services. The licensee failed to ensure that residents received their medication as prescribed for two residents and failed to follow health care provider orders related to blood pressure medications for another resident. This failure resulted in delayed medication administration for one resident, two residents not receiving their full course of antibiotics and placed the residents at risk for health complications. This is an uncorrected deficiency previously cited on April 15, 2025, and a recurring deficiency previously cited on October 4, 2024, for subsections (2)(a), August 27, 2024, for subsections (1)(b), June 4, 2024, for subsections (2)(a), and September 6, 2023, for subsections (2)(a). Administrator North Point Village, Assisted Living & Memory Care License # 2479 June 30, 2025 Page 3 The department has determined that the following conditions shall be placed on your assisted living facility license: • The licensee must hire, at their own expense, a Registered Nurse Consultant (RNC) not currently or previously associated with the facility no later than July 22, 2025, who is familiar with assisted living facility regulations, to assist with the following: o Assess the current medication system and if necessary, develop a new system or modify the existing system to comply with all applicable medication regulations for assisted living facilities to include but not limited to WAC 388-78A-2210. o Train all current staff performing as medication technicians in the new or updated medication system to ensure a clear understanding of safe medication delivery and to ensure residents receive medications as prescribed. o Audit the medication delivery system weekly until such a time as the facility can demonstrate sustained compliance with WAC 388-78A-2210. • The licensee will provide the RNC with a copy of September 6, 2023, June 24, 2024, August 27, 2024, October 4, 2024, April 15, 2025, and June 16, 2025, Statement of Deficiencies reports. • The licensee will provide the Residential Care Services (RCS) Field Manager with the RNC contact information as soon as the RNC is hired. • The licensee must coordinate a meeting with the RCS Field Manager and Regional Administrator to discuss continued non-compliance and Department expectations by August 4, 2025. • The RNC will be available to the Department for questions. • The RNC will send weekly progress reports to the RCS Field Manager for review. • The licensee must post this Notice of Conditions of Operation, with the license, in a visible location in a common use area accessible to residents and visitors. These conditions are effective on June 30, 2025, and remain in effect until lifted by formal Department of Social and Health Services notice. NOTE: These are the violations, which resulted in the fines and conditions; see the attached Statement of Deficiencies for any additional violations. Attestation (Plan of Correction): Administrator North Point Village, Assisted Living & Memory Care License # 2479 June 30, 2025 Page 4 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: Stephanie Jenks, Field Manager Region 1, Unit B 8517 E Trent Ave, Suite 102 Spokane Valley, WA 99212-2329 Phone: (509) 993-7821/ Fax: 509-921-2426 rcsregion1email@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. Please email your request(s) and supporting documentation to: RCSIDR@dshs.wa.gov OR FAX to: 360-725-3225 Formal Administrative Hearing Administrator North Point Village, Assisted Living & Memory Care License # 2479 June 30, 2025 Page 5 You may contest the civil fines and conditions by requesting a formal administrative hearing to challenge the deficiencies, which resulted in the civil fines and conditions. 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 fines is due to the Office of Financial Recovery twenty-eight (28) calendar days after receipt of this letter. Mail a check for $1,500.00 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, WA 98507-9501 (360) 664-5919 / FAX: (360) 664-8401 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 North Point Village, Assisted Living & Memory Care License # 2479 June 30, 2025 Page 6 NOTICE: State and federal law provide protections to defendants who are in military service, and to their dependents. Dependents of a service member are the service member’s spouse, the service member’s minor child, or and individual for whom the service member provided more than one-half of the individual’s support for one hundred eight days immediately preceding an application for relief. One protection provided is the protection against the entry of a default judgment in certain circumstances. This notice pertains only to a defendant who is a dependent of a member of the National Guard or a military reserve component under a call to active service, or a National Guard member under a call to service authorized by the governor of the state of Washington, for a period of more than thirty consecutive days. Other defendants in military service also have protections against default judgments not covered by this notice. If you are the dependent of a member of the national guard or a military reserve component under a call to active service, or a national guard member under a call to service authorized by the governor of the state of Washington, for a period of more than thirty consecutive days, you should notify the Department in writing of your status as such within twenty days of the receipt of this notice. If you fail to do so, then a court or an administrative tribunal may presume that you are not a dependent of an active duty member of the national guard or reserves, or a national guard member under a call to service authorized by the governor of the state of Washington, and proceed with the entry of an order of default and/or a default judgment without further proof of your status. Your response to the Department about your status does not constitute an appearance for jurisdictional purposes in any pending litigation nor a waiver of your rights. If you have any questions, please contact Stephanie Jenks, Field Manager, at (509) 993-7821. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 1, Unit B RCS Regional Administrator, Region 1 HCS Regional Administrator, Region 1 DDA Regional Administrator, Region 1 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW HP

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 April 28, 2025 ELECTRONIC-FACSIMILE Administrator North Point Village, Assisted Living & Memory Care 1110 E Westview Ct Spokane, WA 99218 Assisted Living Facility License # 2479 Licensee: PSL Associates, LLC IMPOSITION OF CIVIL FINES Dear Administrator: On April 15, 2025, the Department of Social and Health Services (DSHS), Residential Care Services completed a complaint investigation and full inspection at your facility. This letter constitutes formal notice of civil fines on the license for your assisted living facility, also known as North Point Village, Assisted Living & Memory Care, located at 1110 E Westview Ct, Spokane, 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 fines on the license are based on the following violation of the RCW and/or WAC as described in the attached Statement of Deficiencies (SOD) report dated April 15, 2025. Civil Fines WAC 388-78A-2210 (1)(a)(b)(2)(a)(b) Medication services. $1,000.00 The licensee failed to ensure a safe medication system was in place and medications were given as prescribed to five residents. This failure resulted in medications not given as prescribed for three residents and physician's orders not being followed for two residents. This is a recurring deficiency previously cited on October 4, 2024, for subsection (2) (a), August 27, 2024, for subsection (1) (b), June 24, 2024, for subsection (2) (a), and September 6, 2023, for subsections (2)(a). Administrator North Point Village, Assisted Living & Memory Care License # 2479 April 28, 2025 Page 2 WAC 388-78A-2371 (1)(2) Investigations. $1,000.00 The licensee failed to investigate, document investigative findings, and determine circumstances of incidents for residents who had falls for three residents. These failures placed the residents at risk for injury and recurring falls. This is a recurring deficiency previously cited on October 4, 2024, June 21, 2024, and December 28, 2022, for subsections (1) (2). WAC 388-78A-2120 (1)(2)(b) Monitoring residents' well-being. $300.00 The licensee failed to monitor for changing physical health conditions for one resident. This failure placed the resident at risk for health complications. This is a recurring deficiency previously cited on December 5, 2023, for subsections (1)(3)(a)(4) and January 4, 2023, for subsections (3)(a)(4). WAC 388-78A-2474 (2)(a)(b)(c)(d) Training and home care aide $400.00 certification requirements. The licensee failed to ensure orientation and safety training was completed for one staff, failed to ensure basic training and professional certification was completed and obtained by two staff, failed to ensure specialty training for mental health was completed by one staff, and failed to ensure cardiopulmonary resuscitation and first aid training was obtained by three staff. These failures placed residents at risk of receiving care from unqualified facility staff. This is a recurring deficiency previously cited on December 23, 2024, for subsections (2)(a)(b)(c) and December 5, 2023, for subsections (2)(a). NOTE: These are the violations, which resulted in the fines; see the attached Statement of Deficiencies for any additional violations. 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. Administrator North Point Village, Assisted Living & Memory Care License # 2479 April 28, 2025 Page 3 Return the signed and dated SOD to: Stephanie Jenks, Field Manager Region 1, Unit B 8517 E Trent Ave, Suite 102 Spokane Valley, WA 99212-2329 Phone: (509) 993-7821/ Fax: 509-921-2426 rcsregion1email@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. Please email your request(s) and supporting documentation to: RCSIDR@dshs.wa.gov OR FAX to: 360-725-3225 Formal Administrative Hearing You may contest the civil fines by requesting a formal administrative hearing to challenge the deficiency, which resulted in the civil fines. All hearing requests must be in writing and include: • A copy of this letter; and • A copy of the Statement of Deficiencies. Administrator North Point Village, Assisted Living & Memory Care License # 2479 April 28, 2025 Page 4 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 fines are due to the Office of Financial Recovery twenty-eight (28) calendar days after receipt of this letter. Mail a check for $2,700.00 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, WA 98507-9501 (360) 664-5919 / FAX: (360) 664-8401 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. NOTICE: State and federal law provide protections to defendants who are in military service, and to their dependents. Dependents of a service member are the service member’s spouse, the service member’s minor child, or and individual for whom the service member provided more than one-half of the individual’s support for one hundred eight days immediately preceding an application for relief. One protection provided is the protection against the entry of a default judgment in certain circumstances. This notice pertains only to a defendant who is a dependent of a member of the National Guard or a military reserve component under a call to active service, or a National Guard member under a call to service authorized by the governor of the state of Washington, for a period of more than thirty consecutive days. Other defendants in military service also have protections against default judgments not covered by this notice. If you are the dependent of a member of the national guard or a military reserve component under a call to active service, or a national guard member under a call to service authorized by the governor of the state of Washington, for a period of more than thirty consecutive days, you should notify the Department in writing of your status as such within twenty days of the receipt of this notice. If you fail to do so, then a court or an administrative tribunal may presume that you are not a dependent of an active duty member of the national guard or reserves, or a national guard member under a call to service authorized by the governor of the state of Washington, and proceed with the entry of an order of default and/or a default judgment without further proof of your status. Your response to the Department about your status does not constitute an appearance for jurisdictional purposes in any pending litigation nor a waiver of your rights. Administrator North Point Village, Assisted Living & Memory Care License # 2479 April 28, 2025 Page 5 If you have any questions, please contact Stephanie Jenks, Field Manager, at (509) 993-7821. Sincerely, Rathana Duong Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 1, Unit B RCS Regional Administrator, Region 1 HCS Regional Administrator, Region 1 DDA Regional Administrator, Region 1 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW SN

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 8517 E Trent Ave, Ste 102, Spokane Valley, WA 99212 Statement of Deficiencies License #: 2479 Compliance Determination # 61069 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 1 of 11 Licensee: PSL Associates, LLC 06/16/2025 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 06/12/2025, 06/13/2025 and 06/16/2025 of: North Point Village, Assisted Living & Memory Care 1110 E Westview Ct Spokane, WA 99218 This document references the following SOD dated: 06/16/2025 The following sample was selected for review during the unannounced on-site visit: 7 of 83 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Veronica Jackson, Assisted Living Facility Licensor Joy Pipgras, LTC Surveyor From: DSHS, Aging and Long-Term Support Administration Residential Care Services, Region 1 , Unit B 8517 E Trent Ave, Ste 102 Spokane Valley, WA 99212 This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 61069 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 2 of 11 Licensee: PSL Associates, LLC 06/16/2025 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. Residential 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-2210 Medication services. (1) An assisted living facility providing medication service, either directly or indirectly, must: (a) Meet the requirements of chapter 69.41 RCW Legend drugs Prescription drugs, and other applicable statutes and administrative rules; and (b) Develop and implement systems that support and promote safe medication service for each resident. (2) The assisted living facility must ensure the following residents receive their medications as prescribed, except as provided for in WAC 388-78A-2230 and 388-78A-2250 : (a) Each resident who requires medication assistance and his or her negotiated service agreement indicates the assisted living facility will provide medication assistance; and (b) If the assisted living facility provides medication administration services, each resident who requires medication administration and his or her negotiated service agreement indicates the assisted living facility will provide medication administration. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure that residents received their medication as prescribed for 2 of 7 residents (Resident 2 and 13) and failed to follow health care provider orders related to blood pressure medications for 1 of 1 resident (Resident 1) sampled for medication services. This failure resulted in delayed medication administration for Resident 13, two residents not receiving their full course of antibiotics and placed the residents at risk for health complications. Findings included… This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 61069 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 3 of 11 Licensee: PSL Associates, LLC 06/16/2025 <Resident 1> Review of Resident 1’s Negotiated Care Plan (NCP, the facility’s titled negotiated service agreement), dated 05/27/2025, showed that Resident 1 had diagnoses of and . The care plan showed the resident had chronic diagnoses and that any changes in health condition would be reported so that new treatments could be implemented if necessary. Further review showed that the resident required assistance with medications from facility staff. Review of Resident 1’s June 2025 Medication Administration Record (MAR) showed that the resident took two medications for hypertension twice daily and each had instructions to take the resident’s blood pressure (BP). The MAR showed one medication had additional instructions with parameters to obtain the resident’s heartrate (HR). Further review showed the instructions stated to notify the Health & Wellness Specialist (HWD) if the top number of blood pressure (systolic or SBP) was greater than 140 or less than 110, the bottom blood pressure number (diastolic or SBP) was greater than 90 or less than 60, or if the heartrate (HR) was greater than 100 or less than 60. Review of the MAR showed the health measurements (HR, BP, and HR) were outside of parameters and required notification to the HWD on the following dates: Mornings: 06/02/2025 HR was 56, 06/04/2025 HR was 57, 06/05/2025 BP was 141/78, 06/06/2025 BP was 148/76, 06/08/2025 HR was 56, 06/09/2025 BP was 145/90, 06/10/2025 HR was 57, and on 06/12/2025 HR was 57. Evenings: 06/02/2025 BP was 164/98, 06/04/2025 BP was 154/89, 06/05/2025 BP was 151/84, 06/06/2025 BP was 151/73, and on 06/09/2025 BP was 148/83. In an interview on 06/13/2025 at 10:55 AM Staff G, Regional Health & Wellness Specialist, stated that the blood pressure parameters were ordered by the physician. Staff G further stated that staff had not notified them of the health measures that were out of parameters and that the residents’ physician had not been notified. <Resident 2> Review of Resident 2’s NCP, dated 12/23/2024, showed the resident was diagnosed with and . Further review showed that Resident 2 required assistance with medications from facility staff and would receive medications as they were ordered. Review of Resident 2’s Resident Notes, dated 06/05/2025, showed that the resident had a cough and cold symptoms. The notes showed that on /2025 the resident had trouble breathing and was sent to the emergency room for evaluation. Further review This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 61069 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 4 of 11 Licensee: PSL Associates, LLC 06/16/2025 showed that Resident 2 returned on /2025 with new medication orders. Review of Resident 2’s June 2025 MAR showed a prescription for azithromycin (an antibiotic that treats infection) ordered to start on 06/08/2025 and to be given for a total of five days. Further review showed that only three days of azithromycin were administered, and that the medication was not given on 06/11/2025 or 06/12/2025. In an interview on 06/13/2025 at 11:45 AM, Staff I, Director of Regulatory Training and Compliance, confirmed that Resident 2’s June 2025 MAR showed that two days of antibiotics had not been given as prescribed. <Resident 13> Review of Resident 13’s NCP, dated 06/03/2025, showed that Resident 13 was diagnosed with and received medication assistance from facility staff. Review of a Resident Note, dated 05/31/2025, showed that Resident 13 had an abscess (a confined pocket of pus inside the body) on their chest and was on alert charting due to receiving antibiotic treatment. Review of Resident 13's physician’s order, dated 05/30/2025, showed an order for doxycycline (an antibiotic medication for infections) twice daily for seven days. Review of Resident 13’s June 2025 MAR showed that the doxycycline had not been given to the resident until 06/04/2025, six days after being prescribed. The MAR showed that the resident had not received the full prescription. Further review showed that Resident 13 did not receive one dose on 06/08/2025, with no explanation as to the reason. Review of Resident 13's facility investigation, dated 06/12/2025, showed that the doxycycline had not been administered when prescribed and that the facility was still investigating the reason for the delay in the medication being administered. In an interview on 06/13/2025 at 1:36 PM, Staff G confirmed that Resident 13 did not start the doxycycline until six days from the prescription date, and that it had been a medication error. This is a uncorrected deficiency previously cited on 04/15/2025, and a recurring deficiency previously cited on 10/04/2024 for subsections (2)(a), 08/27/2024 for subsections (1)(b), 06/04/2024 for subsections (2)(a), and 09/06/2023 for subsections (2)(a). This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 61069 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 5 of 11 Licensee: PSL Associates, LLC 06/16/2025 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, North Point Village, Assisted Living & Memory Care 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 WAC 388-78A-2600 Policies and procedures. (1) The assisted living facility must develop and implement policies and procedures in support of services that are provided and are necessary to: (a) Maintain or enhance the quality of life for residents including resident decision-making rights; (b) Provide the necessary care and services for residents, including those with special needs; This requirement was not met as evidenced by: Based on interview and record review, the facility failed to follow their fall program policy and procedures for 6 of 6 residents (Resident 4, 5, 7, 9, 10, and 12) sampled for falls. This failure resulted in the residents’ falls not being tracked to potentially decrease further risk and placed the residents at risk of harm. Review of the facility’s policy titled, “Fall Management and Recovery, subsection Tracking and Trending,” dated 01/2025, showed that the facility would review the number of resident falls for the week during the Weekly at Risk Meeting. <Resident 4> Review of a facility incident report/investigation, dated 06/05/2025, showed that Resident 4 had a fall that resulted in a fractured vertebra (back). <Resident 5> This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 61069 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 6 of 11 Licensee: PSL Associates, LLC 06/16/2025 Review of a facility incident report/investigation, dated 06/06/2025, showed that Resident 5 had a fall that resulted in skin tears (wounds). <Resident 7> Review of a facility incident report/investigation, dated 06/06/2025, showed that Resident 7 had a fall. <Resident 9> Review of a facility incident report/investigation, dated 06/07/2025, showed that Resident 9 had a fall and injured their head and shoulder. <Resident 10> Review of a facility incident report/investigation, dated 06/09/2025, showed that Resident 10 had a fall that resulted in skin tears. <Resident 12> Review of a facility incident report/investigation, dated 06/10/2025, showed that Resident 12 had a fall that resulted in bruises to their left arm. In an interview on 06/13/2025 at 9:32 AM, Staff G, Regional Health and Wellness Specialist, stated they did not discuss resident falls during the Weekly at Risk Meeting unless a resident had two falls in the past month. Review of the Weekly at Risk Report, dated 06/13/2025, showed no falls listed for the six residents from 06/05/2025 to 06/10/2025. This is an uncorrected deficiency previously cited on 04/15/2025. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 61069 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 7 of 11 Licensee: PSL Associates, LLC 06/16/2025 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, North Point Village, Assisted Living & Memory Care 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 WAC 388-78A-2120 Monitoring residents' well-being. The assisted living facility must: (1) Observe each resident consistent with his or her assessed needs and negotiated service agreement; (2) Identify any changes in the resident's physical, emotional, and mental functioning that are a: (b) Recurring condition in a resident's physical, emotional, or mental functioning that has previously required intervention by others. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to monitor the need for as needed medications for bowel movements for 1 of 7 residents (Resident 3). This failure placed the resident at risk of health complications. Findings included… <Resident 3> Review of Resident 3’s Negotiated Care Plan (the facility's titled negotiated Service agreement), dated 05/21/2025, showed that the resident had a diagnosis of and had been observed to respond to questions by smiling and nodding their head even when they may not have understood the question. The care plan showed that the resident was not able to walk, used a wheelchair, and required staff assistance to use the restroom and after incontinence episodes (involuntary elimination of urine and bowel). Further review showed that the resident required assistance with medications from facility staff. Review of Resident 3’s June 2025 Medication Administration Record (MAR) showed an This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 61069 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 8 of 11 Licensee: PSL Associates, LLC 06/16/2025 order to give loperamide (used to treat loose stool) every morning. Review of Resident 3’s June 2025 MAR showed an order to give senna laxative (used to treat constipation) two tablets as needed for no bowel movement (BM) after 48 hours. Review of Resident 3's June 2025 MAR showed an order to give polyethylene glycol (used to treat constipation) as needed for no BM in 24 hours after senna. Review of Resident 3’s undated medical chart showed no documentation of monitoring for bowel movements. In an interview on 06/13/2025 9:20 AM, Staff G, Regional Health & Wellness Specialist, stated that facility staff had not been monitoring bowel function for Resident 3. In an interview on 06/13/2025 at 2:25 PM, Resident 3 showed they did not have the cognitive functioning to determine if they had suffered from constipation or not and could not remember when or if they had a bowel movement recently. This is an uncorrected deficiency previously cited on 04/15/2025, and a recurring deficiency previously cited on 12/05/2023 for subsection (1). 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, North Point Village, Assisted Living & Memory Care 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 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 This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 61069 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 9 of 11 Licensee: PSL Associates, LLC 06/16/2025 (b) Ensure the requirements of chapters 18.79 RCW and 246-840 WAC are met. (2) The assisted living facility providing nursing services, either directly or indirectly, must ensure that the nursing services systems include: (a) Nursing services supervision; (b) Nurse delegation, if provided; (c) Initial and on-going assessments of the nursing needs of each resident; This requirement was not met as evidenced by: Based on interview and record review, the facility failed to provide safe intermittent nursing service practices for 3 of 3 residents (Resident 2, 13, and 15) sampled for nurse delegation. This failure resulted in the residents receiving delegated nursing tasks without the oversight of a registered nurse and placed the residents at risk of serious health complications. Findings included… Per WAC 246-840-930, Criteria for nurse delegation, before delegating a nursing task, the registered nurse delegator must: - Assess the ability of the Nursing Assistant (NA) or Home Care Aid (HCA) to competently perform the delegated nursing task in the absence of direct or immediate nurse supervision. -With delegation of insulin injections, the supervision occurs at least every two weeks for the first four weeks and may be more frequent. -Checking blood sugars and administering insulin are nurse delegated tasks that require registered nurse supervision and oversight by trained staff. - The registered nurse delegator ensures safe and effective services are provided. Re-evaluation and documentation occur at least every 90 days. <Resident 2> Review of Resident 2’s Negotiated Care Plan (NCP, facility’s negotiated service agreement), dated 12/23/2024, showed the resident was diagnosed with and . Further review showed that the resident required assistance with medications and diabetic management that included blood sugar checks (measurement of sugar in the blood) This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 61069 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 10 of 11 Licensee: PSL Associates, LLC 06/16/2025 and insulin administration by trained staff. Review of Resident 2’s June 2025 Medication Administration Record (MAR) showed an order to obtain the resident’s blood glucose (blood sugar) prior to meals and at bedtime. The MAR showed the resident received long-acting insulin by injection every evening. Review of Resident 2’s Nurse Delegation Visit form, dated 03/13/2025, showed that the resident required nurse delegation for blood glucose monitoring and for insulin administration. Review of Resident 2’s records showed no documentation of a nurse delegation reevaluation that was required to be completed by 06/13/2025. <Resident 13> Review of the facility’s Resident Characteristic Roster, dated 06/12/2025, showed that Resident 13 was admitted to the facility on /2022 and required nurse delegation. Review of Resident 13’s June 2025 MAR showed an order stating, “May crush medications,” starting 06/04/2025. In an interview on 06/13/2025 at 1:39 PM, Staff H, Medication Aide, stated that they had been crushing medications “just recently” and had received no instruction from the RND regarding crushing Resident 13’s medications. Review of the facility’s nurse delegation records showed no documentation of a RND assessment of staff to safely crush medications (nurse delegated task). <Resident 15> Review of the facility’s Resident Characteristic Roster, dated 06/12/2025, showed that Resident 15 was admitted to the facility on /2025, was on insulin, and required nurse delegation. Review of Resident 15’s NCP, dated 06/13/2025, showed that the resident had diagnoses of Review of Resident 15’s Nurse Delegation Visit form, dated 05/30/2025, showed that the resident required nurse delegation for blood glucose monitoring and for insulin This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 61069 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 11 of 11 Licensee: PSL Associates, LLC 06/16/2025 administration. Review of the facility’s nurse delegation records showed no documentation of a RND visit that was required to occur by 06/13/2025. Review of Resident 15’s June 2025 MAR showed that the resident received blood sugar checks and long-acting insulin injections twice daily. This is an uncorrected deficiency previously cited on 04/15/2025. 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, North Point Village, Assisted Living & Memory Care 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 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.

