Willow Grove.

This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: Willow Grove Provider Type: Assisted Living Facility License/Cert.#: 2399 Compliance Determination #: 60742 Intake ID: 182103 Investigator: Veronica Jackson Region/Unit #: RCS Region 1 / Unit B Investigation Date(s): 06/06/2025 through 06/10/2025 Complainant Contact Date(s): Allegation(s): 1. Food was undercooked, no handwashing. 2. Administration ignored residents. 3. Residents complained about night shift staff giving rough care. 4. Identified staff worked under the influence of drugs. 5. Identified staff administered insulin incorrectly. 6. Infection control, staff reused diabetic needles and finger poke supplies. Investigation Methods: Sample: Total residents: 19 Resident sample size: 6 Closed records sample size: 0 Observations: Food service, meal prep and hand hygiene in kitchen Medication cart inspected Insulin administration Hand hygiene practices adequate Interviews: Administrator Executive Assistant Staff/Med Techs (3) Identified Residents Sample Residents Record Reviews: Sample Residents Records Identified Resident Records Facility Policy's Staff List Resident Characteristics Roster Staff certifications for home health aide Staff training for nurse delegation core and diabetes training Investigation Summary: 1. Lunch prep service observed with good hand hygiene, sample residents and staff who were also served meals at the facility stated no issues with undercooked foods and that the food was good. No failed practice identified. 2. Residents stated that they received good care and had no complaints. This document was prepared by Residential Care Services for the Locator website. Observations of staff to resident interactions were responsive and respectful. No failed practice identified. 3. Identified resident, their roommate, and sampled residents were observed, interviewed and denied any abuse allegations. One identified resident's social worker visited monthly and they denied any concerns with care. No failed practice identified. 4. Allegations that one staff worked under the influence of marijuana. Observation of identified staff and interviews of facility staff showed no signs of substance use. No failed practice identified. 5. Sampled residents and staff interviews showed that staff had completed nurse delegated tasks that were not supervised by a registered nurse delegator. Facility provided education and implemented corrective plan before the conclusion of the department's visit. Consultation written for 388-78a-2320 (1)(a)(b). 6. Medication cart was thoroughly inspected with no used needles or used finger poke supplies observed. New needle and finger stick supplies were easily accessible. Sharps container was easily accessible. Hand hygiene practices observed. No failed practice identified. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A This document was prepared by Residential Care Services for the Locator website.

This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. 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 #: 2399 Compliance Determination # 67299 Plan of Correction Willow Grove Completion Date Page 1 of 10 Licensee: Legacy1864, LLC 10/27/2025 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 the unannounced on-site full inspection on 10/20/2025, 10/21/2025, 10/22/2025 and 10/23/2025 of: Willow Grove 1620 E Mead St Spokane, WA 99218 The following sample was selected for review during the unannounced on-site visit: 5 of 23 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Patricia Eddy, Community 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 #: 2399 Compliance Determination # 67299 Plan of Correction Willow Grove Completion Date Page 2 of 10 Licensee: Legacy1864, LLC 10/27/2025 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-2350 Coordination of health care services. (1) The assisted living facility must coordinate services with external health care providers to meet the residents' needs, consistent with the resident's negotiated service agreement. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure health care services were coordinated for 1 of 1 resident (Resident 1). This failure resulted in missed appointments and placed the resident at risk for health complications due to not receiving follow-up treatment as ordered by the resident’s physician. Findings included… Review of Resident 1’s Face Sheet showed they were admitted to the facility on /2021. Review of Resident 1’s Negotiated Care Plan, dated /2025, showed that the resident had a diagnosis of . Further review showed that the facility was responsible for setting up appointments, arranging transportation, and that the resident required staff to schedule all appointments due to their developmental delays. Review of an After Visit Summary, dated 08/23/2024, showed that Resident 1 was seen at the emergency room for seizure-like activity (sudden, temporary disruption in brain activity that can cause involuntary movements, altered consciousness, or other neurological symptoms). Further review showed that a referral was sent to an epilepsy (chronic brain disorder characterized by recurrent, unprovoked seizures) center for a This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2399 Compliance Determination # 67299 Plan of Correction Willow Grove Completion Date Page 3 of 10 Licensee: Legacy1864, LLC 10/27/2025 follow-up appointment. Review of a letter from the epilepsy center, dated 10/29/2024, showed that Resident 1 was scheduled for appointments on 11/12/2024 at 09:45 AM and 12/12/2024 at 7:30 AM. Review of a letter from the epilepsy center, dated 06/27/2025, showed that Resident 1 did not attend scheduled appointments on 11/12/2024 and 06/27/2025, and that, due to the failure of keeping scheduled appointments, they would no longer provide neurological care (care of the nervous system to include the brain, spinal cord, and nerves) to the resident. In an interview on 10/22/2025 at 02:20 PM, Staff A, Administrator stated they were aware that the 11/12/2024 appointment with the epilepsy center was missed. Staff A stated they rescheduled the appointment for 06/27/2025 and that appointment was also missed. Staff A further stated due to the missed appointments, the epilepsy center did not allow any further appointments to be scheduled. Staff A confirmed that they had not done any other follow-up. 