NOTICE OF CONTINUED STOP PLACEMENT ORDER ON A LICENSE October 10, 2024 ELECTRONIC-FACSIMILE Based on the Statement of Deficiencies dated September 26, 2024, the Department of Social and Health Services imposes a Continued Stop Placement Order on the license of North Point Village, Assisted Living & Memory Care, License # 2479, located at 1110 E Westview Ct, Spokane, Washington. • The ALF provider must post this Notice of Continued Stop Placement Order, with the license, in a visible location in a common use area of the ALF, accessible to residents and visitors. The stop placement order prohibiting admissions to your assisted living facility was effective immediately upon verbal notice to you on September 5, 2024, in a letter notice dated September 6, 2024. The stop placement order prohibiting admissions is continued on October 10, 2024, and remains in effect until lifted by formal Department of Social and Health Services notice. Matt Hauser Compliance Specialist Residential Care Services

—: WA DSHS report: Investigations (11/2024) —: WA DSHS report: Investigations (11/2024) —: WA DSHS report: Investigations (11/2024) —: WA DSHS report: Investigations (11/2024) —: WA DSHS report: Investigations (11/2024)

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 December 9, 2024 ELECTRONIC-FACSIMILE Administrator North Point Village, Assisted Living & Memory Care 1110 E Westview Ct Spokane, WA 99218 Assisted Living Facility License # 2479 Licensee: PSL Associates, LLC LIFT STOP PLACEMENT ORDER PROHIBITING ADMISSIONS Dear Administrator: This letter is formal notice that the stop placement order prohibiting admissions placed on your license verbally on September 5, 2024, in a notice letter dated September 6, 2024, and then continued on October 10, 2024, in a letter notice dated October 10, 2024, is lifted effective November 25, 2024, upon verbal notice to you. If you have any questions, please call Stephanie Jenks, Field Manager, at (509) 993-7821. Sincerely, For: Matt Hauser Compliance Specialist Residential Care Services cc: Field Manager, Region 1, Unit B RCS Regional Administrator, Region 1 HCS Regional Administrator, Region 1 DDA Regional Administrator, Region 1 WA LTC Ombuds HQ Central Files DRW HP

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 October 10, 2024 ELECTRONIC-FACSIMILE Administrator North Point Village, Assisted Living & Memory Care 1110 E Westview Ct Spokane, WA 99218 Assisted Living Facility License # 2479 Licensee: PSL Associates, LLC IMPOSITION OF CIVIL FINE, AND CONTINUED STOP PLACEMENT ORDER PROHIBITING ADMISSIONS Dear Administrator: On September 26, 2024, the Department of Social and Health Services (DSHS), Residential Care Services completed a Complaint Investigation at your facility. This letter constitutes formal notice of a civil fine, and continued stop placement order prohibiting admissions for your assisted living facility, also known as North Point Village, Assisted Living & Memory Care, located at 1110 E Westview Ct, Spokane, 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 and 18.20.520. The civil fine and continued stop placement order prohibiting admissions are based on the following violations of the RCW and/or WAC as described in the attached Statement of Deficiencies (SOD) report dated September 26, 2024. Civil Fine WAC 388-78A-2450 (1)(a)(b)(2)(e) Staff. $500.00 The licensee failed to ensure staff maintained a safe environment for one resident, failed to provide required and necessary training to one staff and failed to ensure staff provided care identified in negotiated service agreements for three residents. These failures contributed to a second degree burn to one resident, a fall with injury for another resident, unmet shower needs for two other residents, and placed residents at risk of having unmet care needs and injury. This is a recurring deficiency previously cited on December 5, 2023, for subsection (1) (a). Administrator North Point Village, Assisted Living & Memory Care License # 2479 October 10, 2024 Page 2 Continued Stop Placement order prohibiting admissions WAC 388-78A-2300 (2)(a)(i) Food and nutrition services. The licensee failed to ensure specialty diets were served per a diet manual and as ordered for seven residents and failed to have a diet manual available for food preparation. These failures resulted in a choking episode with aspiration for one resident, contradictory diet service for six other residents, and placed residents at risk for unmet dietary needs and preferences and health complications. The stop placement order prohibiting admissions to your assisted living facility was effective immediately upon verbal notice to you on September 5, 2024, in a letter notice dated September 6, 2024. The stop placement order prohibiting admissions is continued on October 10, 2024, and electronic facsimile receipt of this letter and the attached Statement of Deficiencies report. The continued stop placement order prohibiting admissions will not be postponed pending an administrative hearing or informal dispute resolution process, as is required by RCW 18.20.190(4). The continued stop placement applies to all new admissions, re-admissions, and transfer of residents. During the continued stop placement, you may not admit any new resident to your assisted living facility. In addition, you may not allow any resident who was absent from the home due to a temporary non-out-patient stay (not including out-patient treatment) at a hospital, nursing home or other treatment center to return during the continued stop placement unless you obtain advance approval from the department. You may request such approval by contacting Stephanie Jenks, Field Manager, at (509) 993-7821. Because it may not be possible to reach the Field Manager on a weekend or holiday, any pre- approval requests should be made as soon as possible during the business week. Such exceptions are made at the sole discretion of the department on a case-by-case basis. The department may impose sanctions or take other legal action if you fail to comply with the continued stop placement of admissions. The department will terminate the continued stop placement order prohibiting admissions when the violations necessitating the continued stop placement have been corrected and you exhibit the capacity to maintain adequate care and service. NOTE: These are the violations, which resulted in the fine, and continued stop placement order prohibiting admissions; see the attached Statement of Deficiencies for any additional violations. Administrator North Point Village, Assisted Living & Memory Care License # 2479 October 10, 2024 Page 3 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: Stephanie Jenks, Field Manager Region 1, Unit B 8517 E Trent Ave, Suite 102 Spokane Valley, WA 99212-2329 Phone: (509) 993-7821/ Fax: 509-921-2426 rcsregion1email@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 North Point Village, Assisted Living & Memory Care License # 2479 October 10, 2024 Page 4 Formal Administrative Hearing You may contest the civil fine and continued stop placement order prohibiting admissions by requesting a formal administrative hearing to challenge the deficiencies, 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 $500.00 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, WA 98507-9501 (360) 664-5919 / FAX: (360) 664-8401 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 North Point Village, Assisted Living & Memory Care License # 2479 October 10, 2024 Page 5 If you have any questions, please contact Stephanie Jenks, Field Manager, at (509) 993-7821. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 1, Unit B RCS Regional Administrator, Region 1 HCS Regional Administrator, Region 1 DDA Regional Administrator, Region 1 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW HP REQUEST FOR AN ON-SITE REVISIT WITHIN 15 WORKING DAYS FACILITY: _____________________________________________________ ADDRESS: ____________________________________________________ ____________________________________________________ DATE REQUEST FAXED: _____________ DATE MAILED: ______________ TO: ________________________, Field Manager, Region ___ Unit ___ I believe we have corrected the violations that led to my facility/home being placed in stop placement of new admissions. I am requesting an onsite revisit within 15 working days of receipt of this letter to verify that correction(s) is complete. The following steps have been taken to ensure lasting correction. 1. 2. 3. 4. 5. 6. 7. __________________________________ _____________ Licensee or Designee Signature Date

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEAL TH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 8517 E Trent Ave, Ste 102, Spokane Valley, WA 99212 PSL Associates, LLC North Point Village, Assisted Living & Memory Care 1110 E Westview Ct Spokane, WA 99218 RE: North Point Village, Assisted Living & Memory Care License# 2479 Dear Administrator: This letter addresses Compliance Determination(s) 41587 (Completion Date 05/21/2024) and 39289 (Completion Date 04/04/2024). The Department completed a follow-up inspection of your Assisted Living Facility on 05/21/2024 and found no deficiencies. Your facility meets the Assisted Living Facility licensing requirements. The Department found that deficiencies for the following licensing laws and regulations were corrected: WAC 388-78A-2484-1, WAC 388-78A-2484-2, WAC 388-78A-2484 The Department staff who did the on-site verification: Carla Rose, NCI Community Licensor If you have any questions, please contact me at (509)993-7821. Sincerely, Stephanie Jenks, Field Manager Region 1, Unit B Residential Care Services This document was prepared by Residential Care Services for the Locator website. 04.11.2024 11:16:35 state of Washington 3/6 ST./\TE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALT H SERVICES AGING.A.ND LONG-TERM SUPPORT ADMiNISTR.A.TION 8517 E Trent Ave, Ste 102, Spokane Valley, WA 99212 Statement of Deficiencies License#: 2479 Compliance Determination# 39289 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 1 of 3 Licensee: PSL Associates, LLC 04/04/2024 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 04/03/2024 and 04/03/2024 of: North Point Village, Assisted Living & Memory Care 111 0 E Westview Ct Spokane, WA 99218 This document references the following SOD dated: 04/04/2024 The following sample was selected for review during the unannounced on-site visit: 6 of 101 current residents and 0 fon11er residents. The department staff that inspected the Assisted Living Facility: Carla Rose, NCI Community Licensor Patty Ford, LT C Surveyor From: DSHS. Aging and Long-Term Support Administration Residential Care Services, Region 1 , Unii 8 8517 E Trent Ave, Ste 102 Spokane Valley, WA 99212 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. sh 04/QS/2024 Residential Care Services Date l 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. This document was prepared by Residential Care Services for the Locator website. 04.11.2024 11:16:35 State of Washington 4/6 Statement of Deficiencies License#: 2479 Compliance Determination# 39289 Plan of Correction North Point Village. Assisted Living & Memory Care Completion Date Page 2 of 3 Licensee: PSL Associates, LLC 04/04/2024 Pttd:u 4/15/2024 ~(l, Admini,ator (or Representative} Date WAC 388-7BA-2484 Tuberculosis Two step skin testing. Unless the staff person meets the requirement for having no skin testing or only one test, the assisted living facility choosing to do skin testing, must ensure that each staff person has the following two-step skin testing: (1) An initial skin test within three days of employment; and (2) A second test done one to three weeks after the first test. This requirement was not met as evidenced by; Based on interview and record review, the facility failed to ensure that staff received tuberculosis testing within three days of employment for 3 of 3 staff (Staff AA, BB, and CC)_ This failed practice placed residents at risk of exposure to tuberculosis. Findings included.-. Review of Staff AA's. Care Partner, personnel file showed they were hired on 03/20/2024. Staff AA's of personnel file showed that it contained documentation a first step tuberculosis (TB, a communicable respiratory disease) test, placed on 03/20/2024. Further review of the personnel file showed that the TB test was never read (determination of negative or positive results). In an interview on 04/03/2024 at 12:15 PM, Staff P, Business Office Manager, confirmed that Staff AA did not have their first step TB test read. Staff P stated that the facility no longer did TB testing on-site and had started referring employees to an outside testing facility. Staff P stated they sent a list of staff to the department heads who were to follow up with their staff to verify that their TB testing had been completed. Staff P stated that their new process of using an outside vendor for TB testing was not working. In an interview on 04/03/2024 at 12:35 PM, Staff Y, Dining Services Director, stated that they did get a list of staff in their department who were sent for TB testing. Staff Y further stated that they did not have a system in place to follow up with those staff to ensure their tests were completed_ In an interview on 04/03/2024 at 3:55 PM, Staff A, Executive Director, stated that they needed to work on their process to ensure new staff had completed their TB tests_ Review of the most recent staff list showed that Staff BB, Care Partner, was hired on This document was prepared by Residential Care Services for the Locator website. 04.11.2024 11:16:35 State of Washington 5/6 Statement of Deficiencies License#: 2479 Compliance Determination# 39289 Plan of Correction North Point Village. Assisted Living & Memory Care Completion Date Page 3 of 3 Licensee: PSL Associates, LLC 04/04/2024 03/21/2024 and Staff CC, Care Partner. was hired on 03/26/2024. Review of an email from Staff A, received on 04/04/2024, showed that Staff BB and Staff CC did not get their first step TB tests. This is an uncorrected deficiency previously cited on 01/30/2024 and a recurring deficiency previously cited on 12/05/2023 for subsection (1 ). 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, North Point Village, Assisted Living & Memory Care is or will be in compliance with tllis law and / or regulation on CjO/ Z' / (Date) In addition, I will implement a system to monitor and ensure continued compliance with this requirement. ... ~Jt-/L-........................................................... .. ... ..........'l /!(/...~.... 1/... .................... . ~ i: trator (or Representative) Date This document was prepared by Residential Care Services for the Locator website. 02/10/2024 SAT 14: 07 FAX 5H N. Point Village ~002/010 02.08.2024 08:16:06 state oF Weshlngton 31 STAl"E Of W.AS:Hl~G1'0N DEPARTMB~T OF SOCIAL AND HEALTH SERVlCES AGING AND IL.ONG-TERM SUPPORT .~DMH'-.!!STRATION 1511 E (rem Av~. Ste 1'11., Spokane Valt•Y, WA ·H.t 12 Sfatt$mtmt of Dtfid~ndoss Uc~1~s~ #'. 2479 Ct>m1>lhrnc.st Detetrnin ~-t.n #Y.H 19 Plan -of Co rrndlon Nzyrth Point Villag,€ As.sist~d livlog & M~mvr~ Cate Ct>tnpleti<;in Date P:au~ 1 of SI Li 1~tnlH'. PSL As1,ociato1ss., LLC (ittj.{l/2024 Y,c,:u at·~ r'iqulred ta be: in comp!lani:e .mt all Hmes with 111 Ht;~nslng la\'vs and fl}QUlatk;r1s to mmma:in yocr As8ib1:ed Uv'f't'~) F~c.mty ikens,e, Tut d~partrrnrnt compJ-eted data -contction ,or an tmarmoun4;:ed -0~s1te folioi~up Qfl Oi./2912024 anct 0'1130/2.024 cf: Norttl Po.lnt Village, As~isted Uvmg & M emol')I Care ·11 ·to E vW:.mview Ct ~.;pokane, VVA $921 8 The follow1n~ s~mpl-e W~!i ~fected for ,~view during the unann~.ITTced ~fl .. si-t~ visit S of 89 current resitforits and O fom~r residents. Ct.trf--:lJi RJse. NCI Cornmunit-; Lcensor Antoniet.ta LeWeri-P~rk!n, Lon!} Term Clre Surve-yor Ps1cy Ford, LTC SLwveyor Frnm: DSHS. A~Jing and Lor,g-Te1~rn Suppott Adn~11istratior1 Residentiru Care 9f!Nlc~s. Region t , Ur1~t B eG ·t 7 E: Trent Ave,, Stf:: ·1 02 n Sp(lkane VaU~·t, WA 992 .A~ a reiju!t ot tb~ O!'?-site Vi$U(s} th-':l f,H:pa~rtr~1~t1t found that y"Qtl ~r~, ntit Ir, cnrnpliam:;:: -with the ~censing 'l~ws amf: r~g.ulatons as stated in the i'.':ite-d defkiericies it: tn1: enclosed re~att 02/071'2024 Date I :..m,;.h:ir~and that t() rm1intain an Assisted Uving f tldhly !icense. tl1,e factHty rriust tie in con1pi;ar1,::~ with al! trie i;censmg ~aw-s .:rnd r~g;1li~tions m: ~iii tirne·~- 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 8517 E Trent Ave, Ste 102, Spokane Valley, WA 99212 Statement of Deficiencies License #: 2479 Compliance Determination # 36119 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 1 of 9 Licensee: PSL Associates, LLC 01/30/2024 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 01/29/2024 and 01/30/2024 of: North Point Village, Assisted Living & Memory Care 1110 E Westview Ct Spokane, WA 99218 This document references the following SOD dated: 01/30/2024 The following sample was selected for review during the unannounced on-site visit: 5 of 89 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Carla Rose, NCI Community Licensor Antonietta Lettieri-Parkin, Long Term Care Surveyor Patty Ford, LTC Surveyor From: DSHS, Aging and Long-Term Support Administration Residential Care Services, Region 1 , Unit B 8517 E Trent Ave, Ste 102 Spokane Valley, WA 99212 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. Residential 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. This document was prepared by Residential Care Services for the Locator website. 02/10/2024 SAT 14: 08 FAX 509 N. Point Village ~003/010 02.08.2824 08:16:06 state of Mashington 4/ St~t~nmnt o-f Def1c19n,;:ie$ lk,EI~$$ #. 2479 CompHance Oete~minat~~,, # 3S119 Pi.u\ -1rf Corrii\~titii"! N-0-rth Poirtf. Yill~g-e,, Astlsta•d living S.. Momory C:.lri!l Curopi~t't l)Qhl Pag'i 2 of 9 Lic~ns12'f: PSL Associ.wt~s. LLC 01/3'0l202, WAC 3$8-7tA-2·3~ Foo·d •~ltatf:on. The assitt•d llvlng faciUty musit: ( i} M o1nag~ fo{ld, .tmd maintain .'w.f!Y on-sittll fo-od sr€'lric~ far../Hb~i ln complilllncae wtth chaµt~r 24{)-2 ·f 5 W.A.C, Fond se~-vt::e; {:l} En~-urn emplc.iyee:s V.-'t:!rki'n>J a~ rt'.!od setvk:a, wotf<.ers obtaln n fi:iod 'Y'\<Orl-:~r card ac,;ord;ng to ,;hapter 246-.217 WAC; imd l'his requlrtmentwa~ n-ot me u •vfdeneed by; 8ase:d {1:1' 1nter-i1ew and r,:~ord review, the f aci'l1ty fo1(1.HJ to e~'.lure ttmt slit, ~.unpfQy<ed ~r.: dinlng servic.es had a ~;l.im:mt food wo,rker can::t for 3- of 3 staff (Staff S, T, 11nd U) 5·..'lmphh1 for-fuod samtation. Thi~ f&tlurn place-a resfderits :art. rlsk af faodborne Illnesses. R~\'iew trf th~ diet~uy schedule .shoWfid ~1ti3ff S >/1.'(H"k~d ~n ttle following da.itt j ', 0111 B/1/J24: o ·u-17 12024 ,, tl1f11:-1/2024. i'.H/'I W2024. o·V20l2024-. M/23/2024, and Ot 125lW24. Revi~w Jf tie dietaiv schcdute ·showed St£if.f T worked on the folio\llo'ing di~tts.: 01 H4r2024, 1 01/'I S:12024, G-U1 Tr2024{ 0 U20l2024, tH/n/2.024, and UH2412024. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 36119 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 2 of 9 Licensee: PSL Associates, LLC 01/30/2024 Administrator (or Representative) Date WAC 388-78A-2305 Food sanitation. The assisted living facility must: (1) Manage food, and maintain any on-site food service facilities in compliance with chapter 246-215 WAC, Food service; (2) Ensure employees working as food service workers obtain a food worker card according to chapter 246-217 WAC; and This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure that staff employed in dining services had a current food worker card for 3 of 3 staff (Staff S, T, and U) sampled for food sanitation. This failure placed residents at risk of foodborne illnesses. Findings included… <Staff S> Review of the undated staff list showed Staff S, Dining Services Partner, was hired on 10/17/2023. Review of Staff S’s undated personnel file showed they did not have a food worker card. Review of the dietary schedule showed Staff S worked on the following dates: 01/16/2024, 01/17/2024, 01/18/2024, 01/19/2024, 01/20/2024, 01/23/2024, and 01/25/2024. <Staff T> Review of the undated staff list showed Staff T, Dining Services Partner, was hired on 12/02/2023. Review of Staff T’s undated personnel file showed they did not have a food worker card. Review of the dietary schedule showed Staff T worked on the following dates: 01/14/2024, 01/15/2024, 01/17/2024, 01/20/2024, 01/21/2024, and 01/24/2024. This document was prepared by Residential Care Services for the Locator website. 02/10/2024 SAT 14: 08 FAX 509 N. Point Village ~004/010 02.08.2024 08:16:06 state of lolashington 5/ St~tem~nt 9t Oitid~ndes uce~se #: 2479 CvmpRanee b~tenninitt~~,, #~trn Phm .:>f' Corn!l-ctHH1 N1Htl, ~~cnnt Yilluij·e, P.stiut;e,d Uvi11g & Mtmory C.ira Ctimp-!tetiirn D.itti Pags 3 of 9 Li'"~nse~: FSL Ase~d~tias. LLC -01/J:Ci/2024 R~vi~w o-rtt~e ciIetary sche--r.. \ UI~ sr1tJi..ved Staff' U Wi'lrh\Hi an th!:: folbwing dat:es·. 11'li'rn/2.024; 01irni2024, o-J,'Hl2024, OHHl/2024, 011'19/2024, 01/2212024, DH23J2024: 01124/2024~ OH25/1C24. i~nd OU 2t1/2014•. In ~n int•~t'\m:'N (ln 0112-9/:2024 ~t n :!Ju PM, Sklff Y, Oin1ng s~r'i'i.Cf$ rnrn-:ctor, $t£:•kd th,!lJ:t ~'tilff U tsaci re,,;imtly started wml<ifl:{l .:it th,e fat.tilt~, .:Jnd haJ net 0Ma~!1e-1j t~1~ir-food wmker c~m.t In an fntervl~w {If! 0 ·1! :29/2024 ~t :tJ1 F'M, :Sts~ft Y ~ontirm~rl that St-aff• $ ~md Staff T ~td not have their fo(}d werker c~rds. In .m ir1t~rview oo Oi /2W2024 at t.. ·1 :3 PM , Staff A,, Exficuttve Director, •.~01lfamed that StS3ff S and St&ff Thad worked in dmiM::g ser.vk.e~ in lh~ fo~t h1v~ weEfks. Stsft A '!it;1ted th-e•; n1N::ded to diange their pmcess to ensurii:- tr1a.t ne-w employees ~11!t tht!:lir food worker cards. PlanfA tt•station Statem •nt i hereby certlfy !hat: I ~iav~ revtewed thi~ r.e:port and have t,1k~ri ortlt/i~i takt a.-:tiv·e mi~as.urns t~ t.~rred this defo::.ieni::y. Ely taking this ar:tii.m, Nt:.irth Point vmage, Ar:.si$t~d U\iing .&. Mjl:O_~ Car.a ifl or v1,~lf be in ~cmttlitrnte with this law ond / or regul~)~cn on {Dt~te L_JLld'°Ji':f.------··-·· . In, aJd1ti<Hi. I ...-vii! itnplem~r,t il system to rnonitoi· ~md e.nsuric oont~nued comptianc~ witn this r&quiren-ient. A 1 Date WAC 388-18-.A-2880--Ch~n9in9 use '11" rg.oms. Prior to using a toom for" purp,cs.e other th•n. what wa, approve<i by eonstru~tion review s.ervlcas, the aulstad Uving facmty m us.t; This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 36119 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 3 of 9 Licensee: PSL Associates, LLC 01/30/2024 <Staff U> Review of the undated staff list showed Staff U, Dining Services Partner, was hired on 01/09/2024. Review of Staff U’s undated personnel file showed they did not have a food worker card. Review of the dietary schedule showed Staff U worked on the following dates: 01/15/2024, 01/16/2024, 01/17/2024, 01/18/2024, 01/19/2024, 01/22/2024, 01/23/2024, 01/24/2024, 01/25/2024, and 01/26/2024. In an interview on 01/29/2024 at 12:00 PM, Staff Y, Dining Services Director, stated that Staff U had recently started working at the facility and had not obtained their food worker card. In an interview on 01/29/2024 at 3:37 PM, Staff Y confirmed that Staff S and Staff T did not have their food worker cards. In an interview on 01/29/2024 at 4:13 PM, Staff A, Executive Director, confirmed that Staff S and Staff T had worked in dining services in the last two weeks. Staff A stated they needed to change their process to ensure that new employees get their food worker cards. This is an uncorrected deficiency previously cited on 12/05/2023 for subsection (2). 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, North Point Village, Assisted Living & Memory Care 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 WAC 388-78A-2880 Changing use of rooms. Prior to using a room for a purpose other than what was approved by construction review services, the assisted living facility must: (1) Notify construction review services: This document was prepared by Residential Care Services for the Locator website. 02/10/2024 SAT 14: 08 FAX 509 N. Point Village ~005/010 02,08,2024 08:16:06 State of Mashington 61 $tatlim~~t of Det,d~ncies lic~ms~ #: 2479 Ct;mpHance O~te1mln$f~On #381"!9 Pl.int~ Corri~ti(lf1 No,tti Pomt YlhH·&, Assime--rl t.iviflg & Mernot~ C~re Cmnp-{ilti~n D~tt Page 4 of 9 Uc:en:sn: PSL Assocwtss. LlC Dff.3:0/2024 (a) In w.iting. (c) Descriotl the .•=tnrent ar1:d prnpos~d use ot the room; .met (d} PrDvide a~I additff.lnsl docurn~ntation !J!~ re.qoosted by cnrmtruction re~~w -services; mi;, (2) Obtain the written appr,1Jval of constn.1cti,on r~view services for th~ n~w use of ro~rn. und Bas€d c:n obsetvabDn, interv!i:W, and record reV'iew. the facility faili'J;d to notify constn.1,.;,'tion f{;!View s~r;Ac~s ln ad'.;:.:mc~, obtain apprcvat, arn;li ensure in~ mi:"lm iist was-Llpdateri to refl-ed a chang1:: in the: L~s-e c.if 1 of 1 n:.iorn (st~H break roorn}_ This fa~lurc: g.1iaced r~s1,jents reS!cting ~11 bui~ding Bat risk of inju~ due k\ a pot4l:~tia1iy unsafe bv\ng tnvkorm·~ent. Rt✓iew otth~ fact~ity's room Um. .. dated t 1/M/20:tl, showed rnom G fr1 tn..1Hdin,g B (men,mv care bu~ding) 1i~ti di:;sign~ted iit.s a studio apattrnent approv~-tl f.cr- i:.ine licensed bed. Observatkin on OU2!:ilJ2024 at rn·:1n AM, o·f n:iom G in building B shawed the folldWin.g,: _,-,,, ~1'1'igerntor wi-tn a Hme, ~ red lun~h hag. and 1Wt1 wMt-e grocery .bags !oc.ated in the fr'e:~Mr cornporttnent of the rntri:g:.erntor. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 36119 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 4 of 9 Licensee: PSL Associates, LLC 01/30/2024 (a) In writing; (b) Thirty days or more before the intended change in use; (c) Describe the current and proposed use of the room; and (d) Provide all additional documentation as requested by construction review services; (2) Obtain the written approval of construction review services for the new use of the room; and (3) Ensure the facility functional program and room list are updated to reflect the change. This requirement was not met as evidenced by: Based on observation, interview, and record review, the facility failed to notify construction review services in advance, obtain approval, and ensure the room list was updated to reflect a change in the use of 1 of 1 room (staff break room). This failure placed residents residing in building B at risk of injury due to a potentially unsafe living environment. Findings included... Review of the facility’s room list, dated 11/14/2023, showed room G in building B (memory care building) was designated as a studio apartment approved for one licensed bed. Observation on 01/29/2024 at 10:30 AM, of room G in building B showed the following: -Staff H, Maintenance Director, entered the room without a key. -Room G was not locked and was accessible to residents. -The light did not work. -Personal hygiene items were stored, including liquid soap, hand sanitizer, shampoo, conditioner. -A metal bed frame up against the wall in pieces and unsecured. -A refrigerator with a lime, a red lunch bag, and two white grocery bags located in the freezer compartment of the refrigerator. This document was prepared by Residential Care Services for the Locator website. 02/10/2024 SAT 14: 09 FAX 509 N. Point Village 121006/010 02.08.202'1 08, 16:06 State of l-lashll'l9ton 71 Stat8m~nt of Defici~mdas. Li<:.{ijflS~ #. 2479 C'vmphane.e Da1e:rmin-siti.or~ #3'5H9 Pia~ .'.lf Corr..ic.tioi1 Ninth P~1!'!l. Vilfaf1-e, As:si~ed Living & ~\t1arnory Caril c~rop-!~t~a-1'1 Dute Page 5 of9 LicttnSi$: PSL Assodate1s. LLC 01/3:0.'2C24 In ,tm inkrview on 01 t2~ll2024 ijt 1D :33 /--,M, sw-r H stat~d they dit.1 not h-:.ive an upi'..litltt 011 th € st3tu5 1_.;f ttt~ n:i,on). 111 an inte;view en O1 / 1-St.2024 at 4: 1- :J PM, Sti1ft A, Executive Dire-...-:tcr, stated they had no uo,:.