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, Willow Grove 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-2240 Nonavailability of medications. When the assisted living facility has assumed responsibility for obtaining a resident's prescribed medications, the assisted living facility must obtain them in a correct and timely manner. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure medications were obtained in a timely manner to be available for administration for 1 of 5 residents (Resident 2). This failure resulted in missed medications and missed protein shakes, and placed the resident at risk of health complications. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2399 Compliance Determination # 67299 Plan of Correction Willow Grove Completion Date Page 4 of 10 Licensee: Legacy1864, LLC 10/27/2025 Findings included... Review of Resident 2’s assessment, dated 09/26/2025, showed that the resident had diagnoses of and and that the resident had a decreased appetite over the past few months. Further review showed that the facility provided medication assistance to the resident with instructions to coordinate medication delivery with the pharmacy, resident, or representative. Review of Resident 2’s prescription list, dated 10/08/2025, showed Ensure HP (high protein) vanilla liquid nutrition shake twice a day between meals to supplement protein and calorie intake, one tab of memantine twice a day for dementia, and one tab of trospium a day to improve bladder control. Review of Resident 2’s October 2025 Medication Administration Record (MAR) showed an order for memantine and trospium. The MAR showed that the memantine was not administered for a total of 16 doses on 10/10/2025, 10/11/2025, 10/12/2025, 10/13/2025, 10/14/2025, 10/15/2025, 10/16/2025, 10/17/2025, and 10/18/2025. The trospium showed as not administered for 10/01/2025 and was documented as ‘HOLD’ for the rest of the month of October. The Ensure shake was not documented on the MAR, which indicated that it was not provided. In an interview on 10/21/2025 at 1:20 PM, Staff B, Administrator Assistant, stated they had been waiting for Resident 2’s medications from the Veteran’s Affairs pharmacy. Staff B stated they entered ‘HOLD’ on the MAR “when it seems like it might be a long wait for the medication.” Staff B stated they did not know when they had last contacted the pharmacy or what the outcome was. Staff B further stated that they had no documentation regarding any communication with the pharmacy as to the whereabouts of the medication. In an interview on 10/22/2025 at 2:52 PM, Staff B stated that Resident 2’s family was supposed to provide the Ensure shakes and never brought them to the facility. Staff B stated they were unaware of what the facility had done to follow up on getting the shakes for the resident. Review of Resident 2’s progress notes showed documentation on10/10/2025, 10/14/2025, 10/15/2025, 10/17/2025, and 10/18/2025, during the time the facility was out of memantine, that the resident was exit seeking and was agitated. In an interview on 10/22/2025 at 3:33 PM, Staff D, Caregiver, reported the resident was incontinent every night and about ten times per week during the day. This is a recurring deficiency previously cited on 04/19/2024. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2399 Compliance Determination # 67299 Plan of Correction Willow Grove Completion Date Page 5 of 10 Licensee: Legacy1864, LLC 10/27/2025 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, Willow Grove 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-2140 Negotiated service agreement contents. The assisted living facility must develop, and document in the resident's record, the agreed upon plan to address and support each resident's assessed capabilities, needs and preferences, including the following: (1) The care and services necessary to meet the resident's needs, including: (d) The plan to provide necessary health support services, if provided by the assisted living facility; This requirement was not met as evidenced by: Based on interview and record review, the facility failed to update care needs related to skin integrity and insulin injections, in the negotiated service agreement for 2 of 5 residents (Resident 1 and 5). This failure placed the residents at risk of unmet care needs. Findings included… <Resident 1> Review of Resident 1’s assessment, dated /2025, showed that the resident had a diagnosis of and had dry skin. Review of Resident 1’s Negotiated Care Plan, dated /2025, showed no documentation regarding skin monitoring. Review of Resident 1’s August 2025 Medication Administration Records (MARs) showed an order beginning on 02/25/2025 for ketoconazole (antifungal) cream to be applied topically to dry skin on the face once every three days. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2399 Compliance Determination # 67299 Plan of Correction Willow Grove Completion Date Page 6 of 10 Licensee: Legacy1864, LLC 10/27/2025 Review of Resident 1’s September 2025 and October 2025 MARs showed an order beginning on 09/11/2025 for ketoconazole shampoo to be applied as directed to scalp twice per week. In an interview on 10/22/2025 at 02:20 PM, Staff A, Administrator, stated that with Resident 1’s diagnosis, skin checks should have been in the care plan but were not. <Resident 5> Review of Resident 5’s Face Sheet showed that they were admitted to the facility on /2022 and had a diagnosis of Review of Resident 5’s Negotiated Care Plan, dated 04/15/2025, showed that the resident’s diabetes was controlled with oral medications and diet and that they did not take insulin (regulates blood sugar) injections. Review of Resident 5’s physicians orders, dated 10/13/2025, showed documentation that the resident started Lantus (insulin) injections on 09/14/2025. In an interview on 10/22/2025 at 3:50 PM, Staff B, Administrator Assistant, confirmed the insulin injections had not been addressed in the negotiated care plan. In an interview on 10/22/2025 at 4:25 PM, Staff A confirmed that the resident did have a change of condition and that the Lantus injections should have been updated on the negotiated care plan. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Willow Grove 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. Statement of Deficiencies License #: 2399 Compliance Determination # 67299 Plan of Correction Willow Grove Completion Date Page 7 of 10 Licensee: Legacy1864, LLC 10/27/2025 WAC 388-78A-2090 Full assessment topics. The assisted living facility must obtain sufficient information to be able to assess the capabilities, needs, and preferences for each resident, and must complete a full assessment addressing the following, within fourteen days of the resident's move-in date, unless extended by the department for good cause: (1) Individual's recent medical history, including, but not limited to: (a) A licensed medical or health professional's diagnosis, unless the resident objects for religious reasons; (b) Chronic, current, and potential skin conditions; or (c) Known allergies to foods or medications, or other considerations for providing care or services. (2) Currently necessary and contraindicated medications and treatments for the individual, including: (a) Any prescribed medications, and over-the-counter medications commonly taken by the individual, that the individual is able to independently self-administer, or safely and accurately direct others to administer to him/her; (b) Any prescribed medications, and over-the-counter medications commonly taken by the individual, that the individual is able to self-administer when he/she has the assistance of a caregiver; and (c) Any prescribed medications, and over-the-counter medications commonly taken by the individual, that the individual is not able to self-administer, and needs to have administered to him or her. (3) The individual's nursing needs when the individual requires the services of a nurse on the assisted living facility premises. (4) Individual's sensory abilities, including: (a) Vision; and (b) Hearing. (5) Individual's communication abilities, including: (a) Modes of expression; (b) Ability to make self understood; and (c) Ability to understand others. (6) Significant known behaviors or symptoms of the individual causing concern or requiring special care, including: (a) History of substance abuse; (b) History of harming self, others, or property; or (c) Other conditions that may require behavioral intervention strategies; (d) Individual's ability to leave the assisted living facility unsupervised; and This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2399 Compliance Determination # 67299 Plan of Correction Willow Grove Completion Date Page 8 of 10 Licensee: Legacy1864, LLC 10/27/2025 (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. (7) Individual's special needs, by evaluating available information, or if available information does not indicate the presence of special needs, selecting and using an appropriate tool, to determine the presence of symptoms consistent with, and implications for care and services of: (a) Mental illness, or needs for psychological or mental health services, except where protected by confidentiality laws; (b) Developmental disability; (c) Dementia. While screening a resident for dementia, the assisted living facility must: (i) Base any determination that the resident has short-term memory loss upon objective evidence; and (ii) Document the evidence in the resident's record. (d) Other conditions affecting cognition, such as traumatic brain injury. (8) Individual's level of personal care needs, including: (a) Ability to perform activities of daily living; (b) Medication management ability, including: (i) The individual's ability to obtain and appropriately use over-the-counter medications; and (ii) How the individual will obtain prescribed medications for use in the assisted living facility. (9) Individual's activities, typical daily routines, habits and service preferences. (10) Individual's personal identity and lifestyle, to the extent the individual is willing to share the information, and the manner in which they are expressed, including preferences regarding food, community contacts, hobbies, spiritual preferences, or other sources of pleasure and comfort. (11) Who has decision-making authority for the individual, including: (a) The presence of any advance directive, or other legal document that will establish a substitute decision maker in the future; (b) The presence of any legal document that establishes a current substitute decision maker; and (c) The scope of decision-making authority of any substitute decision maker. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to complete a full assessment within fourteen days of admission for 2 of 5 sampled residents (Resident 2 and 3). This This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2399 Compliance Determination # 67299 Plan of Correction Willow Grove Completion Date Page 9 of 10 Licensee: Legacy1864, LLC 10/27/2025 failure placed the residents at risk of unmet care needs related to not being assessed after they transitioned into the facility. Findings included… <Resident 2> Review of Resident 2’s undated medical chart showed they were admitted on /2025. Further review showed it did not contain a full assessment within 14 days of admission. <Resident 3> Review of Resident 3’s undated medical chart showed they were admitted on /2025. Further review showed it did not contain a full assessment within 14 days of admission. In an interview on 10/21/2025 at 11:15 AM, Staff B, Administrator Assistant, stated that they were not aware that the assessment was to be completed within 14 days. This is a recurring deficiency previously cited on 04/19/2024. 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, Willow Grove 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-2490 Specialized training for developmental disabilities. The assisted living facility must ensure completion of specialized training, consistent with chapter 388-112A WAC, to serve residents with developmental disabilities, whenever at least one of the residents in the assisted living facility has a developmental disability as defined in WAC 388- 823-0040 , that is the resident's primary special need. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2399 Compliance Determination # 67299 Plan of Correction Willow Grove Completion Date Page 10 of 10 Licensee: Legacy1864, LLC 10/27/2025 This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure that specialized training for developmental disabilities had been completed by 1 of 5 staff (Staff C). This failure placed residents at risk of unmet care needs by untrained staff. Findings included... Review of the facility’s Characteristic Roster showed that they had one resident with a primary diagnosis of . Review of Staff C’s, Caregiver, undated personnel file showed a hire date of 05/05/2025. Further review showed it did not contain certification for specialized training for developmental disabilities within 120 days of hire. In an interview on 10/23/2025 at 10:15 AM, Staff E, Director of Business, confirmed the facility did not have certification for specialized training for developmental disabilities for Staff C. 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, Willow Grove 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.

Statement of Deficiencies License #: 2399 Compliance Determination # 39648 Plan of Correction Willow Grove Completion Date Page 3 of 22 Licensee: Legacy1864, LLC 04/19/2024 agreement), dated 03/08/2024, showed that Resident 2 ate a normal diet and was on a fluid restriction. The NSA showed the resident's daily fluid intake needed to be 1500 ML or less (50 ounces). The NSA showed that care staff needed to measure the resident's fluid intake by ensuring the resident used a 24-ounce cup provided by the facility, and care staff were to only provide refills as needed. Review of Resident 2’s task administration records (TARs) for February 2024, March 2024, and April 2024, showed care instructions to “Log each 8oz of liquid given to resident throughout the day." Review of the February 2024 and March 2024 TARs showed a total of four fields (each represented 8 ounces) for staff to document the resident's fluid intake each day. Review of the April 2024 TARs showed a total of three fields (each represented 8 ounces) for staff to document the resident's fluid each day. Further review showed that care staff only documented the resident drank 8 ounces of liquid, six times during the month of February, 25 times during the month of March, and six times during the month of April, indicating that care staff were not documenting/monitoring the resident’s complete fluid intake. In an interview on 04/16/2024 at 11:40 AM Staff B, Director of Care, stated that Resident 2 used a measured cup (fill line) when drinking fluids. Staff B further stated that med techs were responsible to fill the cup and track the fluid intake. When asked how the med techs tracked the fluid intake, Staff B stated that it should be documented on the TARs. In an interview on 04/16/2024 at 11:46 AM, Staff B stated that there were paper fluid trackers kept on the med cart that staff utilized to track Resident 2’s fluid intake. In an interview on 04/16/2024 at 11:52 AM, Staff B stated that staff discarded the paper fluid trackers at the end of the day. Staff B stated they would provide a copy of the fluid tracker being utilized for the week of 04/15/2024 – 04/21/2024 for review. Review of an undated Fluid Tracker, provided by Staff B, showed Resident 2’s name and fields for each day of the week covering a span of two weeks. Entries under Week 1 Monday read “20oz @ breakfast” and “20oz @ lunch”. A single entry under Week 2 Monday (a date that had not yet occurred) read “20oz”. A single entry under Week 1 Tuesday read “15 BF [breakfast]”. All other fields on the tracker, including the dates and daily totals, were blank. In an interview on 04/16/2024 at 11:54 AM Staff C, Caregiver/Med-tech, stated that Resident 2 had a cup they carried around during the day that had a line of measurement on it. Staff C stated that the cup used by Resident 2 at lunch that day was a regular cup and not the measured cup designated for Resident 2. Observation of lunch service on 04/16/2024 at 11:55 AM, showed Resident 2 in the dining room drank from a large, clear, unmarked cup that was identical to the cups being used by other residents in the dining room (not the their measured cup). This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2399 Compliance Determination # 39648 Plan of Correction Willow Grove Completion Date Page 4 of 22 Licensee: Legacy1864, LLC 04/19/2024 In an interview on 04/16/2024 at 11:58 AM Staff G, Kitchen Manager, stated that kitchen staff gave Resident 2 an 8-ounce cup of the beverage being served at every meal and that no refills were permitted. Staff G stated that they would let the med tech know so they could record the fluid intake. When asked about Resident 2’s personal measured cup, Staff G stated the resident did not use it at meals. Observation in the kitchen on 04/16/2024 at 12:11 