-:um~,n~ton regm'dfng thi~ drnng~ ~n th:i! us•J uf rocm G iJl'ld p!.tmned on pl~drig the rs.:,om ''back m ir1'v<?.ntorv~-tc hec~me a re:sid.ant room again. In an \ntervltw en O'l/30/2024 at tVi10 AM, S~aff A stated frrny hi,dn't h-nn:i t,~i,ck from the1r c:nrrnrat~ offi~~ about pladng m~ worn back into. in¥€ntory . TI1is ls m1 Ut)C~rre:eted dafide~cy previous~y dted on 12/0S/2023 and a rncoMng d,e-fide-ncy pri!!V!OUS~1 cited on 1..1:B.l') 8l2011 for su.bsectkit'IS p }{a}(b)( c}{d). PlanJAtt•statlon Statement I h~t!:!by cert~fy that I h~:1ve r~v~~-w1~d this rep,:11t olnd ha"V~ t.Jken or wM tai,;e <>lctiw rrn~as:ur~s to C:<.W~ct this defi.dam:y. By tah1ng this actkm, North i::ioint Vil~atge, Assisted Uving :& Mtltrnory C~rn ii ,::r '!Mlf b:➔- in comµli~nt:e with thi,;;. law and for r~1Julatinn cm l (Oat<:)~_/$' i,y_w . In. additioq, I wlH imp/ernent e"l syclem tc monitor i:1:l!ci ~nmJr~ c,t1nfo1u~d rnrnphllh'ite with this requlremiE-nt. A WAC 388•7iA-2090 PuH anessmant top:fcs. The assisted livlrtg facility must obtain tufflcfant informatien to be abie to usess th• capabmt1es, ntt11uic, -and prafer-enee• for c,ac:h resident· 1 and must tomplete ~ fwn an•ssment addreuh',g the foHowin-g, wtthin fourte,en. dayt afthe resident's mov•°'1n d1te, unless exbmd•d by the-dep:artm~nt for good cause: (SJ Sl9t1tfa.ant knovvn beh~!viors 1x sympt,::irr.s ~f the lru:Aividuai •.:auslng concern or requirln~ ~pecia~ caM, !nciud~ng: ( e) Other safdy (:on-sid~raoons that may po% tl d~in:;ier to the ~ntfrv\ju ~, or otl'l~rn, :':iUCh as use ,:,f rne(fr:af d~vi~~i:\"s or the lr1dlviduai's. abWty tL-1 ~rnoke unwpt:M!!.!l:d, !f srrwkfr:_,g is p~rrnitted in tirn asiisted livmg fav~mty. 8l':!sed o,n t)bWJrvuh~n .. in~iv;!.'W. . and rec~rrl re;·,,-iew, the tadliiy railed t~1 compl-'.:te a fo!i (.i:sse~sm,rnt V1.~ir, ·l4 dav~ of adm\sgfon tor ·1 of 2 reslde11:ts {Res1d~nt ·1&} V..'h-o had recently Mrrntt~d ta the hH.:~li!.y and safety :a:sGtiJ-ssments for 3 nf' 3 res1d·t nts {Re~dt•nts ··t 4, -r f.i, ~r:,ci 1' 9) wth mia:-dioll <.:h:•,;ice.~. These- foilure.-s. pla-ced ramd,;,!li~ at rist ct rnnmet c;;ire This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 36119 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 5 of 9 Licensee: PSL Associates, LLC 01/30/2024 In an interview on 01/29/2024 at 10:33 AM, Staff H stated they did not have an update on the status of the room. In an interview on 01/29/2024 at 4:13 PM, Staff A, Executive Director, stated they had no documentation regarding the change in the use of room G and planned on placing the room “back in inventory” to become a resident room again. In an interview on 01/30/2024 at 8:30 AM, Staff A stated they hadn’t heard back from their corporate office about placing the room back into inventory. This is an uncorrected deficiency previously cited on 12/05/2023 and a recurring deficiency previously cited on 06/18/2021 for subsections (1)(a)(b)(c)(d). 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, North Point Village, Assisted Living & Memory Care 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 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: (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. This requirement was not met as evidenced by: Based on observation, interview, and record review, the facility failed to complete a full assessment within 14 days of admission for 1 of 2 residents (Resident 16) who had recently admitted to the facility and safety assessments for 3 of 3 residents (Residents 14, 16, and 19) with medical devices. These failures placed residents at risk of unmet care This document was prepared by Residential Care Services for the Locator website. 02/ 10/2024 SAT 14: 09 FAX 509 N. Point Village ~007/010 02.08.2024 08:16:06 state or M8Shlngton Bl StatEment of Defic~*ndes lfoerise ¥ 2479 C'ompUan-:.ia Detetmrn.mm1 #361"!9 Phm M Corn1ction Nortfi l='o,~f VlU.3§1-e. Assist'8-u livltig & Memory CQra Cam~twn 0.ltt Page G ot 9 Lii::-en~6!\:$: PSL A:ssadMss. lLC 0100/2024 needs ,jue t!l t''lOt having -a fl~lt a-ss~s~1,~mt arid of harm from tn~ use ot niedit~,! dev~•::-es n"at had not been ass~ssrsd to Siltely use. Ri:;view oHhe faci~ity's undated ~:;huatt<l:t~stk rester shoi.~4'1 Resictsnt ·14 was adm:ltt1d 'to th~ facility on /1(}2 3. Observ~tiGn on GV29i20.24 m 2:.:W PM, showed Rie-stdent 14 had~ b':d <md~ mi! iMt:aU~d <in one ru<le of th~r bed and e b1edtrapeze. Rtview of the Bed Sid~ Ra1~s tBSf~}, Enah!er & Transfer Pote Assessrnent!Evalo:c1~cn form, -tizite,1 01/2at2024 {the dat1? thz document w3r:: r~~ested}. sho~d Staff H. Maintenance Dir~dnr, h~cl assessed lt,e 8SR and tra~e:t:i?: tm· prnp-.er~nstallat~~r,. Furtttf~r review !Sh:}:,.\Ned rtmt Re$i:cient ·14··s. 3biMy tct, saf~~ use the 8SR and trap~ze had net been GS!e~s:ed. R~view otth:e- Func~o11a~E :11·a;uatlon (the bdiiiy~stitl-ed .lssessment): dated 01/0irl024, showed no dornn:~ntatbn of Resident M's U§e! of medical dev~ces i:w their abmfy tc safeh/ usf.' tl1~ dtvices. In an interview on 01 t30l!W24 >if ·i O: ·1 a J-.M .. Stan G, Regioflal H~alth and \'Vei~ness Specfalist, stat~ri the fon-nthi'?iy ubhzed for the assessment (l-f Resident 14's medical deyi,~~g; w.;is the smne foim usei:l for .,u re~kieri~s' madftal d~vk:a'S. Staff G 1;t1nt!rmed tr.~ h:mn djd not include $lr\ auessment of Resident ·j 4;1a ~bi~ty to sa-re~r use thi::ir BSR ~nd trape-z:e. Staff G fwther st~ted that Resid~t 14 had been using a bed tra:pe.ze sinc-e they w~r~ :acirnittect to th~ fac.nity. Staff G :stated ttliy wera unwre v1,,hen the SSR w~s ;n-stailed Cr"I R~Sl-01{)->'lt 14's bed. R·eview crt the facility's undnted charactensti~5 rtJS~!H' sht,wed Rj!jsrdent HJ wm:1 admitted to ttie facmty ors 20:'1-4 Obs.ervatbn on OJ !2912.02.:.1 i.llt ·t ·.50 PM. sh-uw~d Ro!\sident -~6 had a bed $~·ane on the- slide of their l~l:!d. in an intervi~w ;at that time; Rf:is1dent 16 stE1ted ~ie ted c~ne twd been on ttieir bmj sirice tt1ey mov-f:d into the f~dHtv. Review of Re~dent Hi-"s: Functit'll"lell Ev~bathm, :fated 1.2024, sh.w.;td rn.J dci•:~:mentm.ton ,:ff rste.siaent 15':s uie af a rnectir::aJ -d~vic-e or their ability to satel·t use the This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 36119 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 6 of 9 Licensee: PSL Associates, LLC 01/30/2024 needs due to not having a full assessment and of harm from the use of medical devices that had not been assessed to safely use. Findings included… <Resident 14> Review of the facility’s undated characteristic roster showed Resident 14 was admitted to the facility on /2023. Observation on 01/29/2024 at 2:20 PM, showed Resident 14 had a bed side rail installed on one side of their bed and a bed trapeze. Review of the Bed Side Rails (BSR), Enabler & Transfer Pole Assessment/Evaluation form, dated 01/29/2024 (the date the document was requested), showed Staff H, Maintenance Director, had assessed the BSR and trapeze for proper installation. Further review showed that Resident 14’s ability to safely use the BSR and trapeze had not been assessed. Review of the Functional Evaluation (the facility’s titled assessment), dated 01/01/2024, showed no documentation of Resident 14’s use of medical devices or their ability to safely use the devices. In an interview on 01/30/2024 at 10:10 AM, Staff G, Regional Health and Wellness Specialist, stated the form they utilized for the assessment of Resident 14’s medical devices, was the same form used for all residents’ medical devices. Staff G confirmed the form did not include an assessment of Resident 14’s ability to safely use their BSR and trapeze. Staff G further stated that Resident 14 had been using a bed trapeze since they were admitted to the facility. Staff G stated they were unsure when the BSR was installed on Resident 14’s bed. <Resident 16> Review of the facility’s undated characteristics roster showed Resident 16 was admitted to the facility on /2024. Observation on 01/29/2024 at 1:50 PM, showed Resident 16 had a bed cane on the side of their bed. In an interview at that time, Resident 16 stated the bed cane had been on their bed since they moved into the facility. Review of Resident 16’s Functional Evaluation, dated /2024, showed no documentation of Resident 16’s use of a medical device or their ability to safely use the This document was prepared by Residential Care Services for the Locator website. 02/10/ 2024 SAT 14: 10 FAX 5H N. Point Village ~008/010 02.06.202'1 08c16:06 state of Ma9hlngton 9/ Sfi;t~ment vi Oifid~nciss L~ce~s0, #: 24h) C'cmplhrnce Dete~min9tioin #36119 l:1lan ◊! Cornl!dior1 N">r\h ~>eMt Ylll.ifte, ~isi1t~ti livlog a Memory c~,-a c~mp-!~tE~n t'.J.utti Pa9i:! 7 *f 9 Lii;~nse~: PSL Assodatss. LLC 01/30/2024 In an inte!Yif:::Y.,' lJll ()·j r.H:t/2024 at-4·dO PM, ~"Staff G co11finned th~ Flm<:tion£1~ Evaluation. dat,i;d :Jt)24,. Wt!IS R~s.;dent Hli's PHN.ldmisskm aSS,',!SS:rm-1nt Staff O st;ateid ttHfy did nn:t {';Jmplit~ ~m asses'a{-ml:!nt w~thin ·14 dayt of .admi:ss.ion and Vilas unaware of l~es-id1mt 16'-s medk:t\l d~vici:. In an-mtervie•N (JI t3:Ut2u24 at 8.30 AM, Sroft A, E.--...:1::·i:utwe Director, ~litte-d th•~Y wer~ ~nabl.u flnd -a {'ll) 14-day o~sessml'.l:nt or md€ ic:at d~v~c~ sclfety asS,~gsment for R-esid~nr Ht R€view af ttw.J 'hljCtlify'lll WHbtrzd charn1::;ter~stk:s roster st10wed Resident rn rnov~d ·mto the l'adlity <.m .Ja2s and was pl~:eed in t.a,e (If me fair.:ilit,/s merr10!)1 care t1uUding. Obsew;i1tkm on ,:1!/30!2CJ24 at HJ.-!5 AM, !:lb~1wed Res.\dent 19 had a bed t:~ne att:a;c.h~d h, one sld& of t/1.eir bM. Heview of Resiuer1t 1S 's Functiona{ Ev~lH.rntions. dated D2~~ l-mi J 1/0812024 ,. ~how-e-d no docurnentatwn of Resident Hf~ i.JSe 1)f a fnedical d~vi-~~· rH' their abimy to $a1°~1y use lt~e r.fovk:e. In ~,n int;;:Me-w i.:io OH:HU2fJ24 -at 10:23 AM, Staff Z, Care-gl'l.l~f, stat~d that Rf.lsldet)t ·1g . had tn~ tie-cl can~ on their bel'l for s tew rn~ntns. In ~n interview ~m 0·1! 8012014 ai! 10: 10 AM, Stllff G stated fo~,y w~ l'e Lma•Nargi that R.esis~en't ·! 0 had~ bed cdnis on thtit b~d whtn asi~ed rr an ~s~~ssi·n.~nt was den~ h:ir that medical; devit~~. PlanJAttestatlon Statement I hereby certify t~wt I havre reviewed ttw:; 1eport and have Mkc:rr or wiHt ake acti¥e n'1easmes b corred this dtfbency. 8y tc:kiiig this ilCtion_. r-..kirtt: Point \/il~age., .Assisted LiVlng & sM;1,~ rrnnv C.;1r,:., is or- wll be in ~orr~DliMt~ ~-.~th this law ~rnd i Gf n::gt.:ilation on s-1 {□~te} z_':L_ . · - ln addition, I ~11,m 1mp!tH'nerit a syst-em to monitor .anti ensure t:xmfo"~U~d rnmpiian~:e Vlift'rl thi~ rr::~~uhBrn~nt This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 36119 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 7 of 9 Licensee: PSL Associates, LLC 01/30/2024 device. In an interview on 01/29/2024 at 4:00 PM, Staff G confirmed the Functional Evaluation, dated /2024, was Resident 16’s preadmission assessment. Staff G stated they did not complete an assessment within 14 days of admission and was unaware of Resident 16’s medical device. In an interview on 01/30/2024 at 8:30 AM, Staff A, Executive Director, stated they were unable find a 14-day assessment or medical device safety assessment for Resident 16. <Resident 19> Review of the facility’s undated characteristics roster showed Resident 19 moved into the facility on /2023 and was placed in one of the facility’s memory care building. Observation on 01/30/2024 at 10:15 AM, showed Resident 19 had a bed cane attached to one side of their bed. Review of Resident 19’s Functional Evaluations, dated /2023 and 01/08/2024, showed no documentation of Resident 19’s use of a medical device or their ability to safely use the device. In an interview on 01/30/2024 at 10:23 AM, Staff Z, Caregiver, stated that Resident 19 had the bed cane on their bed for a few months. In an interview on 01/30/2024 at 10:10 AM, Staff G stated they were unaware that Resident 19 had a bed cane on their bed when asked if an assessment was done for that medical device. This is an uncorrected deficiency previously cited on 12/05/2023. 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, North Point Village, Assisted Living & Memory Care 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. This document was prepared by Residential Care Services for the Locator website. 02/10/ 2024 SAT 14: 10 FAX 5H N. Point Village ~009/010 02.08.2024 08:16:06 State of Mashing~on 10/ St~t~ma-nt o1 Deflc~n~ies Lice~51;1 #: 2479 C'r.mpli1h1~ia Oetermin~iion #girn Pl.m ,o.f Ccirrllletit~~~ N-0-rth Point Vlhg·t , Assist:e-d Livi!'!g & Mtrnory Care C!itnp!sfam Datt Page e cf 9 Lic~hse•; PSL AsSGdat;;s, LLC 01/30/2024 • Date WAC 388.:18A-24:M Tub-treuiosls Two st:•P skin testing. Unf••-~ th~ staff person meets: the req.ufrem•ntfor having nc skin t•1tlng or oniv on• t•st. th. as,ist9d Uvlnt faclJit\f choo,s.tna to do skin te-stina,, must e:n:lure that -•.ach 1t•ff person has th• following two. .1 t•p skin ~sting: ('i} i~n inibal skin t-est Wthin three days tl!' empl,oyment; and (2) A se~:;ot,(1 t-ut tfon~ one ta thr~e 1Na-eks after tl'le ~rst test. Based en in:ter.,iew and record revie1N, the fad~ity f0i1e-d to ensure that ~taff received tuber:euluS1is testing wJt~1in ttiree dats of employment fot 3 of 3 staff (Staff tl, V: and V'.f}. This fa~led p-,~:tice pl;.ll,ced residents at risk ct ~•~~rcu~os·is expo!tj;/'e. Re'lliew of Staff U'$, Oining S:ervlc~s Patme-r undated personn~I rnl:I si1owed they we-rn hire<J. or. 1 1 01/09/2024. Fu~iher r·evi-Bw-ath:t~d Staff U's We did :not c~1r,tl:ii~1 any d~cumel'lh·tl~r1 of a luber<:ulosis (1"8, communicable re:sp;rlittlfY <l~sease) s!,;in test. l~evi~w of Staff V'·s; Care Pmtr,rer. undated p~rs'lnn.e! fil,e shewed th~y ~,e hired on 12!W5!202B. S'taff V's pe~onnel We cild not ~onta,in ~ny docum~t'\fation of u TB skin test r~~view o·t Staft •/V's, M e<d Aid~. uni.t ..i t:ed pets(.mn~~ rnt! shriwed the~, were hired on O1 . r:i-t /JO:l4i. Further review st1~)W~d Staf!'VVs rne did rmt contain any dt)curner,tatirm at~ TB tkin teit.. o tn~t In an interview iJn 1129/2024 at ·) 1: 1O A M, 5-'taff Q, Buftine~s 01h~e Manag!:r, mated Staff U, StaffV, and Sfal'f ',.N did not have 113 £kin t~sts ..:;ornp1eted .as tne facility ran out of tMe Ta solutw11 ne~ded to pNhJ1n1 the te~t1!. PlanlA tte,~tion Sta-t~:m •nt This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 36119 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 8 of 9 Licensee: PSL Associates, LLC 01/30/2024 Administrator (or Representative) Date WAC 388-78A-2484 Tuberculosis Two step skin testing. Unless the staff person meets the requirement for having no skin testing or only one test, the assisted living facility choosing to do skin testing, must ensure that each staff person has the following two-step skin testing: (1) An initial skin test within three days of employment; and (2) A second test done one to three weeks after the first test. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure that staff received tuberculosis testing within three days of employment for 3 of 3 staff (Staff U, V, and W). This failed practice placed residents at risk of tuberculosis exposure. Findings included… Review of Staff U’s, Dining Services Partner, undated personnel file showed they were hired on 01/09/2024. Further review showed Staff U’s file did not contain any documentation of a tuberculosis (TB, communicable respiratory disease) skin test. Review of Staff V’s, Care Partner, undated personnel file showed they were hired on 12/05/2023. Staff V’s personnel file did not contain any documentation of a TB skin test. Review of Staff W’s, Med Aide, undated personnel file showed they were hired on 01/21/2024. Further review showed Staff W’s file did not contain any documentation of a TB skin test. In an interview on 01/29/2024 at 11:10 AM, Staff Q, Business Office Manager, stated that Staff U, Staff V, and Staff W did not have TB skin tests completed as the facility ran out of the TB solution needed to perform the tests. This is an uncorrected deficiency previously cited on 12/05/2023 for subsection (1). Plan/Attestation Statement This document was prepared by Residential Care Services for the Locator website. 02/10/2024 SAT 14: 10 FAX 509 N. Point Village ~010/010 02.08,2024 08:16:06 state of Ma5hington 11/ St~t~rn~nt of bet1dsndes Li,.~~s~ #. 24'f9 Cr.mptlaftcie Da~etmin~tmn #~119 Pian M Corr!llr..ti1'.:!Jli No-rth Pc:m'lt V\ll:ag-e, A.:ssisiia-~ living & Memo-ry C~,-e Cump~t~i~f1 O.at~ P·aga: 9 cf 9 Lic,ense~: PSL A.sscd3t~ $, LlC 010012024 I h~retir ,certify 1hat I hl!lve rev~e-w~d this report and hav~ taken or will take act.ve rne-~,w·o;s to ::.-crr.::ctthis dettd ency. By t.ahing this -actkm, North Point Vll!a~a\ ,. !\islsted 1 Uving ,& Me-rrit.:itV C&re is or wlf be in :comptiance wtth thii bw a:nd .t or rn,g,Jl~tlon on 3/IC/ , (Dat'~) 'I __ . In ~1dditlon, I will imp/el'!"!lent .a system to rno:nlt()f anu ens.mi~ i::·ontinued <:omplit1r1~~ wit-ti th:is reqtJi!~me-nt. Date This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 36119 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 9 of 9 Licensee: PSL Associates, LLC 01/30/2024 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, North Point Village, Assisted Living & Memory Care 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 This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: North Point Village, Assisted Provider Type: Assisted Living Facility Living & Memory Care License/Cert.#: 24 79 Intake ID: 104750 Compliance Determination #: 32296 Region/Unit#: RCS Region 1 / Unit B Investigator: Carla Rose Investigation Date(s ): 11/14/2023 through 12/05/2023 Complainant Contact Date(s): Allegation(s): Diversion Investigation Methods: Sample: Total residents: 92 Resident sample size: 11 Closed records sample size: 2 Observations: Residents Staff Medication room Narcotic medication storage Interviews: Floor staff Nursing manager Representatives Residents Record Reviews: Narcotic medication log book Medication policy Named resident MAR Named resident progress notes Investigation Investigation Summary: Syringes of morphine were lost after they were delivered to the facility. The facility reported to the department and law enforcement, and completed an internal investigation which included a review of their medication policy. The facility determined that the process for checking in narcotic medication needed to be changed from one designated staff checking delivered narcotics to two staff. This report was investigated during a full inspection. The facility received a consultation under WAC 388-78A-2260 for Storing, Securing, and Accounting for medications. Conclusion/ Action: This document was prepared by Residential Care Services for the Locator website. ~ Failed Provider Practice Identified/ Citation(s) Written D Failed Provider Practice Not Identified / No Citation Written □ NIA This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: North Point Village, Assisted Provider Type: Assisted Living Facility Living & Memory Care License/Cert.#: 24 79 Intake ID: 102688 Compliance Determination #: 32296 Region/Unit#: RCS Region 1 / Unit B Investigator: Carla Rose Investigation Date(s ): 11/14/2023 through 12/05/2023 Complainant Contact Date(s): 11/21/2023 Allegation(s): 1. Housekeeping services not provided per disclosure. 2. Misappropriation of resident incontinent products supplied by family. 3. Monitoring residents condition. Investigation Methods: Sample: Total residents: 92 Resident sample size: 11 Closed records sample size: 2 Observations: Named Resident Sampled Residents Staff to Resident interactions. Resident Rooms & Cleanliness Cleanliness of resident common areas Resident activities in memory care Resident dining services in memory care Interviews: Named Resident Representative Named Resident Case Manager Caregivers Med Tech's Sampled Residents Sampled Resident Representative Health and Wellness Nurse Resident Care Coordinator Record Reviews: Named Resident NSA Named Resident Assessment, MARS, Care notes. Sampled Resident Records Disclosure of Services Characteristics Roster Investigation Summary: 1. The facility common areas, interior and exterior of building were observed unclean and unsanitary. Citation issued for lack of housekeeping services to resident common This document was prepared by Residential Care Services for the Locator website. areas inside and outside of facility WAC 388-78A-3090 (1 )(a)(b) written on 12/01/2023. 2. The named resident's represented had no concerns about the resident's briefs being used for other residents. Staff interviewed stated they did not use the named resident's briefs for other residents. No failed practice identified. 3. Sampled residents were not monitored or evaluated for changes in condition. Failed practice was identified and citation for WAC 388-78A-2120 (1 )(3)(a)(b)(4) written on 12/01/2023. Conclusion/ Action: ~ Failed Provider Practice Identified/ Citation(s) Written D Failed Provider Practice Not Identified / No Citation Written □ N/A This document was prepared by Residential Care Services for the Locator website. STATE OF WASHilN!GTON DEPARTMENT OF SOCIAL AiND HEAlT H SERVICES AGIING AND LONG-TERM SUPPORT ADMINISTRATION 1511 E Trent Ave, Ste 1fJ'2,. Spokane Valley, WA 99212' PSL Associates, LLC North Point Villlage, Assisted l ivin.9 & Memory Care 11 '10 E Westview Ct Spokane, WA 99218 RE: North Point Village, Assisted Living & Memory Care# 24 79 Dear Administrator: This document references the following complaint numbers 104 7 50, 1038:64, 102'688, 106 798, 10603-B. T-ne Department comp eted a full inspection of your Assisted Living Facility on 12/05/2023 and found ~hat your facility does not meet lihe Assisted Living Facility requirements. T:he De,putment: • Wrote the enclosed report; and • Ml ay take licensing enforcement acti.on based on many deficiency listed on the endosed report; and • May inspect your program to determine if you have corrected all defic1enc1es; and • Expects all deficiencies to be corrected vvithin the time~rame accepted by the department. You: !Must: • Begin the process of correcting lihe deficiency or deficiencies immediately; • Contact the Field Manager for clarifications related to the Statement of Deficiencies (SOD}; • Within 10 calendar days after you receive this letter, complete and return ~he endosed 'Plan/Attestahon Statement"; o Sign and date the enclosed report; o For each deficiency, indicate the date you have or will correct each deficiency; o Mail the Plan/Atl:estati.on Statement and report with origfnal signatures to: Stephanie Jenks, Fie d Manager This document was prepared by Residential Care Services for the Locator website. North Point Village, Assisted Living & Memory Care #2-479 12/05/2023 Page 2 of 3 Residential Care Services Region 1, Unit 8 8517 E Trent Ave, Ste 102 Spokane Valley, WA 99212 • Compl:ete correction(s) within 45 days, or sooner if directed by the Department, after re ·ew of your p oposed correction dates. • Have your pl:an approved by the Department. Co nsulta:tio-n(s),: fn addition, the Department provided consultation on the folfowing deficiency or deficiencies not listed on the enclosed report_ WAC 388-78A-3000 Venti1lation. The as:s·sted !living facility 1must meet the venrtilation 1 requi:rem.ents o·ft:he1mechanica·1 code as adopt1ed and amended by theWashiington sta~e 1 bu:ilding counci,I; and (1} Ventil'ate rooms to: (a) Prevent excessive odors or motSJbure; and The facility failed to have ventilation 1n 9 common bathrooms and showel' rooms to prevent con ensation and odors_ This failure resulted in strong and un1pleasant odors in residen . athrnoms and a dark substance i1n resident shower rooms, placing residents at risk o· discomfort and illness. WAC 388-78.A-2260, Storing, securing,, .aiind accounting for ;medications .. (2} The assisted living facility must ensure all medications under the assisted living facility's control are property stored: (d} In a locked comp,arbnen that is accessible only to desfgrnated responsible staff' persons; and Controlled medications that were elivered, checked in and secured by one staff, were unaccounted for. Prior to this incident, the facility only required one staff member to count, verify, log, and l·ock up deliveries of controlled medicati.ons. After the incident, the facility changed the1rr prnctice to require two designated staff to count, verify, log, and lock up controlled medications delivered to the facility_ WAC 388-78•A-271Q, Discfosure of services. (2} T~ e assisted living faci,lity must provide the seivices disclosed, The facility's Disclosure of Seivices stated the facility will •typically" have a registered nurse and a lfcensed practical nurse on site as well as a registered nurse on calll_R eview of the This document was prepared by Residential Care Services for the Locator website. North Point Village, Ass·sted Living & Memory Care# 2479 12/05/2023 Page 3 of3 current Di;sclosure of Services showed that it did reflect the actual. nursing hours p ovided. The Execuulve Director stated they will be changing the discllosure of services to reflect l~ess nursing hours. You Are Not: • Required to subm1 a plan of correction for the consultation defici.ency or deficiencies stated in this letter and not llisted on the enclosed epott. You May: • Contact me for c arification of the deficiency or deficiencies found. In Addition Y,ou May: • Request an l.nform a.I Dispute R.esollutfoin (:IDR) r•evi,ew within 10 working days after you receive this letter. Your IDR request must i:nclude: o What specific deficiency or deficiencies you disagree with; o Why you disagree w,~h each deficiency; and o Whether you want an IO!R to occur in-person, by telephone or as a paper review. o Send your request to: IDR Program Manager Department of Social and Health Services Aging and Long-Term Support Administration Residential Care Services PO Box 45600 Olympia, WA 98504-5600 If You Have Any Questions: • Please contact me at (509)993-7821. Sincerely, <;57uur (RA signing for FM while on leave) Stephanie Jenks, IF1ield Man ager Region 1 , Unit B Residential Care Services Enclosure This document was prepared by Residential Care Services for the Locator website. /: .,G .i:''AX ::iOSJ N. Point Village 2. 1~.2023 16:47:59 state of lolashington STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALT H SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 8617 E Trent AV9, Ste 102, Spokane Valley, WA 99212 Stateme11i olbeficiencies . .. License#: 2479 Compliance Detenninatlon #32296 Plan of Correction North Point VIiiage. Assisted Living & Memory Care Completion Date Page 4 of 42 Licensee: PSL Associates, LLC 12/05/2023 You are required to be in compliance at all tirnes with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for the unannounced on•site full inspection and complaint investigation on 11/14/2023, 11i15/2.023, 11/16/.2023. 11/17/2023. 11/20/.2023. 11/21/2023 and 11/22/2023 of: North Point Village, Assisted Living & Memory Care e 111 0 Westview Ct Spokane, WA 99218 This document references the following complaint numbers: 104750, 103864, 102688, 106798, 1060:38. The following sample was selected for review during the unannounced on-site visit: 11 of 92 current residents and 2 former residents. The department staff that inspected the Assisted Living Facility: Carla Rose, NCI Community Licensor Antonietta Lettieri•Park.in, Long Term Care Surveyor Veronica Jackson. Assisted Living Facility Licensor Mark Sedhom, Assisted Uving Facility Licensor Patty Ford, LT C Surveyor From: DSHS, Aging and Long. Term Support Administration Residential Care Services, Region 1 . Unit 9 8517 E Trent Ave, Ste 102 Spokane Valley, WA 99212 As a result of the on"sfte 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. 