PM showed a white board noting dietary instructions for residents with Resident 2’s initials followed by “NO FLUIDS (No fluids w/ any meal)”. Review of Resident 2’s TARs, NSA, and assessment showed no documentation of the phosphorus restriction, or instructions and method for tracking. In an interview on 04/17/2024 at 1:05 PM, Staff A stated that they had not received an order to discontinue the phosphorus restriction and that they had not tracked Resident 2’s phosphorus intake. <Skin Breakdown> Review of the facility’s undated policy titled, “Skin Breakdown,” showed the following steps were to be completed when there was a concern of skin breakdown discovered by caregivers: -Chart observation and complete a skin check in the Extended Care Professional (ECP, electronic charting system). -Notify supervisor or Director of Care (DOC), supervisor to notify the DOC. -Notify residents' primary care physician and guardian if applicable. -Continue to monitor and report changes. -Always document changes observed. In an interview on 04/16/2024 at 2:55 PM, Staff B stated that if caregivers found skin issues, the caregivers were to document the findings and notify Staff B immediately. Staff B stated that they (Staff B) would evaluate the resident’s skin, determine the next course of action, and document the assessment and actions to be taken. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2399 Compliance Determination # 39648 Plan of Correction Willow Grove Completion Date Page 6 of 22 Licensee: Legacy1864, LLC 04/19/2024 reported to management.” Further review showed the progress notes did not contain any other documentation regarding evaluation or treatment of the wound noted on 03/19/2024. In an interview on 04/18/2024 at 10:30 AM Staff A, Administrator, and Staff B stated that Resident 4 would frequently get blisters on their buttocks due to incontinence. In an interview on 04/18/2024 at 10:50 AM, Staff A confirmed that no further action had been taken to evaluate or treat Resident 4’s wound that was noted on 03/19/2024. This is a recurring deficiency previously cited on 07/21/2021. 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, Willow Grove 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-2210 Medication services. (1) An assisted living facility providing medication service, either directly or indirectly, must: (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 This requirement was not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that the medication administration records accurately reflected medication services provided and required for 4 of 5 sampled residents (Residents 1, 2, 4 and 5). This failure resulted in Resident 2 and Resident 4 receiving their medications differently than how prescribed due This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2399 Compliance Determination # 39648 Plan of Correction Willow Grove Completion Date Page 7 of 22 Licensee: Legacy1864, LLC 04/19/2024 to transcription errors, inaccurate medication administration documentation, and placed residents at risk of health complications. Findings included… Medication documentation errors <Resident 2> Review of Resident 2’s Negotiated Care Plan (NSA, the facility’s titled negotiated service agreement), dated 03/08/2024, showed that “Care staff will be responsible for medication administration.” Review of Resident 2’s medication administration records (MARs) for February 2024 and March 2024 showed the resident was prescribed a vitamin supplement and levothyroxine (a hormone medication). Further review of the MARs showed the vitamin supplement was documented inaccurately as “administered” on 02/13/2024 and the levothyroxine was documented inaccurately as “administered” on 03/08/2024, 03/10/2024, and 03/12/2024. In an interview on 04/16/2024 at 2:40 PM Staff A, Administrator, and Staff B, Director of Care, stated that the vitamin supplement and the levothyroxine had not been administered on the dates noted above and identified the chartings as documentation errors. Staff B stated the medications had not been available for administration on those dates. <Resident 5> Review of Resident 5’s NSA, dated 04/17/2023, showed that the facility provided medication assistance. Review of Resident 5’s MAR for March 2024 showed the resident was prescribed a vitamin supplement. Further review of the MAR showed the vitamin supplement was documented inaccurately as “administered” on 03/04/2024 and 03/11/2024. In an interview on 04/19/2024 at 11:45am, Staff B stated that the vitamin supplement had not been administered on 03/04/2024 and 03/11/2024 and identified the chartings as documentation errors. Staff B stated that the medication had not been on site the entire month of March. In an interview on 04/17/2024 at 11:20 AM Staff A stated that they had not completed any This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2399 Compliance Determination # 39648 Plan of Correction Willow Grove Completion Date Page 8 of 22 Licensee: Legacy1864, LLC 04/19/2024 medication audits since the end of January 2024. Review of the facility’s last medication audit showed it was completed on 01/27/2024. Transcription documentation errors <Resident 1> Review of Resident 1’s NSA, dated 05/10/2023, showed the resident had orders for crushed medications due to a choking risk and that the facility provided medication assistance. Review of Resident 1’s physician’s orders, dated 09/06/2022, showed instructions to “crush all crushable meds and administer with medium of choice.” Review of Resident 1’s MARs for February 2024, March 2024, and April 2024, showed no transcribed instructions to crush the resident’s medications. <Resident 4> Review of Resident 4’s NSA, dated 12/03/2023, showed they had orders to crush medications due to their history of choking and that the facility provided medication assistance. Review of Resident 4’s physician’s orders, dated 