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 8517 E Trent Ave, Ste 102, Spokane Valley, WA 99212 Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 4 of 42 Licensee: PSL Associates, LLC 12/05/2023 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 the unannounced on-site full inspection and complaint investigation on 11/14/2023, 11/15/2023, 11/16/2023, 11/17/2023, 11/20/2023, 11/21/2023 and 11/22/2023 of: North Point Village, Assisted Living & Memory Care 1110 E Westview Ct Spokane, WA 99218 This document references the following complaint numbers: 104750, 103864, 102688, 106798, 106038. The following sample was selected for review during the unannounced on-site visit: 11 of 92 current residents and 2 former residents. The department staff that inspected the Assisted Living Facility: Carla Rose, NCI Community Licensor Antonietta Lettieri-Parkin, Long Term Care Surveyor Veronica Jackson, Assisted Living Facility Licensor Mark Sedhom, Assisted Living Facility Licensor Patty Ford, LTC Surveyor From: DSHS, Aging and Long-Term Support Administration Residential Care Services, Region 1 , Unit B 8517 E Trent Ave, Ste 102 Spokane Valley, WA 99212 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. This document was prepared by Residential Care Services for the Locator website. I:.,~ i''AX JOSI N. Point Village ~007/ 045 2.14.2023 16:47:59 State of' J.lashingtott 4/ Statement of Deficiencie's License#: 2479 Compliance Determination# 32296 Plan of Correction North Point Village, Assisted Living & Memory care Completion Date Page 5 of 42 Licensee: PSL Associates, LLC 12/05/2023 12/14/2023 ··························osa,/g~_.... ............................... ~sid-enti#c are Services Date I understand that to maintain an Assisted Living Fadli1y license. the facility rnust be in compliance with all the licensing laws and regulations at all times. J 1-jt · r/.f;'.t 'J ........... Jin~s~r RepresontaUve) ....... .. . a' WAC 388-78A-2120 Monitoring residents' well-being. The assisted living facility must: (1) Observe each resident consistent with his or her assessed needs and negotiated service agreement; (3} Evaluate. in order to determine if there is a need for further action: (a) The changes identified in the resident per subsection (2) of this section; and (b) Each resident when an accident or incident that is likely to adversely affect the resident's well being, is observed by or reported to staff persons. (4) Take ~ppropriate action in response to each resident's changing needs. This requirement was not met as evidenced by: Based 011 interview and record review, the facility failed to ensure that staff evaluated resident skin injuries and took appropriate action for 2 of 11 sampled residents (Residents 2 and 3). This failure contributed to ongoing skin injuries for Resident 2, a decreased quality of life tor Resident 3 and placed the residents at risk of ongoing skin breakdown. Findings included, .. <Rasident 2> Review of Resident 2's Negotiated Service Plan (NSP, the facility's titled negotiated service agreement), dated 07/06/2023, showed they were diagnosed With . Further review showed that staff were to monitor Resident 2's skin and ''notify the Health and Wellness Director with any red, open. or other skin abnormalities." Review of Resident 2's September 2023 and October 2023 progress notes showed entries This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 5 of 42 Licensee: PSL Associates, LLC 12/05/2023 Residential 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-2120 Monitoring residents' well-being. The assisted living facility must: (1) Observe each resident consistent with his or her assessed needs and negotiated service agreement; (3) Evaluate, in order to determine if there is a need for further action: (a) The changes identified in the resident per subsection (2) of this section; and (b) Each resident when an accident or incident that is likely to adversely affect the resident's well- being, is observed by or reported to staff persons. (4) Take appropriate action in response to each resident's changing needs. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure that staff evaluated resident skin injuries and took appropriate action for 2 of 11 sampled residents (Residents 2 and 3). This failure contributed to ongoing skin injuries for Resident 2, a decreased quality of life for Resident 3 and placed the residents at risk of ongoing skin breakdown. Findings included… <Resident 2> Review of Resident 2’s Negotiated Service Plan (NSP, the facility’s titled negotiated service agreement), dated 07/06/2023, showed they were diagnosed with . Further review showed that staff were to monitor Resident 2’s skin and “notify the Health and Wellness Director with any red, open, or other skin abnormalities.” Review of Resident 2’s September 2023 and October 2023 progress notes showed entries This document was prepared by Residential Care Services for the Locator website. ,: , G J,'AX :iOSI N. Point Vill age il)008/045 .,, 2.14.2023 16:47:59 state of Ueshinstoo Stateme.nt of Deficiencies License#: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory care comptetion Date Pag& 6 of 42 Licensee: PSL Associates, LLC 12/05/2023 for the following concerns: M09/23/2023 at 7:04 AM, Staff E, Assisted Living Med Aide, documented, "resident called for a med tech to come look at a wound on [their) left forearm ... I called [facility nurse], rewrapped the area with gauze and gauz.e pad to absorb the blee-ding.' ' 09/23/2023 at 6:01 PM, Staff Q. Assisted Living Med Aide. documented, "I noticed blood on [their] shirt. .. I observed a skln tear on the inside of [their] left arm, I took photos and sent them to [facility nurse], got resident wound cleaned up and bandaged." 09/25/2023 at 1:54 AM, Staff R, Assisted Living Med Aide, documented. "resident complained to this writer that [their] right foot was hurting, second toe appears to be red and swollen, [facility nurse) notified.'' 09/25/2023 at 4:46 PM, Staff F. Assisted Living Med Aide. documented, •·rewrapped residents' arm.,. res [resident] said ,t didn't look like [their] arm was healing at all. I explained that it will take a while for it to heal as bad as it is.'' 10/14/2023 at 5:39 AM, Staff E documented, "Resident was observed ... holding a paper towel to !their] right lower leg with red on the paper towel which was clearly blood. [T.hey) stated I caught my leg on the chair and pinched it ... I am unable to stop the bleeding. .. This writer noticed what appeared to be a small cut or scrape that was bleeding, I text [facility nurse] to apprise [them] of the situation and bandaged the area." In an interview on 11/20/2023 at 1 0: 15 AM, Staff G, Regional Health and Wellness Specialist, stated that caregivers and med aides were to notify nursing when there were concerns about skin or reddened areas. Staff G stated that nursing staff would then need to as sass the area, write a progress note, and create an alert chart (system used by caregivers and nurses to monitor resident haalth concerns). Review of Resident 2's September 2023, October 2023 and November 2023 progress notes showed no documentation to show that the resfdents wounds/skin tears were evaluated or interventions to prevent further skin injury. -<Resident 3:;> Review of Resident 3's· NSP, dated 07/29/2023, showed a history of . The NSP showed that med techs were responsible for monitoring the resident's skin weekly and as needed. Tl1e NSP further showed that med techs were to notify the Health and Wellness Director for any increased warmth, redn~ss to bilateral lower extremities (both legs), or weeping edema to bilateral lower extremities. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 6 of 42 Licensee: PSL Associates, LLC 12/05/2023 for the following concerns: -09/23/2023 at 7:04 AM, Staff E, Assisted Living Med Aide, documented, “resident called for a med tech to come look at a wound on [their] left forearm…I called [facility nurse], rewrapped the area with gauze and gauze pad to absorb the bleeding.” 09/23/2023 at 6:01 PM, Staff Q, Assisted Living Med Aide, documented, “I noticed blood on [their] shirt…I observed a skin tear on the inside of [their] left arm, I took photos and sent them to [facility nurse], got resident wound cleaned up and bandaged.” 09/25/2023 at 1:54 AM, Staff R, Assisted Living Med Aide, documented, “resident complained to this writer that [their] right foot was hurting, second toe appears to be red and swollen, [facility nurse] notified.” 09/25/2023 at 4:46 PM, Staff F, Assisted Living Med Aide, documented, “rewrapped residents’ arm…res [resident] said it didn’t look like [their] arm was healing at all. I explained that it will take a while for it to heal as bad as it is.” 10/14/2023 at 5:39 AM, Staff E documented, “Resident was observed…holding a paper towel to [their] right lower leg with red on the paper towel which was clearly blood. [They] stated I caught my leg on the chair and pinched it…I am unable to stop the bleeding…This writer noticed what appeared to be a small cut or scrape that was bleeding, I text [facility nurse] to apprise [them] of the situation and bandaged the area.” In an interview on 11/20/2023 at 10:15 AM, Staff G, Regional Health and Wellness Specialist, stated that caregivers and med aides were to notify nursing when there were concerns about skin or reddened areas. Staff G stated that nursing staff would then need to assess the area, write a progress note, and create an alert chart (system used by caregivers and nurses to monitor resident health concerns). Review of Resident 2’s September 2023, October 2023 and November 2023 progress notes showed no documentation to show that the residents wounds/skin tears were evaluated or interventions to prevent further skin injury. <Resident 3> Review of Resident 3’s NSP, dated 07/29/2023, showed a history of . The NSP showed that med techs were responsible for monitoring the resident’s skin weekly and as needed. The NSP further showed that med techs were to notify the Health and Wellness Director for any increased warmth, redness to bilateral lower extremities (both legs), or weeping edema to bilateral lower extremities. This document was prepared by Residential Care Services for the Locator website. 4 V.L.l1L vi1.1.age !4.2023 16:47:59 state Of Washington Statement of Deficiencies ' License#: 2479 compliance Detennination # 3·2200· Plan of Correction North Point VIiiage. Asststed living & Memo~ care Completfon Date Page 7 of 42 Licensee: PSL Associates. LLC 12/05/2023 Review of Resident S's October 2023 and November 2023 progress notes showed two entries with concerns regarding Resident 3's skin. The entries were as follows: 10/03/2023 at 3:01 PM, Staff F documented, "Res (resident] has some redness to [their] left leg and wanted to see a nurse about this. It was warm to touch." 10/04/2023 at 1:07 PM, Staff F wrote '·Res [resident] is upset (they] asked for a nurse to come up and look at [theii1 legs yesterday and no one did. I asked [facility nurse] to go look when I [saw them] in [their) office." Further review of Resident 3's October 2023 and November 2023 progress notes showed no documentation to show that the resident's skin was evaluated or interventions to prevent further skin injury. In an interview on 11/16/2023 at 10:45 AM, Resident 3 stated that staff did not check their skin weekly. During the interview, Collateral Conmct 1 (CC1}, who was present at the time, stated they (themselves) were the one who checked Resident 3's skin weekly and have had to call nursing in the past to tell them to monitor areas of concern. This is a recurring deficiency previously cited on 01/04/2023 for subsections (3) (a) (4), 06/18/2021 for subsections (3) (a) (4). and 04/19/2021 for subsections (3) (a) (4). Plan/Attestation Statement I hereby certify that I have reviewed this repl>rt and have taken or will take active measures to correct this deficiency. By taking this action, North Point. Village, Assisted Living & Memo~ Care is or will be in compliance with this law and / or regulation on . (Date) ✓/7µtJ#'/ In addition, I will implement a system to monitor and ensure continued compliance with this requitement. .. 0n<L ........_. ..... ...- .................................... 1,/ ·······.l .. ~/ '· z ? .............. . ~trator (or Representative) Date WAC 388-78A•2930 Communication system. (1) The assisted living facility must: (a} Provide residents and staff persons with the means to summon on-duty staff assistance from all resident-acce~ible areas including: (iii) Corridors. as well as common and outdoor areas accessible to residents. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 7 of 42 Licensee: PSL Associates, LLC 12/05/2023 Review of Resident 3’s October 2023 and November 2023 progress notes showed two entries with concerns regarding Resident 3’s skin. The entries were as follows: 10/03/2023 at 3:01 PM, Staff F documented, “Res [resident] has some redness to [their] left leg and wanted to see a nurse about this. It was warm to touch.” 10/04/2023 at 1:07 PM, Staff F wrote “Res [resident] is upset [they] asked for a nurse to come up and look at [their] legs yesterday and no one did. I asked [facility nurse] to go look when I [saw them] in [their] office.” Further review of Resident 3’s October 2023 and November 2023 progress notes showed no documentation to show that the resident's skin was evaluated or interventions to prevent further skin injury. In an interview on 11/16/2023 at 10:45 AM, Resident 3 stated that staff did not check their skin weekly. During the interview, Collateral Contact 1 (CC1), who was present at the time, stated they (themselves) were the one who checked Resident 3’s skin weekly and have had to call nursing in the past to tell them to monitor areas of concern. This is a recurring deficiency previously cited on 01/04/2023 for subsections (3) (a) (4), 06/18/2021 for subsections (3) (a) (4), and 04/19/2021 for subsections (3) (a) (4). 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, North Point Village, Assisted Living & Memory Care 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 WAC 388-78A-2930 Communication system. (1) The assisted living facility must: (a) Provide residents and staff persons with the means to summon on-duty staff assistance from all resident-accessible areas including: (iii) Corridors, as well as common and outdoor areas accessible to residents. This document was prepared by Residential Care Services for the Locator website. L.l.,f z.v1 z.vz..;, w:,:;u (: n !,'AX ~o Sl N. Point Village ~010/ 045 2. 14,2023 16:47;59 state of Uash i ngton 71 Statement of Deficiencies .. .. Liceii'se #: 2479 Complia'nce Determinatioii·# 322136. Plan of Correction North Point Village. Assisted Living & Memory Care Completion Date Page 8 of 42 Licensee: PSL Associates, LLC 12/05/2023 Thi$ requirement was not met as evidenood by: Based on observation and interview, the facility failed to provide a way for residents and staff to call for assistance from 4 of 4 outdoor areas of the facility. This failure placed residents at risk of not receiving potential emergency assistance when outdoors and on facility property. Findings included ... Observation on 11/17/2023 at 1 :10 PM, during outside environmental tour, showed no communication system or means to summon staff in the fenced courtyard of ttie facility's building C. In an interview on 11/17/2023 at 1:15 PM, Staff B, Memory Care Coordinator, stated they were unsure as to why there was no call system in the courtyard. Staff B further stated buildings A and B were the same. having no communication system in the fenced in courtyards. Observation on 11/17/2023 at 1 :20 PM showed n.o communication system or means to summon staff in the f~nced 1n courtyards of building A or 8. Observation on 11/17/2023 at 1 :25 PM, showed no communication system or means to summon staff in the open courtyard between the main building and buildings A, B, and C. This is a recurring deficiency previously cited on 06/18/2021 for subsections (1)(a)(iii) and 04/19/2021 for subsections (1). 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, North Point Village, Assisted Living & Memory Care is or will be In compliance with this law and I or regulation on (Date) / / 1 /t~i"f . r • In addition, I will implement a system to monitor anq ensure continued compliance with this requirement. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 8 of 42 Licensee: PSL Associates, LLC 12/05/2023 This requirement was not met as evidenced by: Based on observation and interview, the facility failed to provide a way for residents and staff to call for assistance from 4 of 4 outdoor areas of the facility. This failure placed residents at risk of not receiving potential emergency assistance when outdoors and on facility property. Findings included… Observation on 11/17/2023 at 1:10 PM, during outside environmental tour, showed no communication system or means to summon staff in the fenced courtyard of the facility’s building C. In an interview on 11/17/2023 at 1:15 PM, Staff B, Memory Care Coordinator, stated they were unsure as to why there was no call system in the courtyard. Staff B further stated buildings A and B were the same, having no communication system in the fenced in courtyards. Observation on 11/17/2023 at 1:20 PM showed no communication system or means to summon staff in the fenced in courtyards of building A or B. Observation on 11/17/2023 at 1:25 PM, showed no communication system or means to summon staff in the open courtyard between the main building and buildings A, B, and C. This is a recurring deficiency previously cited on 06/18/2021 for subsections (1)(a)(iii) and 04/19/2021 for subsections (1). 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, North Point Village, Assisted Living & Memory Care 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. This document was prepared by Residential Care Services for the Locator website. ...... , wv, z.vz.;; n:c,u 1: ;);) !''AX :>OSI N. Point Vil lage ~011/045 2.14.2023 16:47;59 state of ueshin9ton 81 St-atement'cif't:ieflciencie"s ··············" ············ .. 1.ic"ei,se"#: 24Ys·'"" ·----··c·ompliance Dete:'nninatiOn # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 9 of 42 licensee: PSL Associates, LLC 12/05/2023 13/,1 f/1'3 , Date WAC 388~78A-3090 Maint~nance and housekeeping. (1) The assisted living facility must: (a) Provide a safe, sanitary and well-maintained environment tor residents; (b) Keep exterior grounds, assisted living facility structure, and component parts safe, sanitary and in good repair; (c) Keep facilities, equipment end furnishings clean and in good repair; and This requirement was not mat as evidenced by: Based on observation and interview, the facility failed to ensure that the interior and exterior of the facility and grounds were safe, sanitary, and well maintained, This failure placed residents at risk of illness. injury and decreased quality of life. Findings included ... a During the environmental t□ur on 11/14/2023. from 9: 1 AM ta 11 :30 AM, and from 12:30 PM to 3:00 PM, accompanied by Staff H, Maintenance Director, the following was observed: -.t'.Main assisted living facility:;,, -First floor housekeeping closet sink' was plugged with debris, lint, and a hard grey substance. -Upon entering the first-floor south side laundry room, the department licensors and Staff H were informed by a resident that an ironing board was placed in front of the wall heater vent. The resident stated, "it almost burned.'' -The drain water cabinet in that laundry room was unlocked an open. In an interview at that time, Staff H stated the door to the cabinet should have been locked. ~The washer ahd dryer in that laundry room had lint, a used fabric softener sheet, and debris behind the machines. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 9 of 42 Licensee: PSL Associates, LLC 12/05/2023 Administrator (or Representative) Date WAC 388-78A-3090 Maintenance and housekeeping. (1) The assisted living facility must: (a) Provide a safe, sanitary and well-maintained environment for residents; (b) Keep exterior grounds, assisted living facility structure, and component parts safe, sanitary and in good repair; (c) Keep facilities, equipment and furnishings clean and in good repair; and This requirement was not met as evidenced by: Based on observation and interview, the facility failed to ensure that the interior and exterior of the facility and grounds were safe, sanitary, and well maintained. This failure placed residents at risk of illness, injury and decreased quality of life. Findings included… During the environmental tour on 11/14/2023, from 9:10 AM to 11:30 AM, and from 12:30 PM to 3:00 PM, accompanied by Staff H, Maintenance Director, the following was observed: <Main assisted living facility> -First floor housekeeping closet sink was plugged with debris, lint, and a hard grey substance. -Upon entering the first-floor south side laundry room, the department licensors and Staff H were informed by a resident that an ironing board was placed in front of the wall heater vent. The resident stated, “it almost burned.” -The drain water cabinet in that laundry room was unlocked an open. In an interview at that time, Staff H stated the door to the cabinet should have been locked. -The washer and dryer in that laundry room had lint, a used fabric softener sheet, and debris behind the machines. This document was prepared by Residential Care Services for the Locator website. /: .,... .i:''AX ::iOSJ N. Point Village ~012/ 045 2.14.2023 16:47:59 State of ~ashiT19ton Statement of Deficiencies License#: 2479 Compliance Determination# 32296 Plan of Correction North Point VIiiage, Assisted Living & Memory care Completion Date Page 10 of 42 Licensee: PSL Associates, LLC 12/05/2023 •A stairway to the second floor had e wet vacuum, a walker and a wheelchair stored by the stairway/staircase (potential fall risks). • The mechanical room door was blocked by boxes marked with a delivery date of 11/11/2023. -Broken tile was observed on the ceiling next to the stairway and kitchen entrance. In an lnterview at that time, Staff H stated the tile need~d to be replaced. -A second stairway/staircase to the second floor had obstacle.s that included a carpet cleaner, walker and wheelchair. -The carpet in the south side stairway up to the second floor was stained with a dark substance. -The seconcf..floor south side laundry room had an empty kitty litter plastic Jug and a broken-down adult undergarment box stored in the room. The floor was covered with stains and dust clumps. -The carpet in the central stairway down to the first floor was covered in dirt and debris. In an interview at that time, Staff H stated the entire facility required a vacuum. -The second-floor mechanical room panels were blocked by a cart with painting supplies and a carpet cleaner. -The second-floor, northwest side laundry room had debris, a fabric softener sheet, and a universal wall adapter behind the washer and dryer. -The stairway up to the third floor on the northwest side of the building had stained carpets and debris on the floor. -The third-floor northwest side laundry room had dust and debris behind the washer and dryer, -The northwest side stairway to the fourth floor had paper, dust, and debris on the carpet. • The fourth-floor south side laundry room had dust, debris, and a drinl<ing cup behind the washer and dryer. The floor had dirt stains and dust clumps. A panel behind the machines was observed to be detached from the wall and on the floor. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 10 of 42 Licensee: PSL Associates, LLC 12/05/2023 -A stairway to the second floor had a wet vacuum, a walker and a wheelchair stored by the stairway/staircase (potential fall risks). -The mechanical room door was blocked by boxes marked with a delivery date of 11/11/2023. -Broken tile was observed on the ceiling next to the stairway and kitchen entrance. In an interview at that time, Staff H stated the tile needed to be replaced. -A second stairway/staircase to the second floor had obstacles that included a carpet cleaner, walker and wheelchair. -The carpet in the south side stairway up to the second floor was stained with a dark substance. -The second-floor south side laundry room had an empty kitty litter plastic jug and a broken-down adult undergarment box stored in the room. The floor was covered with stains and dust clumps. -The carpet in the central stairway down to the first floor was covered in dirt and debris. In an interview at that time, Staff H stated the entire facility required a vacuum. -The second-floor mechanical room panels were blocked by a cart with painting supplies and a carpet cleaner. -The second-floor, northwest side laundry room had debris, a fabric softener sheet, and a universal wall adapter behind the washer and dryer. -The stairway up to the third floor on the northwest side of the building had stained carpets and debris on the floor. -The third-floor northwest side laundry room had dust and debris behind the washer and dryer. -The northwest side stairway to the fourth floor had paper, dust, and debris on the carpet. -The fourth-floor south side laundry room had dust, debris, and a drinking cup behind the washer and dryer. The floor had dirt stains and dust clumps. A panel behind the machines was observed to be detached from the wall and on the floor. This document was prepared by Residential Care Services for the Locator website. il)0l3/ 045 2.14.2023 16i47:59 State or t.lashington 10/ Statement of Deficiencies Lice11$e #: 2479 Compliance Determination# 3229tf Plan of Correction North Point VIiiage, Assisted Living & Mernol"j Care Completion Date Page 11 of 42 Licensee: PSL Assoclates, LLC 12/05/2023 -Observation on 11115/2023 at 11: 55 AM, showed the firsHloor bathroom of the main assisted living building, had dirt and debris along the inside perimeter of the walls and the toilet had dried urine on the seat. <Exterior/grounds> -Pieces of paper receipts, a chip bag, and a paper cup were observed on the ground in the front of the facility. -Styrofoam debris was on the ground, on the side of tha dumpster. -Two discarded refrigerators, a shopping cart, and a broken free.i:er were stored behind a shed by the smoking area. -A discarded air conditioner unit and cabinets were stored by the dumpster. ~Four windows Or'I the back of the main assisted living building were missing shutters. -Four discarded pillows were observed outside the porch area of a resident's living unit. -Seven pieces of garbage were observed outside building C including a chip bag and paper trash. -An outleVelectrical unlt on the exterior of building C was pulled out two inches from the building with exposed wires. <Building C> -Lint, dust, debris, and a pillowcase were observed behind the dryer in the laundry room. In an· interview on 11/14/2023 at 12:25 PM, Resident 15 stated tl1at food is left on the floor of the large resident dining room for "four or five days" before it is cleaned up by housekeeping. Observation on 11/20/2023 at 9:40 AM, showed the large resident dining room floor had food particles scattered over the carpet. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 11 of 42 Licensee: PSL Associates, LLC 12/05/2023 -Observation on 11/15/2023 at 11:55 AM, showed the first-floor bathroom of the main assisted living building, had dirt and debris along the inside perimeter of the walls and the toilet had dried urine on the seat. <Exterior/grounds> -Pieces of paper receipts, a chip bag, and a paper cup were observed on the ground in the front of the facility. -Styrofoam debris was on the ground, on the side of the dumpster. -Two discarded refrigerators, a shopping cart, and a broken freezer were stored behind a shed by the smoking area. -A discarded air conditioner unit and cabinets were stored by the dumpster. -Four windows on the back of the main assisted living building were missing shutters. -Four discarded pillows were observed outside the porch area of a resident’s living unit. -Seven pieces of garbage were observed outside building C including a chip bag and paper trash. -An outlet/electrical unit on the exterior of building C was pulled out two inches from the building with exposed wires. <Building C> -Lint, dust, debris, and a pillowcase were observed behind the dryer in the laundry room. In an interview on 11/14/2023 at 12:25 PM, Resident 15 stated that food is left on the floor of the large resident dining room for “four or five days” before it is cleaned up by housekeeping. Observation on 11/20/2023 at 9:40 AM, showed the large resident dining room floor had food particles scattered over the carpet. This document was prepared by Residential Care Services for the Locator website. ...... , wv, z.vz.;; n:c,u 1: ,:)'ol !''AX :>OSI N. Point Village ~014/045 2.14.2023 16:47:50 State of l,Jashington II/ Statement of Deficiencies "'· License#: 2479 Compliance Determination# 3.2296 Plan of Correction North Point Village, Assisted Living & Memory care completion Date Page 12 of 42 Licensee: PSL Associates, Ll,C 12/05/2023 Observation on 11/15/2023 at 12:10 PM. prior to lunch being served, showed the dining room floor of building 8 was sticky. In an interview on 11/17/2023 at 1: 35 PM, Resident 4 stated housekeeping does not wet mop when c:leaning their floor. Resident 4 further stated that housekeeping will only clean the shower if they are asked to. In an interview on 11/21/2023 at 4:60 PM, Collateral Contact 2 (CC2), stated they have asked staff for a broom and dustpan to sweep their family member's room due to the floor being dirty. CC2 further stated they have swept the resident's floor themselves. In an interview on 11/27/2023 at 4:27 PM, Collateral Contact 4 (CC4) stated that Resident 10's trash was not taken out regularly. CC4 further stated that staff were not cleaning the resident's room. This is a recurring deficiency previously cited on 06/18/2021 for subsections (1)(a)(b). 