04/05/2021, showed instructions to “crush medications and administer with medium of choice.” Review of Resident 4’s MARs for February 2024, March 2024, and April 2024, showed no transcribed instructions to crush medications. In an interview on 04/16/2024 at 2:20 PM, Staff A was asked how caregivers knew which residents had crushed medication orders. Staff A replied that caregivers knew from their medication training. Observation of the facility’s medication cart on 04/16/2024 at 2:20 PM, showed a post-it note on the computer monitor that read “medications whole [not crushed] in sauce,” with a list of resident names that included Resident 1 and Resident 4. In an interview on 04/17/2024 at 12:25 PM, Staff F, Caregiver/Med-tech, was asked which This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2399 Compliance Determination # 39648 Plan of Correction Willow Grove Completion Date Page 9 of 22 Licensee: Legacy1864, LLC 04/19/2024 residents had crushed medication orders. Staff F stated that Resident 6 was the only resident that had an order to crush medications. When asked how Staff F knew when to crush medications, Staff F replied, “because they told me and there is a post-it here.” Observation at that time showed Staff F then pointed to the post-it note on the computer monitor on the medication cart. In an interview on 04/17/2024 at 3:20 PM, Staff A stated that med-techs were not crushing medication for Resident 4 because “he chews them.” 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, Willow Grove 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-2240 Nonavailability of medications. When the assisted living facility has assumed responsibility for obtaining a resident's prescribed medications, the assisted living facility must obtain them in a correct and timely manner. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure medications were renewed and available for administration for 3 of 5 sampled residents (Residents 1, 2, and 5). This failure resulted in the residents not receiving their prescribed medications and placed the residents at risk of health complications. Findings included… Review of the facility’s undated policy titled, “Medication Reordering,” showed, “Medications will be reordered eight days prior to running out,” “Medication/Pill audits will be conducted regularly to ensure we have adequate stock,” and “Medications will be in house prior to running out.” <Resident 1> This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2399 Compliance Determination # 39648 Plan of Correction Willow Grove Completion Date Page of 22 Licensee: Legacy1864, LLC 04/19/2024 the MARs showed that Resident 2 did not receive the medication from 02/20/2024 through 03/04/2024 and was documented as, “waiting on delivery,” “waiting on med arrival,” “oos [out of stock],” “waiting on delivery,” and “held”. Review of Resident 2’s February 2024 MAR showed that the resident had a prescription order for melatonin (supplement) one time a day. Further review of the MAR showed the Resident 2 did not receive the medication from 02/20/2024 through 02/28/2024 and was documented as, “waiting on pharmacy” and “held.” Review of a fax document, dated 02/26/2024 and regarding Resident 2’s sodium chloride, multivitamin, and melatonin, showed a request for the medications. No documentation was provided to show the facility attempted to renew the medications prior to 02/26/2024. Review of Resident 2’s March 2024 and April 2024 MARs showed that the resident had a prescription order for magnesium oxide (supplement) one time a day. Further review of the MARs showed that Resident 2 did not receive the medication from 03/14/2024 through 04/10/2024 and was documented as, “medication is not available. Will order today” and “held”. Review of a fax document, dated 03/14/2024 and regarding Resident 2’s magnesium oxide, showed that the pharmacy faxed the provider regarding the prescription. No documentation was provided to show the facility attempted to renew the medication after 03/14/2024. Review of Resident 2’s March 2024 MAR showed that the resident had a prescription order for levothyroxine (hormone medication for underactive thyroid) one time a day. Further review of the MAR showed that Resident 2 did not receive the medication from 03/07/2024 through 03/13/2024 and was documented as “waiting on pharmacy” and “held”. In an interview on 04/16/2024 at 2:40 PM Staff A and Staff B, Director of Care, stated that on the dates reviewed (listed above) the medications were not on site and that anytime the MARs documented the lack of medication administration as “held,” it meant they were waiting on a refill. In an interview on 04/17/2024 at 12:39 PM, Staff D, Administrative Assistant/Caregiver, stated that the facility’s protocol was to put a medication on hold if it was not on site, so they didn’t continue to document the medication as not given, on the MARs. In an interview on 04/18/2024 at 4:24 PM, Staff A and Staff B stated they did not have orders from the residents’ health care providers to hold the medications when they were waiting on refills. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2399 Compliance Determination # 39648 Plan of Correction Willow Grove Completion Date Page of 22 Licensee: Legacy1864, LLC 04/19/2024 <Resident 5> Review of Resident 5’s March 2024 and April 2024 MARs showed that the resident had a prescription order for vitamin D2 (vitamin supplement) one time a week. Further review of the MARs showed that Resident 5 did not receive the medication from 03/18/2024 through 04/08/2024 and was documented as “waiting on meds,” “still have not received med from pharmacy,” “out of medication,” and “medication out of stock.” In an interview on 04/19/2024 at 11:45 AM, Staff B stated there had been documentation errors on the Resident 5’s MAR and that Resident 5 did not receive the vitamin D2 from 03/04/2024 through 04/08/2024 as the medication was not on site. Staff B stated they had two different orders from two different providers, and the facility had not addressed the issue until the middle of March. 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, Willow Grove 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 (b) Ensure the requirements of chapters 18.79 RCW and 246-840 WAC are met. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure that nurse delegated tasks were performed by qualified and trained staff for 3 of 5 sampled residents (Residents 1, 3, and 4). This failure placed the residents at risk of harm and medication errors due to receiving nurse delegated medication and tasks from unqualified caregivers. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2399 Compliance Determination # 39648 Plan of Correction Willow Grove Completion Date Page of 22 Licensee: Legacy1864, LLC 04/19/2024 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, Willow Grove 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-2730 Licensee's responsibilities. (1) The assisted living facility licensee is responsible for: (a) The operation of the assisted living facility; (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 for 4 of 4 sampled staff (Staff A, B, C, and D). This failure placed residents and staff at risk of exposure to an infectious communicable disease. Findings included… Per WAC 296-842-15005, facilities must conduct fit testing (test completed by specially trained personnel to ensure N95 mask seals effectively to reduce the chance of exposure to respiratory viruses) before employees are assigned duties that may require the use of respirators and at least every twelve months after initial testing. 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," including respirator fit testing for long term care workers. Review of Staff A’s, Administrator, personnel file showed a hire date of 02/18/2022. Further review showed no documentation of respirator fit testing. Review of Staff B’s, Director of Care, personnel file showed a hire date of This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2399 Compliance Determination # 39648 Plan of Correction Willow Grove Completion Date Page of 22 Licensee: Legacy1864, LLC 04/19/2024 04/18/2023. Further review showed no documentation of respirator fit testing. Review of Staff C’s, Caregiver/Med-tech, personnel file showed a hire date of 03/02/2023. Further review showed no documentation of respirator fit testing. Review of Staff D’s, Administrative Assistant/Caregiver, personnel file showed a hire date of 04/04/2023. Further review showed no documentation of respirator fit testing. In an interview on 04/12/2024 at 9:10 AM, Staff A indicated they had not been conducting fit testing. In an interview on 04/19/2024 at 11:04 AM, Staff E, Director of Business, stated that they had no records for respirator fit testing for any staff. 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, Willow Grove 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-2140 Negotiated service agreement contents. The assisted living facility must develop, and document in the resident's record, the agreed upon plan to address and support each resident's assessed capabilities, needs and preferences, including the following: (1) The care and services necessary to meet the resident's needs, including: (a) The plan to monitor the resident and address interventions for current risks to the resident's health and safety that were identified in one or more of the following: (iii) On-going assessments of the resident; This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure the contents of the negotiated service agreement were updated to accurately reflect the services and interventions for 1 of 5 sampled residents (Resident 1). This failure placed the resident at This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2399 Compliance Determination # 39648 Plan of Correction Willow Grove Completion Date Page of 22 Licensee: Legacy1864, LLC 04/19/2024 risk of having unmet service needs. Findings included… Review of Resident 1’s assessment, dated 11/29/2023, showed that Resident 1 had multiple falls since their last assessment, they were to eat in the dining room to allow for staff supervision due to aspiration (when something you swallow enters the airway or lungs), and they had orders for blood sugar checks and Trulicity (an injectable medication used to lower blood sugar). Review of Resident 1’s Negotiated Care Plan (NSA, the facility’s titled Negotiated Service Agreement), dated 05/10/2023, showed it did not contain any documentation related to their multiple recent falls or interventions to be implemented to reduce fall risk. Resident 1’s NSA did not contain information related to their high aspiration risk or that they required supervision while they ate their meals. Further review showed the NSA did not document and define the facility’s role in the administration of the Trulicity injection. In an interview on 04/16/2024 at 09:20 AM, Staff A, Administrator, stated that NSAs were done independently from the assessments. Staff A stated that assessments should reflect what is required to be in the NSA. 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, Willow Grove 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; (b) Complete an assessment specifically focused on a resident's identified problems and related issues: (iii) When the resident has an injury requiring the intervention of a practitioner. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2399 Compliance Determination # 39648 Plan of Correction Willow Grove Completion Date Page of 22 Licensee: Legacy1864, LLC 04/19/2024 on 01/20/2024. <Resident 5> Review of Resident 5’s annual assessment, dated 04/07/2023, showed it was a CARE assessment completed by a department case manager. In an interview on 04/17/2024 at 4:35 PM, Staff A stated they used the CARE assessments for their state pay residents. Staff A stated that they were unaware that the state CARE assessments could not be utilized as the facility’s annual assessment. 