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, North Point Village. Assisted living & Memor¥ Care is or will be in compliance with this law and / or regulation on 4/7/UI/ . (Date) In addition, I will implement a system to monitor and ensure continued compliance with this requirement. ~ .: ......... /~/1/F)Z--3 __····· "·.. ... ···········• - -··-••······--·-•··-· ··-A---· ~;;;;r (or ····•·• Representative) Date WAC 388~78A-230S Food sanitation. The assisted living facility must: (1) Manage food, and maintain any on-site food service facilities in compliance with chapter 246~215 WAC, Food service; (2) Ensure employees working as food service workers obtain a food worker card according to chapter 246-217 WAC; and This requirement was not met as evidenced by: Based on observation, interview and record review, the facility failed to maintain on-site food service in compliance with Washington State Retail Food Code related to hand hygiene/glove use, cross contamination of ready to eat foods, cleanliness of food storage and food preparation areas, and food handler cards. This failure placed residents at risk of This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 12 of 42 Licensee: PSL Associates, LLC 12/05/2023 Observation on 11/15/2023 at 12:10 PM, prior to lunch being served, showed the dining room floor of building B was sticky. In an interview on 11/17/2023 at 1:35 PM, Resident 4 stated housekeeping does not wet mop when cleaning their floor. Resident 4 further stated that housekeeping will only clean the shower if they are asked to. In an interview on 11/21/2023 at 4:50 PM, Collateral Contact 2 (CC2), stated they have asked staff for a broom and dustpan to sweep their family member’s room due to the floor being dirty. CC2 further stated they have swept the resident's floor themselves. In an interview on 11/27/2023 at 4:27 PM, Collateral Contact 4 (CC4) stated that Resident 10’s trash was not taken out regularly. CC4 further stated that staff were not cleaning the resident’s room. This is a recurring deficiency previously cited on 06/18/2021 for subsections (1)(a)(b). 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, North Point Village, Assisted Living & Memory Care 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 WAC 388-78A-2305 Food sanitation. The assisted living facility must: (1) Manage food, and maintain any on-site food service facilities in compliance with chapter 246-215 WAC, Food service; (2) Ensure employees working as food service workers obtain a food worker card according to chapter 246-217 WAC; and This requirement was not met as evidenced by: Based on observation, interview and record review, the facility failed to maintain on-site food service in compliance with Washington State Retail Food Code related to hand hygiene/glove use, cross contamination of ready to eat foods, cleanliness of food storage and food preparation areas, and food handler cards. This failure placed residents at risk of This document was prepared by Residential Care Services for the Locator website. I:.,,. .l''AA :JV)I N. Point Village IZJ015/ 045 2.14,2023 16:47:59 State of Uashington Ill St-atement of Deficiencies ' License#: 2479 Compliance Determination# 32296 Plan of Correction North Point Village, Assisted Ltving & Memory Care Completion Date Page 13 of 42 Licensee: PSL Associates, LLC 12/05/2023 food borne illnesses. Findings included ... <Cross contamination> Per WAC 246~215-0231 0. Hands and arms- When to wash: Food employees shall clean their hands and exposed portions of their arms immediately before engaging In food preparation. •After handling soiled equipment and utensils. -During food preparation, as often as necessary to prevent cross contamination. -VVhen switching between working with raw end ready to eat foods. -Aijer engaging in other activities that contaminate the hands or gloves. Observation on 11/14/2023 at 11:50 AM, showed Staff J, Cook, prepared lunch for the residents. During the observation, S~aff J handled utensils, freezer door handles, raw foods and then ready to eat foods. Staff J perfonned the following food preparation with the same gloved hands: -Picked up a lid from the grill and tl,en a utensil and removed buns from the grill. •Picked up another utensil and spread mayonnaise onto the bun. -Reached into a container and removed pickles with the same gloved hands. -Picked up another utensil and removed fries from tlie fryer. -Removed slices of cheese with the same gloved hands and placed on bread, then put the extra slice of cheese back into the container. -Opened the freezer door, removed a raw hamburger patty and placed the patty on the grill. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 13 of 42 Licensee: PSL Associates, LLC 12/05/2023 food borne illnesses. Findings included… <Cross contamination> Per WAC 246-215-02310, Hands and arms—When to wash: Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation. -After handling soiled equipment and utensils. -During food preparation, as often as necessary to prevent cross contamination. -When switching between working with raw and ready to eat foods. -After engaging in other activities that contaminate the hands or gloves. Observation on 11/14/2023 at 11:50 AM, showed Staff J, Cook, prepared lunch for the residents. During the observation, Staff J handled utensils, freezer door handles, raw foods and then ready to eat foods. Staff J performed the following food preparation with the same gloved hands: -Picked up a lid from the grill and then a utensil and removed buns from the grill. -Picked up another utensil and spread mayonnaise onto the bun. -Reached into a container and removed pickles with the same gloved hands. -Picked up another utensil and removed fries from the fryer. -Removed slices of cheese with the same gloved hands and placed on bread, then put the extra slice of cheese back into the container. -Opened the freezer door, removed a raw hamburger patty and placed the patty on the grill. This document was prepared by Residential Care Services for the Locator website. /: .,:> .i:''AX ::iOSJ N. Point Village 2,14.2023 16:47:59 state of Waahlngton Statement of Deficiencies ' License#: 2479 Cornplienoe Determination# 32296 Plan of Correction North Point Village, Assisted Living & Memory care Completion Date Page 14 of 42 Licensee: PSL Associates, LLC 12/0S/2023 -With the same gloved hands removed two slices of bread from the bag. -Picked up a spatula and removed a grilled cheese sandwich. -Picked up the bread and then a utensil and spread mayonnaise on the bread. With the same gloved hands, reached into containers and removed picl<les, lettuca, and tomatoes for the sandwich. -Reached into a bucket of sanitizer, removed a rag, wrung out the rag, wiped the counter, returned the rag to the bucket, then picked up the sandwi:ch to cut it in half. -Picked up a spatula and flipped a burger on the grill. ~Removed hamburger buns from a bag. •Staff J tl1en removed their gloves and washed their hands. Observation on 11/15/2023 at 11 :20 AM, s11owed Staff J prepared tacos for the resident lunches. Staff J performed the following food preparation with the same gloved 1,ands: -Opened a box and removed packages of hard taco shells. -Opened the walk-in refrigerator and removed a packiige of tortillas. ~Placed oven mitts on over their gloved hands and removed a large stock pot from the stove. -Poured soup into a container and returned the pot to the stove. •Removed the oven mitts but kept the same gloves on. -Picked up lettu.ce and placed it into zip lock bags. -Removed soft tortilla shells, picked up a utensil and placed cooked meat onto the tortilla. ~Removed shredded cheese and lettuce and placed it on the tortilla. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 14 of 42 Licensee: PSL Associates, LLC 12/05/2023 -With the same gloved hands removed two slices of bread from the bag. -Picked up a spatula and removed a grilled cheese sandwich. -Picked up the bread and then a utensil and spread mayonnaise on the bread. With the same gloved hands, reached into containers and removed pickles, lettuce, and tomatoes for the sandwich. -Reached into a bucket of sanitizer, removed a rag, wrung out the rag, wiped the counter, returned the rag to the bucket, then picked up the sandwich to cut it in half. -Picked up a spatula and flipped a burger on the grill. -Removed hamburger buns from a bag. -Staff J then removed their gloves and washed their hands. Observation on 11/15/2023 at 11:20 AM, showed Staff J prepared tacos for the resident lunches. Staff J performed the following food preparation with the same gloved hands: -Opened a box and removed packages of hard taco shells. -Opened the walk-in refrigerator and removed a package of tortillas. -Placed oven mitts on over their gloved hands and removed a large stock pot from the stove. -Poured soup into a container and returned the pot to the stove. -Removed the oven mitts but kept the same gloves on. -Picked up lettuce and placed it into zip lock bags. -Removed soft tortilla shells, picked up a utensil and placed cooked meat onto the tortilla. -Removed shredded cheese and lettuce and placed it on the tortilla. This document was prepared by Residential Care Services for the Locator website. /: .,:> .i:''AX ::iOSJ N. Point Village ~017/045 2.14.2023 16:47:59 State OF Mashill9tOn Ml Statement of Deficiencies License#: 2479 Compliance Determination# 32296 Plan of Correction North Point Village, Asslsted Living & Memory care Completion Date Page 15 of 42 Licensee: PSL Associates, LLC 12/05/2023 -Staff J then removed their gloves and washed their hands. In an interview on 11/15/2023 at 11:45 AM, the department licensor asked Staff J about the training they received regarding ~afe food handling and prevention of cross contamination. Staff J stated they received "soma" training as they had food handling experience at a previous employer. Staff J stated they worked with new employees and provided most of the hands-on training to new employees. Staff J then confirmed that the facility provided online training through Relias and stated ;'admittedly, we're all behind on it". Observation on 11112/2023 at 12:12 PM. showed Staff 0, Memory Care Partner, in building A. prepared tacos. With glo.ved hands, Staff O touched tl,e cabinet door handles and an opened package of hard taco shells. With the same gloved hands, placed a hard taco shell on the plate. Staff O then changed their gloves without washing their hands. Observation on 11/15/2023 at 1.2:.25 PM, showed Staff D, Memory Care Med Aide, in building B, prepared tacos. With gloved hands. Staff D touched the cabinet door handles and the binder with the food temperature log. VVlth the same gloved hands, Staff D picked up hard taco shells and crunched them up to make a taco salad. <Cleanliness> Per WAC 246-215--0460: Equipment. food-contact surfaces. nonfood-contact surfaces, and utensils: -Equipment, food contact surfaces, antt uten·sils must be clean to sight and touch. -Food contact surfaces of cooking equipment must be kept free of encrusted grease deposits and other soil accumulations. -Non~food contact surfaces of equipment must be kept free of an accumulation of dust, dirt, food residue, and other debris. Observation on 11/14/2023 at 9:00 AM, during the tour of the kitchen, showed the m,crowave, stove top cooking area. three ovens, and floors were covered with dirt. food particles and encrusted grease deposits. Further observation of the kitchen on 11/14/2023, showed ·the following: -The walk-in refrigerator had a brown liquid substance splattered on two walls and several This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 15 of 42 Licensee: PSL Associates, LLC 12/05/2023 -Staff J then removed their gloves and washed their hands. In an interview on 11/15/2023 at 11:45 AM, the department licensor asked Staff J about the training they received regarding safe food handling and prevention of cross contamination. Staff J stated they received “some” training as they had food handling experience at a previous employer. Staff J stated they worked with new employees and provided most of the hands-on training to new employees. Staff J then confirmed that the facility provided online training through Relias and stated “admittedly, we’re all behind on it”. Observation on 11/12/2023 at 12:12 PM, showed Staff O, Memory Care Partner, in building A, prepared tacos. With gloved hands, Staff O touched the cabinet door handles and an opened package of hard taco shells. With the same gloved hands, placed a hard taco shell on the plate. Staff O then changed their gloves without washing their hands. Observation on 11/15/2023 at 12:25 PM, showed Staff D, Memory Care Med Aide, in building B, prepared tacos. With gloved hands, Staff D touched the cabinet door handles and the binder with the food temperature log. With the same gloved hands, Staff D picked up hard taco shells and crunched them up to make a taco salad. <Cleanliness> Per WAC 246-215-0460: Equipment, food-contact surfaces, nonfood-contact surfaces, and utensils: -Equipment, food contact surfaces, and utensils must be clean to sight and touch. -Food contact surfaces of cooking equipment must be kept free of encrusted grease deposits and other soil accumulations. -Non-food contact surfaces of equipment must be kept free of an accumulation of dust, dirt, food residue, and other debris. Observation on 11/14/2023 at 9:00 AM, during the tour of the kitchen, showed the microwave, stove top cooking area, three ovens, and floors were covered with dirt, food particles and encrusted grease deposits. Further observation of the kitchen on 11/14/2023, showed the following: -The walk-in refrigerator had a brown liquid substance splattered on two walls and several This document was prepared by Residential Care Services for the Locator website. I• ~'J r·,v. :>V)I N. Point Vill11.ge ~018/045 2.1q,2023 16:47:59 State of Mashlngton I.JI Statement of Deficiencies License#: 2479 Compliance Determination #-32296- Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 16 of 42 Licensee: PSL Associates, LLC 12/05/2023 pieces of fruit on the floor. ~T he dry storage area had flour and oats spilled on the floor. -Three utility carts, used to transport unprepared food and trays of clean dishes, were sticky and. covered with food debris. -The chest tree~er had ice-cream dripping down the inside and food debris along all the edges of the freezet. -The door handles to the walk-in refrigerator and freezers were sticky. -Two food blenders were observed to have food debris and dried/caked foods on them. In an interview on 11/14/2023 at 10:30 AM, Staff J stated the kitchen staff did not have a cleaning schedule. Staff J stated the "ovens are due for a cleaning". In an Interview on 11/15/2023 at 10:35 AM, Staff I, Cook, stated the kitchen staff used to have a cleaning schedule. the last manager took them down. and they have not had one since. <Food Handler cards> Per WAC 246-215-02120, Food worker cards. The permit holder and person in charge shall ensure that all food employees are in compliance with the provisions of chapter 69.06 RCWand chapter 246-217 WAC for obtaining and renewing valid food worker cards. In an inteNiew on 11/15/2023 at 10:35 AM, Staff I stated they were the evening cook. Review of Staff l's food handler card showed it expired on 02/18/2023. In an interview on 11/21/2023 at 9:30 AM, Staff P, Business Office Manager, confirmed that Staff l's food handler card expired on 02/18/2023. This is a recurring deficiency previously cited on 06/18/.2021 for subsection (1). This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 16 of 42 Licensee: PSL Associates, LLC 12/05/2023 pieces of fruit on the floor. -The dry storage area had flour and oats spilled on the floor. -Three utility carts, used to transport unprepared food and trays of clean dishes, were sticky and covered with food debris. -The chest freezer had ice-cream dripping down the inside and food debris along all the edges of the freezer. -The door handles to the walk-in refrigerator and freezers were sticky. -Two food blenders were observed to have food debris and dried/caked foods on them. In an interview on 11/14/2023 at 10:30 AM, Staff J stated the kitchen staff did not have a cleaning schedule. Staff J stated the “ovens are due for a cleaning”. In an interview on 11/15/2023 at 10:35 AM, Staff I, Cook, stated the kitchen staff used to have a cleaning schedule, the last manager took them down, and they have not had one since. <Food Handler cards> Per WAC 246-215-02120, Food worker cards. The permit holder and person in charge shall ensure that all food employees are in compliance with the provisions of chapter 69.06 RCW and chapter 246-217 WAC for obtaining and renewing valid food worker cards. In an interview on 11/15/2023 at 10:35 AM, Staff I stated they were the evening cook. Review of Staff I’s food handler card showed it expired on 02/18/2023. In an interview on 11/21/2023 at 9:30 AM, Staff P, Business Office Manager, confirmed that Staff I’s food handler card expired on 02/18/2023. This is a recurring deficiency previously cited on 06/18/2021 for subsection (1). This document was prepared by Residential Care Services for the Locator website. --1 -wt.,.'tl"-"..I """"IJ l'fi.11. ~IJ)il N. Point Village ~o 19/ 045 2.14.2023 16:47.59 State of Mash I n9ton 16/ Statement oftieflciencies ···········" ............. .. .. Tiriei1se'ii:·2~i'1e...... .. ...... Compi,ii,nc"e.. 5 etermin·atlon .#° 322Bff Plan of Correction North Point Village. Assisted Living & Memory Care completion Data Page 17 of 42 Licensee: PSL Associates, LLC 12/05/2023 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, North Point Village, Assisted Uving & MenJary Care is or will be in compliance with this I.aw and I or regulation on (Date) IL?/ ZOt-'( . } I In addition, I will implement a system to monitor and ensure continued compliance with this requirement. ............. ri-............................................................... . ... ....... / /1_<1/ ~ z_ l/ ...... ... Adm~;~. ., ;~· Representative) Date WAC 388-78A~2880 Changing use of rooms. Prior to using a room for a purpose other than what was approved by construction review services, the assisted living facility must: (1) Notify construction review services: (a) In writing; (b) Thirty days or more before the intended change ln use; (c) Describe the current and proposed use of the room; and (d) Provide all additional documentation as requested by construction review services; (2) Obtain the written approval of construction review services for the new use of the room: and (3) Ensure the facility functional program and room list are updated to reflect the change. This requirement was not met as evid~nced by: Based on observation, interview, and record review, the facility failed to notify construction review services in advance, obtain approval, and ensure the room list was updated to reflect a change in the use of 1 of 1 room (staff break room). This failure placed residents residing in byilding Bat risk of injury due to a potentially unsafe living environment. Findings included ... Review of the facility1s room list, dated 05/11/2021, showed room G in building B (memory care building) was designated as a studio apartment approved for one licensed bed. Observation on 11/14/2023 at 2:15 PM, of room Gin building B showed the following: This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 17 of 42 Licensee: PSL Associates, LLC 12/05/2023 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, North Point Village, Assisted Living & Memory Care 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 WAC 388-78A-2880 Changing use of rooms. Prior to using a room for a purpose other than what was approved by construction review services, the assisted living facility must: (1) Notify construction review services: (a) In writing; (b) Thirty days or more before the intended change in use; (c) Describe the current and proposed use of the room; and (d) Provide all additional documentation as requested by construction review services; (2) Obtain the written approval of construction review services for the new use of the room; and (3) Ensure the facility functional program and room list are updated to reflect the change. This requirement was not met as evidenced by: Based on observation, interview, and record review, the facility failed to notify construction review services in advance, obtain approval, and ensure the room list was updated to reflect a change in the use of 1 of 1 room (staff break room). This failure placed residents residing in building B at risk of injury due to a potentially unsafe living environment. Findings included… Review of the facility’s room list, dated 05/11/2021, showed room G in building B (memory care building) was designated as a studio apartment approved for one licensed bed. Observation on 11/14/2023 at 2:15 PM, of room G in building B showed the following: This document was prepared by Residential Care Services for the Locator website. 4 V.L.l1L vi1.1.age 14,2023 16;47:59 State of Washington i020/045 St.atement of Deficiencies License#: 2479 Compliance Oeterminetfon ·# 32296- a. Plan of Correction North Point Village, Assisted Living Memory Care Completion Date P~ge 18 of 42 Licensee: PSL Associates, LLC 1 '2/05/2023 ~Staff entered the room. -The door was unsecured, as the coded lock did not work. ~ The light did not work. ~Personal hygiene items were stored. including shampoo, shaving cream, and body powder. ~A refrigerator with staff food. In an interview an 11/14/2023 at 2:17 PM, Staff H, Maintenance Director, stated the facility changed the resident apartment into a staff break room. a year prior. Observation on 11115/23 at 11 :15 AM showed roorn Gin building B was not locked ar,d was accessible to residents. In an interview on 11/15/2023 at 12:10 PM. Staff A, Executive Director, stated they had no documentation. regarding the change in the use of room G. In an interview on 11/15/2023 at 4:00 PM, Staff A stated they had no construction review service (CRS) documentation of approval for the room change. This is a recurring deficiency previously cited on 06/18/2021 for subsection {1)(a)(b)(c}(d). Plan/Attestation Statem,mt wm I hereby certify that I hava reviewed this report and have taken or take active measures to correct this deficiency. By taking thls action. North Point Village, Assisted Living & M t e p lJ10 ry Care is or will be in compliance with this law and r or regulation on (Date) 7 l: ~ _ . 1 In addition. I will impfement a system to monitor and ensure continued compliance with this requirement. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 18 of 42 Licensee: PSL Associates, LLC 12/05/2023 -Staff entered the room. -The door was unsecured, as the coded lock did not work. -The light did not work. -Personal hygiene items were stored, including shampoo, shaving cream, and body powder. -A refrigerator with staff food. In an interview on 11/14/2023 at 2:17 PM, Staff H, Maintenance Director, stated the facility changed the resident apartment into a staff break room, a year prior. Observation on 11/15/23 at 11:15 AM showed room G in building B was not locked and was accessible to residents. In an interview on 11/15/2023 at 12:10 PM, Staff A, Executive Director, stated they had no documentation regarding the change in the use of room G. In an interview on 11/15/2023 at 4:00 PM, Staff A stated they had no construction review service (CRS) documentation of approval for the room change. This is a recurring deficiency previously cited on 06/18/2021 for subsection (1)(a)(b)(c)(d). 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, North Point Village, Assisted Living & Memory Care 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 This document was prepared by Residential Care Services for the Locator website. /: .,0 .i:''AX ::iOSJ N. Point Village 2,14.2023 16:47:59 Stftte of Mashlngton IU/ Gt-ateinent of Deficiencies license#: 2479 Compliance Determination# 32296 Plan of Correction North Point VIiiage. Assisted Living & Memory Care Completion Date Page 19 of 42 Licensee: PSL Associates, LLC 12/05/2023 WAC 388-78A-2450 Staff, (1) Each assisted living facility must provide sufficient, trained staff persons to: (a) Furnish the services and care needed by each resident consistent with his or her negotiated service agreement; This requirement was not met as evldenC8d by: Based on interview and record review, the facility failed to provide sufficient staff to meet resident care needs for 4 of 9 sampled residents (Residents 1, 2, 3, and 4). This failure resulted in difficulty breathing for Resident 1 and long wait times for staff assistance, and placed residents at risk of haatth complications, unmet care needs and risk of injury. Findings included. . , During the resident group meeting on 11/14/2023 at 2:30 PM, Resident 14 stated that it often took "30 minutes to an hour' for caregivers to respond to the resident's call light. <Resident 1 > Review of Resident 1 's Negotiated Service Plan (NSP, the facilities titled negotiated service agreement). dated 07/14/2023. showed Resident 1 was diagnosed with . Further review showed that Resident 1 required facility assistance with medications, assistance to and from meals, and assistance with toileting. In an interview on 11/20/2023 at 10:30 AM, Resident 1 stated they had frequently waited 30 minutes to over an hour, after pressing t11elr pendant. tor staff to respond to their request to use their rescue inhaler for shortness of breath. Resident 1 rurther stated that they had to wait a long tirne to, staff assistance for escorts to and from the dining room and when needing assistance in the bathroom. Review of the Facility's October 2023 Response Time Report for Resident 1, showed the staff facility's response time to the resident's call light was 30 minutes or longer on tne following dates/times: 10/02 at 8:32 AM - 32 min. 10/02 at 12:15 PM~ 31 min. 10/02 at 1:26 PM - 31 min. 10/02 at 5:22 PM - 30 min. 10/03 at 6:38 AM - 37 min. 10/03 at 8:00 AM - 32 min. 10/04 at 6: 13 AM - 30 min. 10/04 at 7:34 AM 34 min. w This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 19 of 42 Licensee: PSL Associates, LLC 12/05/2023 WAC 388-78A-2450 Staff. (1) Each assisted living facility must provide sufficient, trained staff persons to: (a) Furnish the services and care needed by each resident consistent with his or her negotiated service agreement; This requirement was not met as evidenced by: Based on interview and record review, the facility failed to provide sufficient staff to meet resident care needs for 4 of 9 sampled residents (Residents 1, 2, 3, and 4). This failure resulted in difficulty breathing for Resident 1 and long wait times for staff assistance, and placed residents at risk of health complications, unmet care needs and risk of injury. Findings included… During the resident group meeting on 11/14/2023 at 2:30 PM, Resident 14 stated that it often took “30 minutes to an hour” for caregivers to respond to the resident’s call light. <Resident 1> Review of Resident 1’s Negotiated Service Plan (NSP, the facilities titled negotiated service agreement), dated 07/14/2023, showed Resident 1 was diagnosed with . Further review showed that Resident 1 required facility assistance with medications, assistance to and from meals, and assistance with toileting. In an interview on 11/20/2023 at 10:30 AM, Resident 1 stated they had frequently waited 30 minutes to over an hour, after pressing their pendant, for staff to respond to their request to use their rescue inhaler for shortness of breath. Resident 1 further stated that they had to wait a long time for staff assistance for escorts to and from the dining room and when needing assistance in the bathroom. Review of the Facility’s October 2023 Response Time Report for Resident 1, showed the staff facility’s response time to the resident’s call light was 30 minutes or longer on the following dates/times: 10/02 at 8:32 AM - 32 min. 10/02 at 12:15 PM - 31 min. 10/02 at 1:26 PM - 31 min. 10/02 at 5:22 PM - 30 min. 10/03 at 6:38 AM - 37 min. 10/03 at 8:00 AM - 32 min. 10/04 at 6:13 AM - 30 min. 10/04 at 7:34 AM - 34 min. This document was prepared by Residential Care Services for the Locator website. 14.2023 16:47:59 state of l-lashlngton /ZJ022/ 045 Statement of Deficiencies License#: 2479 Compliance DeterrniMtlon # 32296 Plan of Correction North Point Village. Assisted Living & Memory care completion Date Page 20 of 42 Licensee: PSL Associates, LLC 12/05/2023 •·-··-·--•-·-······•··--•·-··•··--·•···. ...... , ..............................•. __ , ___, ____ , .....•............................•....•...........................................................•.....•. _, ........................~ --- 10/05 at 8:09 AM - 32 min. 10/05 at 7:51 PM - 38 min. 10/06 at 12:50 AM - 60 min. 10/07 at 10:29 AM• 54 min. 10/09 at 2:07 AM ~ 32 min. 10/09 at 6:47 AM • 44 min. 10/09 at 12:50 PM - 45 min. 10110 at 1:11PM-33 min. 10110 at 5:25AM - 50 min. 10/10 at 6:46 AM - 33 min. 10/10 at 8:18 AM• 41 min. 10111 at 8:27 AM - 37 min. 10 t11 at 7:59 PM - 33 min. 10112 at 8:33 PM - 46 rnin. 10/13 at 8:19 AM - 30 min. 10/13 at 8:13 PM - 38 min. 10/16 at 6:57 AM - 43 min. 10/16 at 12:02 PM - 1 hour23 min. 10/17 at 7:10 AM - 34 min. 1D/17 at 8:41 AM - 37 min. 10/18 at 5:02 AM • 52 min. 10/18 at 8:22 AM - 36 min. 10/18 at 10:59 AM• 33 min. 10/18 at 9:18 AM~ 35 min. 10/19 at 6:57 AM - 50 min. 10/19 at 8,24 AM - 41 min. 10120 at 1:56 AM - 34 min. 10/20 at 8;15 AM - 30 min. 10/20 at 12:15 PM• 42 min. 10/21 at 7:22 PM ~ 1 hour 3 min. 10/22 at 5:53 AM - 34 min. 10/22 at 8:13 AM - 55 min. 10/22 at 10:32 AM - 47 min. 10122 at 12:06 PM - 33 min. 10/24 at 12:56 PM - 49 rnin. 10/25 at 1:33 PM ~ 36 min. 10/2.5 at 5: 13 PM - 36 min. 10/27 at 3:23 AM - 56 min. 10/27 at 6:41 AM - 49 min. 10/27 at 8:32 AM - 33 min. 10/29 at 6:56 AM - 44 min. 10/29 at 8:52 AM - 42 min. 10/30 at 8:10 AM - 1 hour 2 min. 10/31 at 12:11 PM - 40 min. <Resident 2> Review of Resident 2's NSP, dated 07/06/2023, showed the resident required assistance with transfers from their wheelchair, toileting. dressing, bathing, and escorts to meals and activities. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 20 of 42 Licensee: PSL Associates, LLC 12/05/2023 10/05 at 8:09 AM - 32 min. 10/05 at 7:51 PM - 38 min. 10/06 at 12:50 AM - 50 min. 10/07 at 10:29 AM - 54 min. 10/09 at 2:07 AM - 32 min. 10/09 at 6:47 AM - 44 min. 10/09 at 12:50 PM - 45 min. 10/10 at 1:11PM - 33 min. 10/10 at 5:25 AM - 50 min. 10/10 at 6:46 AM - 33 min. 10/10 at 8:18 AM - 41 min. 10/11 at 8:27 AM - 37 min. 10/11 at 7:59 PM - 33 min. 10/12 at 8:33 PM - 46 min. 10/13 at 8:19 AM - 30 min. 10/13 at 8:13 PM - 38 min. 10/16 at 6:57 AM - 43 min. 10/16 at 12:02 PM - 1 hour 23 min. 10/17 at 7:10 AM - 34 min. 10/17 at 8:41 AM - 37 min. 10/18 at 5:02 AM - 52 min. 10/18 at 8:22 AM - 36 min. 10/18 at 10:59 AM - 33 min. 10/18 at 9:18 AM - 35 min. 10/19 at 6:57 AM - 50 min. 10/19 at 8:24 AM - 41 min. 10/20 at 1:56 AM - 34 min. 10/20 at 8:15 AM - 30 min. 10/20 at 12:15 PM - 42 min. 10/21 at 7:22 PM - 1 hour 3 min. 10/22 at 5:53 AM - 34 min. 10/22 at 8:13 AM - 55 min. 10/22 at 10:32 AM - 47 min. 10/22 at 12:06 PM - 33 min. 10/24 at 12:56 PM - 49 min. 10/25 at 1:33 PM - 36 min. 10/25 at 5:13 PM - 36 min. 10/27 at 3:23 AM - 56 min. 10/27 at 6:41 AM - 49 min. 10/27 at 8:32 AM - 33 min. 10/29 at 6:56 AM - 44 min. 10/29 at 8:52 AM - 42 min. 10/30 at 8:10 AM - 1 hour 2 min. 10/31 at 12:11 PM - 40 min. <Resident 2> Review of Resident 2’s NSP, dated 07/06/2023, showed the resident required assistance with transfers from their wheelchair, toileting, dressing, bathing, and escorts to meals and activities. This document was prepared by Residential Care Services for the Locator website. 1: .,, J,'AX :iOSI N. Point Vill age il)023/ 045 2.14.2023 16:47:59 state of Washington WI Staternent of Deficiencies Lice11se #: 2479 Cornpliance Determination # 32296 Plan of Correction North Point Village. Assisted Living & Memory care Completion Date Page 21 of 42 Licensee: PSL Associates, LLC 1.2/05/2023 In an interview on 11/17/2023 at 1:52 PM, Resident2 stated that call light responses were often longer than 30 minutes. <Resident 3-> Review of Resident 3's NSP, dated 07/29/2023, showed the resident used a walker for mobility in their room and required a wheelchair for mobility outside of their room. Further review showed that the resident required facility assistance with medications and escorts to meals and activities. In an Interview on 11/16/2023 at 10:45 AM, Resident 3 stated they frequently had to wait at least 30 minutes for the care staff to respond to their call light. Resident 3 further stated they often had to wait over one hour tor staff assistance for escorts to the dining room. In an interview on 11/16/2023 at 10:45 AM, Collateral Contact 1 (CC1) stated they had observed long response times to Resident 3's call light. CC1 stated the response time had been up to an hour. Review of the Facility's October 2023 Response Time Report for Resident 3, showed the staff facility's response time to the resident's call light was 30 minutes or longer on the following dates/times: 10/04 at 9:15 AM ... 31 min. 10/05 at 7:24 AM - 31 min. 10/07 at 12:50 AM - 50 min. 10/09 at 7:18 AM- 31 min. ·10/09 at 4:55 PM .... 33 min, 10/11 at 8:45 AM - 35 min. 10/13 at 8:48 AM - 30 min. 10/14 et 7:09 AM - 35 min. 10/14 at 12:15 PM - 33 min. 10/15 at 8:35 AM - 48 min. 10/17 at 9:3·8 AM - 45 min. 10/20 at 7:10 AM - 39 min. 10/20 at 8:34 AM - 55 min. 10/21 at 5:24 PM - 33 min. 10/23 at 7:23 AM - 55 min. 10/24 at 7:36 AM - 41 min. 10/27 at 7:19 AM - 52 min. 10/27 at 9:30 AM - 42 min. 10/29 at 9:04 AM - 31 min. <Resident 4> This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 21 of 42 Licensee: PSL Associates, LLC 12/05/2023 In an interview on 11/17/2023 at 1:52 PM, Resident 2 stated that call light responses were often longer than 30 minutes. <Resident 3> Review of Resident 3’s NSP, dated 07/29/2023, showed the resident used a walker for mobility in their room and required a wheelchair for mobility outside of their room. Further review showed that the resident required facility assistance with medications and escorts to meals and activities. In an interview on 11/16/2023 at 10:45 AM, Resident 3 stated they frequently had to wait at least 30 minutes for the care staff to respond to their call light. Resident 3 further stated they often had to wait over one hour for staff assistance for escorts to the dining room. In an interview on 11/16/2023 at 10:45 AM, Collateral Contact 1 (CC1) stated they had observed long response times to Resident 3’s call light. CC1 stated the response time had been up to an hour. Review of the Facility’s October 2023 Response Time Report for Resident 3, showed the staff facility’s response time to the resident’s call light was 30 minutes or longer on the following dates/times: 10/04 at 9:15 AM – 31 min. 10/05 at 7:24 AM – 31 min. 10/07 at 12:50 AM – 50 min. 10/09 at 7:18 AM – 31 min. 10/09 at 4:55 PM – 33 min. 10/11 at 8:45 AM – 35 min. 10/13 at 8:48 AM – 30 min. 10/14 at 7:09 AM – 35 min. 10/14 at 12:15 PM – 33 min. 10/15 at 8:35 AM – 48 min. 10/17 at 9:38 AM – 45 min. 10/20 at 7:10 AM – 39 min. 10/20 at 8:34 AM – 55 min. 10/21 at 5:24 PM - 33 min. 10/23 at 7:23 AM – 55 min. 10/24 at 7:36 AM – 41 min. 10/27 at 7:19 AM – 52 min. 10/27 at 9:30 AM – 42 min. 10/29 at 9:04 AM – 31 min. <Resident 4> This document was prepared by Residential Care Services for the Locator website. ,.,,., .:.vi .:.v,,:;-, w.i::.u r: j, J:<'AX :JOSI N. Point Village ~024/045 2, 14,2023 16:47,59 State of Washington 211 Statemant of Deficienc:ies "License#: 2479 Compliance Determination # 32296 Plan of Correction North Point VIiiage, Assisted Living & Memory Care completion Date Page 22 of 42 Licensee: PSL Assoclales, LLC 12/05/2023 Review of Resident 4's NSP, datec:i 10/14/2023, showed Resident 4 required assistance with transfers during resident care. In an interview on 11/21/2023 at -1: 25 PM, Resident 4 stated they frequently waited 20"30 minutes for assistance when they pressed their call pendant. Pf an/Attestation Statement I hereby certify that I have reviewed tl1is report and have taken or will take active measures to correct this deficiency. By taking this action, North Point Village, Assisted Living & Meroory 9are is or will be tn compliance with this law and/ or regulation on (Date) / L 1 t.k: '1 . ' ' I In addition, I will implement a system to monitor and ensure continued compliance with this requirement. ~ ~ ~ ... ... ,,,,.r....!/(...t/.. .. ?.. l . ... ,.. ........ . ,,,, ...... ..... .. ......... ,,,,,,,. ..................., ,,,, .......... . A~~t~tor (or Representative) Date WAC 388.78Aw2640 Reporting significant change in a resident's condition. (1) The assisted living facility must consult with the resident's representative, the resider,t·s physician, and other individual(s) designated by the resident as soon as possible whenever: (a) There is a significant change in the resident's condition; This requirement was not met as evidenced by: Based on interview and record review, the facility failed to contact the physician when a resident1s blood sugar was greater than 400 for 1 of 11 residents (Resident 6) who had a significant change of condition. This failure placed the resident at risk of a medical emergency due to untreated high blood sugar. Review of Resident 6's Negotiated Service Plan (NSP, the facility's titled negotiated service agreement), dated 05/08/2023, snowed they were diagnosed With . Further revrew showed that Resident 8 received assistance with blood sugar (BS) testing and insulin (an injectable medication used to lower blood sugar) administration. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 22 of 42 Licensee: PSL Associates, LLC 12/05/2023 Review of Resident 4’s NSP, dated 10/14/2023, showed Resident 4 required assistance with transfers during resident care. In an interview on 11/21/2023 at 1:25 PM, Resident 4 stated they frequently waited 20-30 minutes for assistance when they pressed their call pendant. 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, North Point Village, Assisted Living & Memory Care 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 WAC 388-78A-2640 Reporting significant change in a resident's condition. (1) The assisted living facility must consult with the resident's representative, the resident's physician, and other individual(s) designated by the resident as soon as possible whenever: (a) There is a significant change in the resident's condition; This requirement was not met as evidenced by: Based on interview and record review, the facility failed to contact the physician when a resident's blood sugar was greater than 400 for 1 of 11 residents (Resident 6) who had a significant change of condition. This failure placed the resident at risk of a medical emergency due to untreated high blood sugar. Review of Resident 6’s Negotiated Service Plan (NSP, the facility’s titled negotiated service agreement), dated 05/08/2023, showed they were diagnosed with . Further review showed that Resident 6 received assistance with blood sugar (BS) testing and insulin (an injectable medication used to lower blood sugar) administration. This document was prepared by Residential Care Services for the Locator website. ...... , wv, z.vz.;; n:c,u 1: :JI !''AX :>OSI N. Point Village ~025/045 2.14.2023 16:47:59 State of Washington L1.f Statement of Deficiencies License #: 2479 Compliance Datenninstion # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 23 of 4.2 Licensee; PSL Associates. LLC 1.2/05/2023 In an interview on 11./17/2023 at 1:10 PM, Staff G, Regional Health and Wellness Speclalist, stated when Resident 6's BS was greater than 400, the physician should have been notified. Staff G further stated, staff should write a progress note when the physiciar1 is notified. Staff G confirmed there were times when the physician was not notified when Resident Efs BS was above 400. Review of Resident 6's medication administration records (MAR) for September 2023, October 2023 and November 2023, showed that Resident 6 had blood sugars above 400. Further review of the MA Rs she.wed no documentation to indicate that Resident 6's physician had been notified on the following dates: 09/02 at 11 :00 AM, BS 436 09/04 at 07:00 AM, BS 409 09/11 at 07:0'0 AM, BS 466 and at 11 :00 AM, BS 496 09/17 at 11:00AM, BS467 09/29 at 07;00 AM, BS 476 09/30 at 11 :oo AM, BS 451 10/07 at 08;00 PM, BS 411 10/21 at 11:00 AM, BS 407 10/27 at 07:00 AM, BS 430 11/13 at 11:00 AM, BS 409 11/14 at 07:00 AM, BS 444 Review of Resident 6's progress notes tor September 2023, October 2023, and November 2023, showed no documentation to indicate that Resident 6's health care provider was notified when the resident's blood sugars were greater than 400 on the dates listed above. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or wilt take active measures to correct this deficiency. By taking this action, North PoiI"lt Village, Assisted Living & Mempry Care is or will be in compliance with this law and I or regulation on (Date) I ~7/l "I . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. /z .. ··········· ... /Z// J' 'f ............. , Date WAC 388-78A~2150 Signing negotiated service agreement. The assisted living facility must ensure that the negotia.ted service agreement is agreed to and signed at leas.t annually by: (1) The resident, or the resident's representative if the resident has one and is unable to sign or chooses not to sign: This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 23 of 42 Licensee: PSL Associates, LLC 12/05/2023 In an interview on 11/17/2023 at 1:10 PM, Staff G, Regional Health and Wellness Specialist, stated when Resident 6’s BS was greater than 400, the physician should have been notified. Staff G further stated, staff should write a progress note when the physician is notified. Staff G confirmed there were times when the physician was not notified when Resident 6’s BS was above 400. Review of Resident 6’s medication administration records (MAR) for September 2023, October 2023 and November 2023, showed that Resident 6 had blood sugars above 400. Further review of the MARs showed no documentation to indicate that Resident 6’s physician had been notified on the following dates: 09/02 at 11:00 AM, BS 436 09/04 at 07:00 AM, BS 409 09/11 at 07:00 AM, BS 466 and at 11:00 AM, BS 496 09/17 at 11:00 AM, BS 467 09/29 at 07:00 AM, BS 476 09/30 at 11:00 AM, BS 451 10/07 at 08:00 PM, BS 411 10/21 at 11:00 AM, BS 407 10/27 at 07:00 AM, BS 430 11/13 at 11:00 AM, BS 409 11/14 at 07:00 AM, BS 444 Review of Resident 6’s progress notes for September 2023, October 2023, and November 2023, showed no documentation to indicate that Resident 6’s health care provider was notified when the resident’s blood sugars were greater than 400 on the dates listed above. 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, North Point Village, Assisted Living & Memory Care 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 WAC 388-78A-2150 Signing negotiated service agreement. The assisted living facility must ensure that the negotiated service agreement is agreed to and signed at least annually by: (1) The resident, or the resident's representative if the resident has one and is unable to sign or chooses not to sign; This document was prepared by Residential Care Services for the Locator website. - ""V"'-U,L. vi.u.age 14.2023 16:47:59 St11te Of Wash i 119ton Statement of Oeflciencies License#: 2479 compliance Determination# 322i6 Plan of Correction North Point Village, Assisted Living & Memory Care completion Date Page 24 of 42 Licensee: PSL Associates, LLC 12/05/2023 (2) A representative of the assisted living facility duly authOrized by the assisted living facility to sign on its behalf; and Thi$ requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure that negotiated service agreements were signed by the resident or the resident's representative for 4 of 11 residents (Residents 3, 4, 10, and 13) sampled for negotiated services agreements. This failure placed residents at risk of unmet care needs and for seNices that were not agreed upon. Findings included ... <Resiqent 3> Review of Resident 3's Negotiated Service Plan (NSP. the facilities titled negotiated service agreement). dated 07/29/2023, showed the plan was not signed by the resident or their representative, to indicate agreement to the plan. In an interview on 11/16/2023 at 10:45 AM, Resident 3 stated the facility had not discussed their annual NSP with them since moving in on /2018. In an interview on 11/16/2023 at 10:45 AM, Collateral Contact 1 (CC1} stated the facility did not discuss the NSP. dated 07/29/2023, with them. <Resident 4> Review of Resident 4's NSP, dated 10/14/2023, showed the plan was not signed by the resident or their representative, to indicate agreement to the plan. In an interview on 11/17/2023 at 1:30 PM, Resident 4 stated that the facility did not request a signature after the resident's NSP had been updated and changed recently to reflect a higher level of care cost. <Resident 10> Review of Resident 10's NSP, dated 10/17/2023, showed the plan was not signed by the resident or their representative. to indicate agreement to the plan. <Resident 13> This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 24 of 42 Licensee: PSL Associates, LLC 12/05/2023 (2) A representative of the assisted living facility duly authorized by the assisted living facility to sign on its behalf; and This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure that negotiated service agreements were signed by the resident or the resident’s representative for 4 of 11 residents (Residents 3, 4, 10, and 13) sampled for negotiated services agreements. This failure placed residents at risk of unmet care needs and for services that were not agreed upon. Findings included… <Resident 3> Review of Resident 3’s Negotiated Service Plan (NSP, the facilities titled negotiated service agreement), dated 07/29/2023, showed the plan was not signed by the resident or their representative, to indicate agreement to the plan. In an interview on 11/16/2023 at 10:45 AM, Resident 3 stated the facility had not discussed their annual NSP with them since moving in on /2018. In an interview on 11/16/2023 at 10:45 AM, Collateral Contact 1 (CC1) stated the facility did not discuss the NSP, dated 07/29/2023, with them. <Resident 4> Review of Resident 4’s NSP, dated 10/14/2023, showed the plan was not signed by the resident or their representative, to indicate agreement to the plan. In an interview on 11/17/2023 at 1:30 PM, Resident 4 stated that the facility did not request a signature after the resident’s NSP had been updated and changed recently to reflect a higher level of care cost. <Resident 10> Review of Resident 10’s NSP, dated 10/17/2023, showed the plan was not signed by the resident or their representative, to indicate agreement to the plan. <Resident 13> This document was prepared by Residential Care Services for the Locator website. .. ... v.a.,.1 t. vi.u age 14.2973 16:47:59 State of Washin9ton Statement of Deficiencies License#: 2479 Compliance Determination# 32.296 Pfan of Correction North Point Villaga. Assisted Living & Memory care Completion Date Page 25 of 42 Licensee: PSL Associates, LLC 12/05/2023 Review of Resident 13's NSP, dated 05/19/2023, showed the plan was not signed by the resident or their representative. to indicate agreement to the plan. Plan/Attestation Statement I hereby certify that I have reviewed lhis report and have taken or will take active measures to correct this deficiency. By taking this action, North Point VIiiage, Assisted Living & Me71oty Cate is or will be in compliance with this law and/ or regulation on lj:1/_lck . (Date) In addition, I Will implement a system to monitor and ensure continued compliance with this requirement. ....... /l/1.I/ l-Y .................... •····•··•···(h___······•···•··· .. ········. . ···••·•··. . ·•····•-······· Admi~ato;·(~~· Representative) Date WAC 388-78A-2290 Family assistance with medieations and treatments. (3) If the assisted living facility allows family assistance with or administration of medications and treatments, and the resident and a family member(s) agree a family member will provide medication or treatment assistance, or medication or treatment administration to "the resident, the assisted living facility must request that the farnily member submit to the assisted living facility- a written plan tor such assistance or administration that includes at a minimum: (a) By name, the family member who will provide the medication or treatment assistance or administration; (b) A description of the medication or treatment assistance or administration that the family member will provide, to be referred to as the primary plar1; (c) An alternate plan if the family member is unable to fulfill his or her duties as specified in the primary plan; This requirement WH' not met as evidenced by: Based on interview and record review. the facility failed to obtain a written plan for family assistance with obtaining medications and diabetic supplies for 1 of 11 sampled residents (Resident 1}. This failure resulted In missed medication and placed Resident 1 at risk of non-availability of medications and diabetic supplies. Findings included ... ReView of Resident 1 's Negotiated Service Plan (NSP, the facilities titled negotiated service agreement), dated 07/14/2023, showed that the facility provided medication assistance to This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 25 of 42 Licensee: PSL Associates, LLC 12/05/2023 Review of Resident 13’s NSP, dated 05/19/2023, showed the plan was not signed by the resident or their representative, to indicate agreement to the 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, North Point Village, Assisted Living & Memory Care 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 WAC 388-78A-2290 Family assistance with medications and treatments. (3) If the assisted living facility allows family assistance with or administration of medications and treatments, and the resident and a family member(s) agree a family member will provide medication or treatment assistance, or medication or treatment administration to the resident, the assisted living facility must request that the family member submit to the assisted living facility a written plan for such assistance or administration that includes at a minimum: (a) By name, the family member who will provide the medication or treatment assistance or administration; (b) A description of the medication or treatment assistance or administration that the family member will provide, to be referred to as the primary plan; (c) An alternate plan if the family member is unable to fulfill his or her duties as specified in the primary plan; This requirement was not met as evidenced by: Based on interview and record review, the facility failed to obtain a written plan for family assistance with obtaining medications and diabetic supplies for 1 of 11 sampled residents (Resident 1). This failure resulted in missed medication and placed Resident 1 at risk of non-availability of medications and diabetic supplies. Findings included… Review of Resident 1’s Negotiated Service Plan (NSP, the facilities titled negotiated service agreement), dated 07/14/2023, showed that the facility provided medication assistance to This document was prepared by Residential Care Services for the Locator website. ...... , wv, z.vz.;; n:c,u 1: ,:n, !''AX :>OSI N. Point Village ~028/045 2.14.2023 16147:59 state of Mashln9ton 251 Statement of Deficiencies Llcer1se #: 2479 Compliance Determination# 32296 Plan of Correction North Point VIiiage, Assisted Living & Memory care Completion Oate Page 26 of 42 Licensee: PSL Associates, LLC 12(05/2023 Resident 1 and obtained their medications from a local ph~rmacy. Further review showed Resident 1' s family member obtained the resident"s diabetic strips and inhalers. Review of Resident 1's undated medical file showed it did not contain a written plan for the family to assist with medications. In an interview on 11/17/2023 at 9:45 AM, Staff G, Regional Health and Wellness Specialist, stated the facility did not have a written plan for tha family to assist with medications with instruction$ on how the facility could obtain the medication if the family member did not. Review of Resident 1 's November 2023 medication administration record (MAR), showed an order for the resident to use their inhaler (long~acting inhaler to treat Asthma: a long.term inflammatory disease of the airways of the lungs) two times a day. Review of Resident 1's November 2023 MAR showed documentation on 11/08/2023 through 11112/2023 that stated Resident 1's family member had not replaced Re$ident 1 's inhaler yet. f:urther review showed documentation of eight rnissed administrations of the inhaler on those days. Plan/Atte5tatlon 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, North Point Village, Assisted Living & Me/ory Care is or will be in compliance with this law and / or regulation on (Date) I. _ 7 / "2,, "I . I 7 In addition, I will implement a system to monitor and ensure continued compliance with this requirement. ,.... ..........0 - ---....... ,... ................................ ................. . ~ .... ........ 1,-.// r1 ~r ........._ .. Admi~~t~·(·~·~·Representative) Date WAC 388•78A-2130 Service agreement planning. The assisted living facility must: (2) Complete the negotiated service agreement for each resident using the resident's preadmlssion assessment, initial resident service plan, and full assessment information, within thirty days of the resident movlng in; This requirement was not met as evidenced by: Based on interview and record review, the facility failed to complete a negotiated service agreement within 30 days of the resident moving into the facility for 1 of 11 sampled residents (Resident 7) sampled for service agreement plannjng. This failure placed the This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 26 of 42 Licensee: PSL Associates, LLC 12/05/2023 Resident 1 and obtained their medications from a local pharmacy. Further review showed Resident 1’s family member obtained the resident's diabetic strips and inhalers. Review of Resident 1’s undated medical file showed it did not contain a written plan for the family to assist with medications. In an interview on 11/17/2023 at 9:45 AM, Staff G, Regional Health and Wellness Specialist, stated the facility did not have a written plan for the family to assist with medications with instructions on how the facility could obtain the medication if the family member did not. Review of Resident 1’s November 2023 medication administration record (MAR), showed an order for the resident to use their inhaler (long-acting inhaler to treat Asthma: a long-term inflammatory disease of the airways of the lungs) two times a day. Review of Resident 1’s November 2023 MAR showed documentation on 11/08/2023 through 11/12/2023 that stated Resident 1’s family member had not replaced Resident 1’s inhaler yet. Further review showed documentation of eight missed administrations of the inhaler on those days. 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, North Point Village, Assisted Living & Memory Care 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 WAC 388-78A-2130 Service agreement planning. The assisted living facility must: (2) Complete the negotiated service agreement for each resident using the resident's preadmission assessment, initial resident service plan, and full assessment information, within thirty days of the resident moving in; This requirement was not met as evidenced by: Based on interview and record review, the facility failed to complete a negotiated service agreement within 30 days of the resident moving into the facility for 1 of 11 sampled residents (Resident 7) sampled for service agreement planning. This failure placed the This document was prepared by Residential Care Services for the Locator website. L.l.,f z.v1 z.vz..;, w:,:;u r: j::I !,'AX ~OSI N. Point Village ~029/ 045 2.14.2023 16:47:59 State of Washington 26/ Statement of Deficiencies Lice1,se #: 24'79 Compliance Deterrnination # 32296 Plan of Correction North Point VIiiage, Assisted Living & Memory Care Completlon Date Pag~ 27 of 42 Licensee: PSL Associates. LLC 1.2/05/2023 resident at risk of a lack of support regardrng the resident's capabllities. preferences, health, safety, and services necessary to meet the resident's needs. Findings included ... Review of Resident 7's undated pro.gress notes showed the resident moved into the facility on /2023. Review of Resident Ts Negotiat&d Service Plan (NSP, the facility's titled negotiated service agreement) showed the plan was written and implemented on /2023, the date of Resident 7's admissio1, to the facility. In an interview on 11/16/2023 at 2;20 PM, Staff G, Regional Health and Wellness Specialist, confirmed that Resident 7 moved into the facility on /2023. Staff G stated that Resident 7 had one plan that served as both the initial service plan end the negotiated service agreement (NSA), and the facility had not completed an NSA within 30 days of Resident 7 moving into the facility, Plan/Attestation Statement I hereby certify that I have revrewed this report and have taken or will take active measures to correct this deficiency. By taking this action, North Point Village., Assisted Living & Mempry pare is or will be in compliance with this law and I or regulation on 17. / I/ . {Date) / _J,, I I In addition, l will implement a system to monitor and ensure continued compliance with this requirement. •··••••• ~=• /l- ......./ .. J--/1 )' !/ .............. . •••••••••-••Uuo,o,o•••••••--•••••••• .. oo,o,•••••-••••••••••··••• Ad~~ (or Representative) Data WAC 388-78A .. 2090 Full assessment topics. The assisted living facility must obtain sufficient information to be able to a!lg.ess the capabilities, needs, and preferences for each resident, and mu.st complete a full assessment addressing the followlngj within fourteen days of the resident's move-in date, unless extended by the department for good cause: (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 unsupeNised, if smoking is permitted in the assisted living facility. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 27 of 42 Licensee: PSL Associates, LLC 12/05/2023 resident at risk of a lack of support regarding the resident’s capabilities, preferences, health, safety, and services necessary to meet the resident’s needs. Findings included… Review of Resident 7’s undated progress notes showed the resident moved into the facility on /2023. Review of Resident 7’s Negotiated Service Plan (NSP, the facility’s titled negotiated service agreement) showed the plan was written and implemented on /2023, the date of Resident 7’s admission to the facility. In an interview on 11/16/2023 at 2:20 PM, Staff G, Regional Health and Wellness Specialist, confirmed that Resident 7 moved into the facility on /2023. Staff G stated that Resident 7 had one plan that served as both the initial service plan and the negotiated service agreement (NSA), and the facility had not completed an NSA within 30 days of Resident 7 moving into the facility. 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, North Point Village, Assisted Living & Memory Care 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 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: (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. This document was prepared by Residential Care Services for the Locator website. , • .n j .. , - ... .., ...... ,., "a.11. :>v )II N. Point Village ~o 30/ 045 Staternent of Deficiencies License#: 2479 Compliance Deterrnination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care completlon Date Page 28 of 42 Licensee: PSL Associates, LLC 12/05/2023 This requirement was not met as evidenced by: Based on observation, interview, and record review, the facility failed to complete a full assessment within 14 days of admission and a safety assessment for the use of a medical device for 2 of 11 sampled residents (Resident 1 and 7). This failure placed residents at risk of unmet care needs due to not having a full assessment and risk of harm from use of a medical device that was not assessed to be used safely. Findings included ... ,Resident 1> Review of Resident 1 's undated medical file showed a move in date of /2023. Further review showed the first full assessment was completed on 10/29/2023, four months after admission. In an interview on 11/22/2023 at 1:15 PM, StaffG, Regional Health and Wellness Specialist, stated they did not complete an assessment within 14 days of admission for Resident 1. <Resident 7> Review of Resident 7's Negotiated Service Plan (NSP, tl1e facility's titled negotiated service agreement) showed the plan was written and implernented on /2023, the date of Resident 7's admission to the facility. Observation on 11/16/2023 at 11 :30 AM. showed Resident 7 had bed rails on the sides and the head of their bed. Review of Resident 7's undated medical file showed no docurnentatior"l of an assessment to determine if the resident could safely use bed rails·. In an interview on 11/17/2023 at 1:29 PM, Staff G stated Resident 7 was not assessed to safely use their bed rails. In an interview on 11/29/2023 at 8:42 AM, Collateral Contact 3 (CC3) stated they were unaware Resident 7 had bed rails on their bed. 7 Plan/Attestation Statement This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 28 of 42 Licensee: PSL Associates, LLC 12/05/2023 This requirement was not met as evidenced by: Based on observation, interview, and record review, the facility failed to complete a full assessment within 14 days of admission and a safety assessment for the use of a medical device for 2 of 11 sampled residents (Resident 1 and 7). This failure placed residents at risk of unmet care needs due to not having a full assessment and risk of harm from use of a medical device that was not assessed to be used safely. Findings included… <Resident 1> Review of Resident 1’s undated medical file showed a move in date of /2023. Further review showed the first full assessment was completed on 10/29/2023, four months after admission. In an interview on 11/22/2023 at 1:15 PM, Staff G, Regional Health and Wellness Specialist, stated they did not complete an assessment within 14 days of admission for Resident 1. <Resident 7> Review of Resident 7’s Negotiated Service Plan (NSP, the facility’s titled negotiated service agreement) showed the plan was written and implemented on /2023, the date of Resident 7’s admission to the facility. Observation on 11/16/2023 at 11:30 AM, showed Resident 7 had bed rails on the sides and the head of their bed. Review of Resident 7’s undated medical file showed no documentation of an assessment to determine if the resident could safely use bed rails. In an interview on 11/17/2023 at 1:29 PM, Staff G stated Resident 7 was not assessed to safely use their bed rails. In an interview on 11/29/2023 at 8:42 AM, Collateral Contact 3 (CC3) stated they were unaware Resident 7 had bed rails on their bed. Plan/Attestation Statement This document was prepared by Residential Care Services for the Locator website. n.c.u 1: ~)I ~·ax :,v:,i N. P01nt Vill age ll!031/ 045 Statement of Deficiencies License#'. 2479 Compliance Deterrninatlon if3229if a. ~Ian of Correction North Point Village, Assisted Living Memory care Completion Oate Page 29 of 42 Licensee: PSL Associates, LLC 12/05/2023 I hereby certify that I have reviewed this report and have taken or will take aetive measures to correct this deficiency. By taking this action. North Point Village, Assisted Living & Memory Care is or will be in compliance with this law and/ or regulation on (Date) J/J/2,,"f . I I In addition, I will implement a system to monitor and ensure continued compliance with this requirement. ~.~.~ .. .... ., .. l..~/lf'/.~ ............. . .. , ......... ... ... ...................... ., .. , ..... ........... . Adml"t~r (or Representative) Date 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; This requirement wa5 not met as evidenced by; Based on observation., interview, and record review. the facility failed to complete an annual safety assessment for a medical device for 1 of 2 residents (Resident 4) sampled for safety assessments. This failure placed Resident 4 at risk of harm due to the uses of a medical device that was not assessed to be used safely. Findings included. .. Per WAC 388-78A-2090 (6)(e) FL1II Assessment Topics, a safety assessment must be completed for medical devices. Review of Resident 4's Negotiated Service Plan (NSA, the facility's negotiated service agreement), dated /2023, showed the resident was admitted on /2022. Observation on 11/17/2023 at 1 :30 PM, showed Resident 4's bed had a triangular trapeze (device to assi.st in bed mobility) attached. In an interview on 11/17/2023 at 1:35 PM, Resident 4 stated they used the bed trapeze to assist in position changes while laying down in bed. Review of Resident 4's undated medical file showed no annual safety assessment for the bed trapeze. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 29 of 42 Licensee: PSL Associates, LLC 12/05/2023 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, North Point Village, Assisted Living & Memory Care 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 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; This requirement was not met as evidenced by: Based on observation, interview, and record review, the facility failed to complete an annual safety assessment for a medical device for 1 of 2 residents (Resident 4) sampled for safety assessments. This failure placed Resident 4 at risk of harm due to the uses of a medical device that was not assessed to be used safely. Findings included… Per WAC 388-78A-2090 (6)(e) Full Assessment Topics, a safety assessment must be completed for medical devices. Review of Resident 4's Negotiated Service Plan (NSA, the facility’s negotiated service agreement), dated /2023, showed the resident was admitted on /2022. Observation on 11/17/2023 at 1:30 PM, showed Resident 4’s bed had a triangular trapeze (device to assist in bed mobility) attached. In an interview on 11/17/2023 at 1:35 PM, Resident 4 stated they used the bed trapeze to assist in position changes while laying down in bed. Review of Resident 4’s undated medical file showed no annual safety assessment for the bed trapeze. This document was prepared by Residential Care Services for the Locator website. J..,G/ &.\I/ ,G\l,G~ WJ;:;LJ r: lilU !,'AX ~OSI N. Point Village ~032/ 045 Staternent of Deficiencies License#: 2479 · Compliance Determination# 3229tif Plan of Correction North Point VIiiage. Assisted Living & Memory care Completion Date Page 30 of 42 Licensee: PSL Associates, LLC 12/0S/2023 In an interview on 11/20/2023 at 10: 15 AM, Staff G, Regional Health and Wellness Specialist, stated a safety assessment for the bed trapeze had not been completed. Plan/Attestation Statement I here.by certify that I have reviewed this report and have. taken or will take active measures to correct this deficiency. By taking this action, North Point Village, Assisted Living & Mt/e2m/o1r=y C'1ar e is or. w ill 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. ~ ~ ... ..... .... / .~t.t/~1.. ... . ............. ..... ............... ........................ ................... .. Adt'"~a;-;(or Representative) Date WAC 38S..78A-2420 Record retention, (2} The assisted living facility may remove outdated information from the resident's active records that is ~o l~n~e~ sign~fica~t or ralejant to the reside~t's current a~sess~~ servi~~ and oa_re needs, and maintain ,t ,n an inactive rec:ord that must remain on the assisted living fac1hty prern1ses as lor1g as the resident remains in the assisted living facillty. (4) All active, inactive, and closed resident records must be available for review by department staff and other authorized persons. This requirement was not met as evidenced by: Based on interview end record r&view, the facility failed to ensure that resident records were maintained and were available for review for 3 of 13 residents (Reaidente 1, 5, and 9) sampled for record retention. This failure resulted in unaccounted for resident records and placed facility staff, residents, and their representatives at risk of not having access to resident records. Findings included ... In an interview on 11/16/2023 at 9:30 AM, Staff G, Ragionat Health and Wellness Specialist, and Staff A, Executive Director, stated that resident records that had been thinned (taken out of the chart) were in their records room. They further stated that the records were not organized and they were unable to locate several requested documents. <Resident 1 > Review of Resident 1's undated meorcal file showed the resident was admitted on This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 30 of 42 Licensee: PSL Associates, LLC 12/05/2023 In an interview on 11/20/2023 at 10:15 AM, Staff G, Regional Health and Wellness Specialist, stated a safety assessment for the bed trapeze had not been completed. 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, North Point Village, Assisted Living & Memory Care 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 WAC 388-78A-2420 Record retention. (2) The assisted living facility may remove outdated information from the resident's active records that is no longer significant or relevant to the resident's current assessed service and care needs, and maintain it in an inactive record that must remain on the assisted living facility premises as long as the resident remains in the assisted living facility. (4) All active, inactive, and closed resident records must be available for review by department staff and other authorized persons. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure that resident records were maintained and were available for review for 3 of 13 residents (Residents 1, 5, and 9) sampled for record retention. This failure resulted in unaccounted for resident records and placed facility staff, residents, and their representatives at risk of not having access to resident records. Findings included… In an interview on 11/16/2023 at 9:30 AM, Staff G, Regional Health and Wellness Specialist, and Staff A, Executive Director, stated that resident records that had been thinned (taken out of the chart) were in their records room. They further stated that the records were not organized and they were unable to locate several requested documents. <Resident 1> Review of Resident 1’s undated medical file showed the resident was admitted on This document was prepared by Residential Care Services for the Locator website. l.~/ ~VI ~v~,; WED 7: 40 FAX 509 N. Point Village ~033/045 Statement of Deficiencies License#: 2479 Compliance Determination# ii296 Plan of Correction North Point Village, Assisted Uvi11g & Memory Care Completion Data Page 31 of 42 Licensee: PSL Associates, LLC 12./05/2023 /2023. Further review of the file showed no documentation of a preadmission assessment. hi an interview on 11/16/2023 at 8:40 AM, Staff G stated that Resident 1 had a preadmission assessment completed, they "remembered doing It", Staff G further stated they looked and could not find it <Resident 5> Review of Resident 5's Negotiated Service Plan (NSP, the facilities titled negotiated service agreement), dated 10/21/2023. showed 1t was not signed by the resident, their representative, or the facility representative. In an interview on 11/17/2023 at 9:50 AM, Staff G stated that Resident S's NSP was signed each year by their legal representative. Staff G stated they knew it had been signed because Resident 5's representative must present the signed documents to the courts for approval for billing, Staff G stated they could not find Residents 5's signed NSP in the records room. <Resident 9> Review of R~sident 9's NSP, dated 08/13/2023. showed the plan did not contain signature(s) by the resident or their representative to indicate agreement to the plan. In an interview on 11/15/2023 at 11 :54 AM, Staff G stated that signed N$Ps would be in the resident binders. In an interview on 11/16/2023 at 2:20 PM, Staff G was asked about the lack of signature of agreement on the 08/13/2023 NSP. Staff G stated the NSP may have been "thinned'1 and was possibly in the tacility's archives. A signed 08/13/2023 NSP was not provided to the department by the conclusion of the inspection. 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, North Point Village, Assisted Living & Men1of¥ Care is or will be in compliance with this law and/ or regulation on 1/1/"k'f . (Date) In addition, I will implement a system to monitor and ensure continued compliance with this requirement. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 31 of 42 Licensee: PSL Associates, LLC 12/05/2023 /2023. Further review of the file showed no documentation of a preadmission assessment. In an interview on 11/16/2023 at 8:40 AM, Staff G stated that Resident 1 had a preadmission assessment completed, they “remembered doing it”. Staff G further stated they looked and could not find it. <Resident 5> Review of Resident 5’s Negotiated Service Plan (NSP, the facilities titled negotiated service agreement), dated 10/21/2023, showed it was not signed by the resident, their representative, or the facility representative. In an interview on 11/17/2023 at 9:50 AM, Staff G stated that Resident 5’s NSP was signed each year by their legal representative. Staff G stated they knew it had been signed because Resident 5’s representative must present the signed documents to the courts for approval for billing. Staff G stated they could not find Residents 5’s signed NSP in the records room. <Resident 9> Review of Resident 9’s NSP, dated 08/13/2023, showed the plan did not contain signature(s) by the resident or their representative to indicate agreement to the plan. In an interview on 11/15/2023 at 11:54 AM, Staff G stated that signed NSPs would be in the resident binders. In an interview on 11/16/2023 at 2:20 PM, Staff G was asked about the lack of signature of agreement on the 08/13/2023 NSP. Staff G stated the NSP may have been “thinned” and was possibly in the facility’s archives. A signed 08/13/2023 NSP was not provided to the department by the conclusion of the inspection. 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, North Point Village, Assisted Living & Memory Care 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. This document was prepared by Residential Care Services for the Locator website. 121201202, WED 7: 40 FAX 5H N. Point Village ~034/045 St-aternent of Deficiencies License#: 2479 Compliance Determlr,ation # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Data Paga 32 of 42 Licensee: PSL Associates, LLC: 12/05/2023 13/Jf ltY oafe· WAC 388~78A-2950 Water supply. The assisted living facility must: (6) Provide all s1n1<.s in resident rooms, toilet rooms and bathrooms, and bathing fixtures used by residents with hot water between 105 F and 120 Fat all times; and · This requirement was not met as evidenced by'. Based on observation and interview, the facility tailed to .ensure water accessible and used by residents measured between 105 degrees and 120 degrees Fahrenheit. This failure placed residents at risk for discomfort, burns and injury. Findings inclwded,_. OLJring the erwironmental tour on 11/14/2023. from 9:10 AM to 11:30 AM, and from 12:30 PM to 3:00 PM, accompanied by Staff H. Maintenance Director, the following was observed: <Main assisted living facility building> 9:58 AM 1st floor, south side laundry room sink water temperature measured 120.9 Fahrenheit (F)_ 10:05 AM 2nd floor, south side laundry room sink water temperature measured 122.0 F. 10:15 AM 2nd floor bathroom sink, near room 207, water temperature measured 123.6 F. 10:27 AM 2nd floor activity room sink water temperature measured 122.8 F. 10:46 AM 3rd floor restroom sink, near room 3·12. water temperature measured 123.6 F. 10:53 AM 3rd floor west side laundry room sink water temperature measured 121. 1 F. 10:56 AM. 4th floor laundry room sink, near room 422, water temperature measured 121.2 F. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 32 of 42 Licensee: PSL Associates, LLC 12/05/2023 Administrator (or Representative) Date WAC 388-78A-2950 Water supply. The assisted living facility must: (6) Provide all sinks in resident rooms, toilet rooms and bathrooms, and bathing fixtures used by residents with hot water between 105 F and 120 F at all times; and This requirement was not met as evidenced by: Based on observation and interview, the facility failed to ensure water accessible and used by residents measured between 105 degrees and 120 degrees Fahrenheit. This failure placed residents at risk for discomfort, burns and injury. Findings included… During the environmental tour on 11/14/2023, from 9:10 AM to 11:30 AM, and from 12:30 PM to 3:00 PM, accompanied by Staff H, Maintenance Director, the following was observed: <Main assisted living facility building> 9:58 AM 1st floor, south side laundry room sink water temperature measured 120.9 Fahrenheit (F). 10:05 AM 2nd floor, south side laundry room sink water temperature measured 122.0 F. 10:15 AM 2nd floor bathroom sink, near room 207, water temperature measured 123.6 F. 10:27 AM 2nd floor activity room sink water temperature measured 122.8 F. 10:45 AM 3rd floor restroom sink, near room 312, water temperature measured 123.6 F. 10:53 AM 3rd floor west side laundry room sink water temperature measured 121.1 F. 10:56 AM, 4th floor laundry room sink, near room 422, water temperature measured 121.2 F. This document was prepared by Residential Care Services for the Locator website. 12/20/ZOZJ WED 7i41 FAX 50~ N. Point Village IZJ035/045 St-atemenl of Deficiencies License#: 2479 Cornplianc:e Determination# 32296 Plan of Correction North Point Villaga. Assisted Living & Memory Care Completion Date Page 33 of 42 Licensee: PSL Associates, LLC 12/05/2023 11 :00 AM. 4th floor bathroom sink water temperature measured 123.6 F. <Building A> 2:05 PM - Bathroom across from room K, water temperature read 134.2 F. <Building B> 2;20 PM - Shower room across from room H, sink water temperatL1re measured 103.6°F. 2:22 PM - Restroom near room J, sink water temperature measured 101. 4 F. <Building C> 2:43 PM - Shower room near room H. sink water temperature measured 122 F 2:45 PM - Restroom across from room L, sink water temperature measured 121.6 F. During the environmental inspection on 11/17/2023, from 11:22 AM to 11:46 AM. the following was observed: <:Main assisted living facility building> 11 :22 AM 1st floor bathroom near the mailbox, sink water temperature measured 121.6 F. 11 :26 AM 2nd floor laundry room (North side), sink water temperature measured 120.9 F. 11 :31 AM 2nd floor activity room sink water temperature measured 120.1 F, 11 :32 AM 2nd ffoor bathroom sink water temperature measured 124.5 F. 11 :35 AM 2nd floor laundry room near room 220, sink water temperature measured 120.9 F. 11 ;40 AM 3rd floor bathroom by room 312, sink water temperature measured 124.8 F. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 33 of 42 Licensee: PSL Associates, LLC 12/05/2023 11:00 AM, 4th floor bathroom sink water temperature measured 123.6 F. <Building A> 2:05 PM – Bathroom across from room K, water temperature read 134.2 F. <Building B> 2:20 PM – Shower room across from room H, sink water temperature measured 103.6°F. 2:22 PM – Restroom near room J, sink water temperature measured 101. 4 F. <Building C> 2:43 PM – Shower room near room H, sink water temperature measured 122 F. 2:45 PM – Restroom across from room L, sink water temperature measured 121.6 F. During the environmental inspection on 11/17/2023, from 11:22 AM to 11:46 AM, the following was observed: <Main assisted living facility building> 11:22 AM 1st floor bathroom near the mailbox, sink water temperature measured 121.6 F. 11:26 AM 2nd floor laundry room (North side), sink water temperature measured 120.9 F. 11:31 AM 2nd floor activity room sink water temperature measured 120.1 F. 11:32 AM 2nd floor bathroom sink water temperature measured 124.5 F. 11:35 AM 2nd floor laundry room near room 220, sink water temperature measured 120.9 F. 11:40 AM 3rd floor bathroom by room 312, sink water temperature measured 124.8 F. This document was prepared by Residential Care Services for the Locator website. , l'I.ZtlZJ lll:'tt:a.1 ..... .,v., n . .t'Ol.nt Village IZJ036/045 of St-stement Deficiencies License#: 2479 Compliance Determination# 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 34 of 4.2 Licensee: PSL Associates, LLC 12/05/2023 1 ·1 :46 AM 4th floor bathroom near room 412, sink water temperature measured 124.5 F. During the environmental inspection on 11/20/2023. from 9:09 AM to 10:28 AM, the following was observed in resident rooms: Room 412: Kitchen sink water temperature measured 122.5 F. Room 304: Kitchen sink water temperature measured 122.7 F. Bathroom sink temperature mea5ured 123.6 F. Room 311: Kitchen sink water temperature measured 124.'I F. Room 212: Kitchen sink w~ter temperature measured 125.4 F. Bathroom sink water temperature measured 125.2 F. Room 207: Kitchen sink water temperature measured 124.3 F. Bathroom sink water temperatllre measured 123.8 F. o Room 104: Kitchen sink water temperature measured 123. F. Bathroom sink water temperature measured 124.1 F. Room 108: Kitchen Sink water temperature measured 123.9 F. Bathroom sink water temperature measured 125.4 F. In an interview on 11/17/2023 at 11:55 AM, Staff H stated the plumber found an issue in the A, B, and C buildings. Observation on 11/17/2023 at 1: 45 PM, in room 305, after running hot water for 3 minutes, the sink tempetature measured 87.0 F. · 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, North Point Village, Assisted Living & M.e."9,o,r ~ Care is or will be in compliance with this law and I or regulation on (Date) t. L7 L -z ~ . In addition. I will implement a system to monitor and ensure continued compliance with this requirement. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 34 of 42 Licensee: PSL Associates, LLC 12/05/2023 11:46 AM 4th floor bathroom near room 412, sink water temperature measured 124.5 F. During the environmental inspection on 11/20/2023, from 9:09 AM to 10:28 AM, the following was observed in resident rooms: Room 412: Kitchen sink water temperature measured 122.5 F. Room 304: Kitchen sink water temperature measured 122.7 F. Bathroom sink temperature measured 123.6 F. Room 311: Kitchen sink water temperature measured 124.1 F. Room 212: Kitchen sink water temperature measured 125.4 F. Bathroom sink water temperature measured 125.2 F. Room 207: Kitchen sink water temperature measured 124.3 F. Bathroom sink water temperature measured 123.8 F. Room 104: Kitchen sink water temperature measured 123.0 F. Bathroom sink water temperature measured 124.1 F. Room 108: Kitchen sink water temperature measured 123.9 F. Bathroom sink water temperature measured 125.4 F. In an interview on 11/17/2023 at 11:55 AM, Staff H stated the plumber found an issue in the A, B, and C buildings. Observation on 11/17/2023 at 1:45 PM, in room 305, after running hot water for 3 minutes, the sink temperature measured 87.0 F. 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, North Point Village, Assisted Living & Memory Care 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. This document was prepared by Residential Care Services for the Locator website. . M.2023 Hi:4t::>~ ..... .,v., n . .t'Ol.nt Village IZJ037 /045 St-aternent of Deficiencies License#: 2470 Cornpfiance Determination# 3-2296 Plan of Correction North Point Village, Assisted living & Mernory care Cornpletion Oate Page 35 of 42 licensee: PSL Associates, LLC 12105/2023 ~ .. .. ... Administrator (or Representative) WAC 388~78A-24701 Background checks Employment Nondisqualifying information. { 1) If the background check results 11how that an employee or prospective employee has a criminal conviction or pending charge for a crime that is not a disqualifying crime under chapter 388-113 WAC. then the assisted living facility must determine whether the person has the character, competence and suitability to work with vulnerable adults in long~term care. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to complete a character, competence, and suitability review for 2 of 6 sampled staff (Staff A and F) with a non~disqualifying crime. This failure placed res·idents at risk of receiving care and services from potentially disqualified staff. Review of Staff A's, Executive Director, undated personnel file showed they were hired on 08/21/2023, Review of Staff A's background check, dated 08/23/2023, showed their record contained information that required a character, competence, and suitability (CC&S) review by the facility. Further review showed Staff A's personnel file did not contain a CC&S review. Review of Staff F's, Assisted Living Med Aide, undated personnel file showed they were hired on 01/28/2021. Review of Staff F1s backgrollnd check, dated 02/08/2023, showed their record contained information that required a CC&S review by the facility. Further revf ew showed Staff F's personnel file did not contain a CC&S review. In an interview on 11/21/2023 at 10:25 AM, Staff P, Business Office Manager, confirmed that Staff A and F required a CC&S review, but it had not been completed. Pran/Attestation Statement I her~by certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, North Point Village, Assisted Living & M&m.P.ry pare is or will be in compliance with this law and I or regulation on IL? Lkvf . (Date) , l In addition, I will implement a system to monitor and .ensure continued compliance with this requirement. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 35 of 42 Licensee: PSL Associates, LLC 12/05/2023 Administrator (or Representative) Date WAC 388-78A-24701 Background checks Employment Nondisqualifying information. (1) If the background check results show that an employee or prospective employee has a criminal conviction or pending charge for a crime that is not a disqualifying crime under chapter 388-113 WAC, then the assisted living facility must determine whether the person has the character, competence and suitability to work with vulnerable adults in long-term care. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to complete a character, competence, and suitability review for 2 of 6 sampled staff (Staff A and F) with a non-disqualifying crime. This failure placed residents at risk of receiving care and services from potentially disqualified staff. Review of Staff A’s, Executive Director, undated personnel file showed they were hired on 08/21/2023. Review of Staff A’s background check, dated 08/23/2023, showed their record contained information that required a character, competence, and suitability (CC&S) review by the facility. Further review showed Staff A’s personnel file did not contain a CC&S review. Review of Staff F’s, Assisted Living Med Aide, undated personnel file showed they were hired on 01/28/2021. Review of Staff F’s background check, dated 02/08/2023, showed their record contained information that required a CC&S review by the facility. Further review showed Staff F’s personnel file did not contain a CC&S review. In an interview on 11/21/2023 at 10:25 AM, Staff P, Business Office Manager, confirmed that Staff A and F required a CC&S review, but it had not been completed. 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, North Point Village, Assisted Living & Memory Care 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. This document was prepared by Residential Care Services for the Locator website. n. ~oint VIiiage ~038/045 Statement of Deficiencies License#: 2479 Compliance Determination# 3229~f Plan of Corr8ction North Polnt Village, Assisted Living & Memory Care completion Date Page 36 of 4.2 Licensee: PSL Associates, LLC 12/05/2023 I 2-J 7,/- ;.~/ Date WAC 388-78A-2450 Staff. (3) The assisted living facility must: (d) Maintain the following documentation on the assisted living facility premises, during employment, and at least two years following termination of employment (i) Staff orientatio11 and training or certification pertinent to duties. including, but not limited to: (A) Training required by chapter 388-112A WAC: This requirement was not met as evidenced by: Based on interview and record r9'1/iew: the facility failed to maintain staff records for 5 of 6 sampled staff (Staff B, C, 0, E, and F). This failure resulted In a lack of verification of staff records and placed residents at risk of receiVing care and services by unciualified staff. Findings included ... Review of the facility's Disclosure of Services, dated 03/2017, showed the facility provided cara to residents with and diagnosis. <Staff B> Review ot Staff B's, Memory Care Coordinator, personnel file showed no documentation of the mental health and dementia specially training. <Staff C> Review of Staff C's, Housekeeper, personnel file showed no documentation of a facility orientation. <Staff D> Review of Staff O's, Memory Care Med Aide, personnel file showed no documentation of a facility orientation or a food handlers· card. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 36 of 42 Licensee: PSL Associates, LLC 12/05/2023 Administrator (or Representative) Date WAC 388-78A-2450 Staff. (3) The assisted living facility must: (d) Maintain the following documentation on the assisted living facility premises, during employment, and at least two years following termination of employment: (i) Staff orientation and training or certification pertinent to duties, including, but not limited to: (A) Training required by chapter 388-112A WAC; This requirement was not met as evidenced by: Based on interview and record review, the facility failed to maintain staff records for 5 of 6 sampled staff (Staff B, C, D, E, and F). This failure resulted in a lack of verification of staff records and placed residents at risk of receiving care and services by unqualified staff. Findings included… Review of the facility’s Disclosure of Services, dated 03/2017, showed the facility provided care to residents with and diagnosis. <Staff B> Review of Staff B’s, Memory Care Coordinator, personnel file showed no documentation of the mental health and dementia specialty training. <Staff C> Review of Staff C’s, Housekeeper, personnel file showed no documentation of a facility orientation. <Staff D> Review of Staff D’s, Memory Care Med Aide, personnel file showed no documentation of a facility orientation or a food handlers’ card. This document was prepared by Residential Care Services for the Locator website. l. l'I.LUL\I 10:"lr ;,KJ • • - - • ,.,...,, :.J\I~ N. .l'Ol.nt Village ij039/045 Statement of Deficiencies Lice11se #: 2479 Compliance Determinetion # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 37 of 4.2 Licensee: PSL Assoolales, LLC 12/05/2023 Observation on 11/15/2023 at 12:25 PM, showed Staff D prepared lunches for the residents in building B. <Staff E::,. Review of Staff E's, Assisted Living Med Aide. personnel file showed no documentation of mental health specialty training. <Staff F> Review of Staff F''s, Assisted Living Med Aide. personnel file showed no documentation of mental health and dementia specialty training. In an interview on 11/21/2023 at 9:30AM, Staff P, Business Office Manager, stated that Staff C and D completed the facility orientation. but they could not locate the records. In an interview on 11/21/2023 at 10:30 AM. Staff P stated that Staff F completed the specialty training, but they did not keep the record. In an interview on 11/21/2023 at 11 :50 AM, Staff P stated thal Staff B was a re-hire, ancl they were unable to locate the copies of their mental health and dementia specialty trainings. Staff P stated the employee records archive room was disorganized and it was difficult to locate records tor employees. In an interview on 11/21/2023 at 11:55 AM, Staff G, Regional Health and Wellness Specialist, stated that Staff B had completed the specialty training at their previous employer, but they did not have a copy of the certificate. 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. North Point Village, Assisted Living & Mem9ry Care Is or will be in compliance with this law and I or regulation on (Date) J L) J e'l . r,7 In addition, J will implement a system to monitor and. ensure continued compliance witl1 this requirement. ~ - ......... 1.z.-/11/2,,'1 ..... _... ........ . ............. .,.-- ................. ... ···--•·····-···•···· Administrator (or Representative) Date This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 37 of 42 Licensee: PSL Associates, LLC 12/05/2023 Observation on 11/15/2023 at 12:25 PM, showed Staff D prepared lunches for the residents in building B. <Staff E> Review of Staff E’s, Assisted Living Med Aide, personnel file showed no documentation of mental health specialty training. <Staff F> Review of Staff F’s, Assisted Living Med Aide, personnel file showed no documentation of mental health and dementia specialty training. In an interview on 11/21/2023 at 9:30AM, Staff P, Business Office Manager, stated that Staff C and D completed the facility orientation, but they could not locate the records. In an interview on 11/21/2023 at 10:30 AM, Staff P stated that Staff F completed the specialty training, but they did not keep the record. In an interview on 11/21/2023 at 11:50 AM, Staff P stated that Staff B was a re-hire, and they were unable to locate the copies of their mental health and dementia specialty trainings. Staff P stated the employee records archive room was disorganized and it was difficult to locate records for employees. In an interview on 11/21/2023 at 11:55 AM, Staff G, Regional Health and Wellness Specialist, stated that Staff B had completed the specialty training at their previous employer, but they did not have a copy of the certificate. 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, North Point Village, Assisted Living & Memory Care 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 This document was prepared by Residential Care Services for the Locator website. 2, 14.2023 16:4/;btf ~040/045 st-atement of Deficiencies License#: 2479 compliance Detenni11atio11 # 32296 Plan of Correction North Point VIiiage, Assisted Living & Memory Care completion Date Page 38 of 42 Licensee; PSL Assocl.ales, LLC 12/05/2023 WAC 388-78A•2474 Training and home care aide certification requirement$. (2) The assisted living facility must ensure all assisted living facility administrators, or their designees, and caregivers hired on or after January 7, 2012 meet the long-term care worker training requirements of chapter 388-112A WAC, including but not limited to: (a) Orientation and safety; This requfrement was not met as evidenced by; Based on interview and record review, the facility failed to ensure u,at staff completed the facility orientation training before caring for residents for 4 of 6 sampled staff (Staff A. B, E, and F). This failure placed residents at risk of receiving care and services from untrained personnel. Findings included ... Per WAC 388-112A·0200, long term care workers are required to complete facility orientatior"l training before having routine interactions with residents. Review of Staff A's, Executive Director, personnel file showed they were hired on 08/21/2023. Further review of the file showed no documentation of a facility orientation . Review of Staff B's, Memory Care Coordinator, personnel file showed they were hired on 01/17/2022. Further review of the fife showed no documentation of a facility orientation. Review of Staff E's, Assisted Living Med Aide, personnel file showed they ware hired on 12/11/2020. Further review of the file showed no documentation of a facility orientation. Review of Staff F's, Assisted Living Med Aide, personnel file showed t11ey were hired on 01/28/2021. Further review of the file showed no documentation of a fac!lity orientation. In an interview on 11/21/2023 at 9:30 AM, Staff P. Business Office Manager. stated that Staff A did not complete the facility orientation. In an interview on 11/21/2023 at 10:30 AM, Staff P stated that Staff F did not complete the facility orientation. In an interview on 11/21/2023 at 11:50 AM, Stafr P stated that Staff Band Staff E did not complete the facility orientation. Plan/Attestation Statement This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 38 of 42 Licensee: PSL Associates, LLC 12/05/2023 WAC 388-78A-2474 Training and home care aide certification requirements. (2) The assisted living facility must ensure all assisted living facility administrators, or their designees, and caregivers hired on or after January 7, 2012 meet the long-term care worker training requirements of chapter 388-112A WAC, including but not limited to: (a) Orientation and safety; This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure that staff completed the facility orientation training before caring for residents for 4 of 6 sampled staff (Staff A, B, E, and F). This failure placed residents at risk of receiving care and services from untrained personnel. Findings included… Per WAC 388-112A-0200, long term care workers are required to complete facility orientation training before having routine interactions with residents. Review of Staff A’s, Executive Director, personnel file showed they were hired on 08/21/2023. Further review of the file showed no documentation of a facility orientation . Review of Staff B’s, Memory Care Coordinator, personnel file showed they were hired on 01/17/2022. Further review of the file showed no documentation of a facility orientation. Review of Staff E’s, Assisted Living Med Aide, personnel file showed they were hired on 12/11/2020. Further review of the file showed no documentation of a facility orientation. Review of Staff F’s, Assisted Living Med Aide, personnel file showed they were hired on 01/28/2021. Further review of the file showed no documentation of a facility orientation. In an interview on 11/21/2023 at 9:30 AM, Staff P, Business Office Manager, stated that Staff A did not complete the facility orientation. In an interview on 11/21/2023 at 10:30 AM, Staff P stated that Staff F did not complete the facility orientation. In an interview on 11/21/2023 at 11:50 AM, Staff P stated that Staff B and Staff E did not complete the facility orientation. Plan/Attestation Statement This document was prepared by Residential Care Services for the Locator website. l. H.i1'1. '.J'J., l'i. .E'Olnt VIiiage IL• 1, I"'" LU IV• I I • WV i041/ 045 St-eiement of Defioiencies License#: 2479 Compliance Oetenninauon # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Data Page 39 of 42 licensee: PSL Associates, LLC 12.105/2023 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, North Point Village, Assisted Living & M~s or w / i 7 ll b/e zin rco mpliance wlth this law and / or regulation on (Date} - / In addition, I wlll implement a system to monitor and ensure contlnued compliance with this requirement. ~ .. /...1/(t/~.~ -...... '" ...... :-:-: . A ..... d . , . m .... ~~~ .. ~ .. ~ . r .... .......... , .......... ... .............................. ... .. Representative) Date WAC 388-78A-2484 Tuberculosis Two step skin testing. Unless the staff person meets the requirement tor having no skin testing or only one test the assisted living facility choosing 1 to do skin testing. must ensure that each staff person has the following twoystep skin testing; (1) An initial skin test within three days of employment: and (2) A second test done one to three weeks after the first test. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure that staff were tested for tuberculosis within three days -of employment for 6 of 1 0 staff sampled for tuberculosis testing (Staff A, C, D, K. L, and N) and failed to ensure a second tuberculosis test was done within one to tt°Jree weeks after the first test for 4 of 10 staff sampled for tuberculosis testing (Staff D, K, L, and N) . This failure placed residents at risk of exposure to tuberculosis. Findings included ... <Staff A> Review of Staff A's, Executive Director, personnel file showed they were hired on 08/21/20.23. Ft.trther review showed Staff A's initial TB skin test was placed on 09/26/2023, 35 days after they were hired. <Staff C> Review of Staff C's, Housekeeper, personnel file showed they were hired on 09/04/2023. Further review showed Staff C's first step TB test was placed on 09/26/2023, 22 days aft.er they were hired. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 39 of 42 Licensee: PSL Associates, LLC 12/05/2023 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, North Point Village, Assisted Living & Memory Care 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 WAC 388-78A-2484 Tuberculosis Two step skin testing. Unless the staff person meets the requirement for having no skin testing or only one test, the assisted living facility choosing to do skin testing, must ensure that each staff person has the following two-step skin testing: (1) An initial skin test within three days of employment; and (2) A second test done one to three weeks after the first test. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure that staff were tested for tuberculosis within three days of employment for 6 of 10 staff sampled for tuberculosis testing (Staff A, C, D, K, L, and N) and failed to ensure a second tuberculosis test was done within one to three weeks after the first test for 4 of 10 staff sampled for tuberculosis testing (Staff D, K, L, and N) . This failure placed residents at risk of exposure to tuberculosis. Findings included… <Staff A> Review of Staff A’s, Executive Director, personnel file showed they were hired on 08/21/2023. Further review showed Staff A’s initial TB skin test was placed on 09/26/2023, 35 days after they were hired. <Staff C> Review of Staff C’s, Housekeeper, personnel file showed they were hired on 09/04/2023. Further review showed Staff C’s first step TB test was placed on 09/26/2023, 22 days after they were hired. This document was prepared by Residential Care Services for the Locator website. 12/20/2023 WED 7i 43 FAX 509 N. Point Villa.ge Statement of Deficiencies License#: 2470 Compliance Determination# 32296 Plan of Correction North Point Village, Assisted Living &. Memory Care Completion Data Page 40 o( 42 L1censee: PSL Associates, LLC 12/05/2023 <Staff O> Review of Staff D's, Memory C~re Med Aide, personnel file showed they were hired on 09/1312023. Further review showed Staff C;s first step TB test was placed on 10/10/2023, 27 days after they were hired. The TB records showed that Staff D did not have a second TB skin test done. <Staff K> Review of the facility's undated staff list showed that Staff K, Mei•nory Care Partner, was hired on 07/2512023. Further review showed that Staff K's first step TB test was placed on 08/23/2023, 29 days after they were hired. The TB records showed that Staff K did not have a second TB sKin test done. <Staff L> Review of the facility's undated staff list showed that Staff L, Memory Care Partner, was hired on 09/26/2022. Further review showed that Staff L's first step TB test was placed on 08/26/2023, 335 days after they were hired. The TB records showed that Staff L did not have a second TB skin test done. <Staff N> Review of the facility's undated staff list showed that Staff N, Memory Care Partner, was hired on 07/25/2023. Further review showed that Staff N's first step TB test was placed on 10/10/2023, 77 days after they were hired. The TB records showed that Staff N did not have a second TB skin test done. In an interview on 11/21/2023, at 10:25 AM, Staff P, Business Office Manager, confirmed that Staff D, K, L, and N did not have a second TB test done. Staff P stated the previous nurse did not complete TB testing as they were supposed to. Plan/Attestation Statement I hereby certify that I heve reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, North Point Village, Assisted Living & Mejory Care is or will be in compliance with this law and/ or regulation on (Date) I _2 / :Z. ~, . I • I In addition, I will implement a system to monitor and ensure continued compliance with this requirement. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 40 of 42 Licensee: PSL Associates, LLC 12/05/2023 <Staff D> Review of Staff D’s, Memory Care Med Aide, personnel file showed they were hired on 09/13/2023. Further review showed Staff C’s first step TB test was placed on 10/10/2023, 27 days after they were hired. The TB records showed that Staff D did not have a second TB skin test done. <Staff K> Review of the facility’s undated staff list showed that Staff K, Memory Care Partner, was hired on 07/25/2023. Further review showed that Staff K’s first step TB test was placed on 08/23/2023, 29 days after they were hired. The TB records showed that Staff K did not have a second TB skin test done. <Staff L> Review of the facility’s undated staff list showed that Staff L, Memory Care Partner, was hired on 09/26/2022. Further review showed that Staff L’s first step TB test was placed on 08/26/2023, 335 days after they were hired. The TB records showed that Staff L did not have a second TB skin test done. <Staff N> Review of the facility’s undated staff list showed that Staff N, Memory Care Partner, was hired on 07/25/2023. Further review showed that Staff N’s first step TB test was placed on 10/10/2023, 77 days after they were hired. The TB records showed that Staff N did not have a second TB skin test done. In an interview on 11/21/2023, at 10:25 AM, Staff P, Business Office Manager, confirmed that Staff D, K, L, and N did not have a second TB test done. Staff P stated the previous nurse did not complete TB testing as they were supposed to. 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, North Point Village, Assisted Living & Memory Care 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. This document was prepared by Residential Care Services for the Locator website. 12/ 20/ 2023 WED 7i 43 FAX 509 N. Point Villa.ge Statement of Deficiencies License#: 2479 CorT'lpliance Determination# 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 41 of 42 Licensee: PSL Associates, LLC 12/05/2023 Adm~ R8J)iesentative) · · · WAC 388-78A~2730 Licensee's responsibilities. (1) The assisted living facility licensee is responsible for: (b) Complying at all times with 1he requirements of this chapter, chapter 18.20 RCW, and other applicable laws and rules; and This requirement was not met as evtdenced by: Based on interview and record review, the facility failed to ensure staff had completed respirator fit tasting prior to providing car& and setvices to residents for 5 of 8 sampled staff (Staff 8, C, D, E and F). This failure placed residents and staff at risk of respiratory infection should an outbreak occur. Findings included ... Per WAC 298-842•15005 the facility must conduct tit testing before employees are assigned duties that may require the use of respirators. Record review of a Department of Social and Health Services provider letter dated 09/14/2023, showed that employers in long term care settings were responsible to "follow regulations pertaining to respiratory protection". <Staff 8> Review of Staff B;s, Memory Care Coordinator, undated personnel file, showed no documentation of fit testing records. Observation on 11/17/2023 at 1: 15 PM showed Staff 6 in the memory care building. <Staff C> Review of Staff C's, Housekeeper, undated personnel file, showed no documentation of fit testing records. <Staff D> This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 41 of 42 Licensee: PSL Associates, LLC 12/05/2023 Administrator (or Representative) Date WAC 388-78A-2730 Licensee's responsibilities. (1) The assisted living facility licensee is responsible for: (b) Complying at all times with the requirements of this chapter, chapter 18.20 RCW, and other applicable laws and rules; and This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure staff had completed respirator fit testing prior to providing care and services to residents for 5 of 6 sampled staff (Staff B, C, D, E and F). This failure placed residents and staff at risk of respiratory infection should an outbreak occur. Findings included… Per WAC 296-842-15005 the facility must conduct fit testing before employees are assigned duties that may require the use of respirators. Record review of a Department of Social and Health Services provider letter dated 09/14/2023, showed that employers in long term care settings were responsible to “follow regulations pertaining to respiratory protection”. <Staff B> Review of Staff B’s, Memory Care Coordinator, undated personnel file, showed no documentation of fit testing records. Observation on 11/17/2023 at 1:15 PM showed Staff B in the memory care building. <Staff C> Review of Staff C’s, Housekeeper, undated personnel file, showed no documentation of fit testing records. <Staff D> This document was prepared by Residential Care Services for the Locator website. 12/20/2023 WED 7: 43 FAX 509 N. Point Village Statement of Deficiencies· · ··· Lice1,se·#: 2479 Compliance Determination # 3229ff a. Plan of Correction North Point Village, Assisted Living Memory Care Completion Date Page 42 of 42 Licensee: PSL Associates, LLC 12/05/2023 Review of Staff D's, Memory Care Med Aide, undated personnel file. showed no documentation of fit testing records. <Staff E> Review of Staff E's. Assisted Living Med Aide. undated personnel file, showed no documentation of fit testing records. <Staff F> Review of Staff F's, Assisted Living Med Aide, undated personnel file, showed no documentation of fit testing records. In an interview on 11/20/2023 at 11: 15 AM, Staff F stated they were assigned to pass medications to residents in the main assisted living building that day. Staff F further stated that in the past they have been assigned to pass meoicetions to residents in the memcry care buildings as well. In an interview on 11/21/2023 at 12:15 PM. Staff P, Business Office Manager, stated that it had been "quite a while'' since fit testing had been done for employees. During tl1is interview Staff G. Regional Health and Wellness Specialist, further stated the facility was not up to date with fit testing. 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, North Point Village, Assisted Living & Merpory: Care is or will be in compliance with this law and/ or regulation on 4L2/.2---tf . . (Date) In addition, I will implement a system to monitor and ensure continued compliance with this requirement. ....i ~/1r/2 J .................... Ad inistrator (or Representative) Date This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2479 Compliance Determination # 32296 Plan of Correction North Point Village, Assisted Living & Memory Care Completion Date Page 42 of 42 Licensee: PSL Associates, LLC 12/05/2023 Review of Staff D’s, Memory Care Med Aide, undated personnel file, showed no documentation of fit testing records. <Staff E> Review of Staff E’s, Assisted Living Med Aide, undated personnel file, showed no documentation of fit testing records. <Staff F> Review of Staff F’s, Assisted Living Med Aide, undated personnel file, showed no documentation of fit testing records. In an interview on 11/20/2023 at 11:15 AM, Staff F stated they were assigned to pass medications to residents in the main assisted living building that day. Staff F further stated that in the past they have been assigned to pass medications to residents in the memory care buildings as well. In an interview on 11/21/2023 at 12:15 PM, Staff P, Business Office Manager, stated that it had been “quite a while” since fit testing had been done for employees. During this interview Staff G, Regional Health and Wellness Specialist, further stated the facility was not up to date with fit testing. 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, North Point Village, Assisted Living & Memory Care 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 This document was prepared by Residential Care Services for the Locator website.

—: WA DSHS report: Investigations (11/2023) —: WA DSHS report: Investigations (11/2023)