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, Willow Grove 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: (1) Individual's recent medical history, including, but not limited to: (a) A licensed medical or health professional's diagnosis, unless the resident objects for religious reasons; (b) Chronic, current, and potential skin conditions; or (c) Known allergies to foods or medications, or other considerations for providing care or services. (2) Currently necessary and contraindicated medications and treatments for the individual, including: (a) Any prescribed medications, and over-the-counter medications commonly taken by the individual, that the individual is able to independently self-administer, or safely and accurately direct others to administer to him/her; This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2399 Compliance Determination # 39648 Plan of Correction Willow Grove Completion Date Page of 22 Licensee: Legacy1864, LLC 04/19/2024 (b) Any prescribed medications, and over-the-counter medications commonly taken by the individual, that the individual is able to self-administer when he/she has the assistance of a caregiver; and (c) Any prescribed medications, and over-the-counter medications commonly taken by the individual, that the individual is not able to self-administer, and needs to have administered to him or her. (3) The individual's nursing needs when the individual requires the services of a nurse on the assisted living facility premises. (4) Individual's sensory abilities, including: (a) Vision; and (b) Hearing. (5) Individual's communication abilities, including: (a) Modes of expression; (b) Ability to make self understood; and (c) Ability to understand others. (6) Significant known behaviors or symptoms of the individual causing concern or requiring special care, including: (a) History of substance abuse; (b) History of harming self, others, or property; or (c) Other conditions that may require behavioral intervention strategies; (d) Individual's ability to leave the assisted living facility unsupervised; and (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. (7) Individual's special needs, by evaluating available information, or if available information does not indicate the presence of special needs, selecting and using an appropriate tool, to determine the presence of symptoms consistent with, and implications for care and services of: (a) Mental illness, or needs for psychological or mental health services, except where protected by confidentiality laws; (b) Developmental disability; (c) Dementia. While screening a resident for dementia, the assisted living facility must: (i) Base any determination that the resident has short-term memory loss upon objective evidence; and (ii) Document the evidence in the resident's record. (d) Other conditions affecting cognition, such as traumatic brain injury. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2399 Compliance Determination # 39648 Plan of Correction Willow Grove Completion Date Page of 22 Licensee: Legacy1864, LLC 04/19/2024 (8) Individual's level of personal care needs, including: (a) Ability to perform activities of daily living; (b) Medication management ability, including: (i) The individual's ability to obtain and appropriately use over-the-counter medications; and (ii) How the individual will obtain prescribed medications for use in the assisted living facility. (9) Individual's activities, typical daily routines, habits and service preferences. (10) Individual's personal identity and lifestyle, to the extent the individual is willing to share the information, and the manner in which they are expressed, including preferences regarding food, community contacts, hobbies, spiritual preferences, or other sources of pleasure and comfort. (11) Who has decision-making authority for the individual, including: (a) The presence of any advance directive, or other legal document that will establish a substitute decision maker in the future; (b) The presence of any legal document that establishes a current substitute decision maker; and (c) The scope of decision-making authority of any substitute decision maker. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to complete a full assessment within fourteen days of the resident's move-in date for 1 of 5 sampled residents (Resident 2). This failure placed Resident 2 at risk of unmet care needs related to not being assessed after they transitioned into the facility. Findings included… Review of Resident 2’s medical chart showed they were admitted on 2024. Further review showed it did not contain a full assessment within 14 days after admission. In an interview on 04/16/2024 at 9:20 AM, Staff A, Administrator, stated that a full assessment is completed prior to a resident’s admission and that the assessment is not updated again until the annual assessment is completed a year after admission. Plan/Attestation Statement This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2399 Compliance Determination # 39648 Plan of Correction Willow Grove Completion Date Page of 22 Licensee: Legacy1864, LLC 04/19/2024 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, Willow Grove 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. Willow Grove # 2399 04/19/2024 Page 2 of 3 Spokane Valley, WA 99212 • Complete correction(s) within 45 days, or sooner if directed by the Department, after review of your proposed correction dates. • Have your plan approved by the Department. Consultation(s): In addition, the Department provided consultation on the following deficiency or deficiencies not listed on the enclosed report. WAC 388-78A-2371 Investigations. The assisted living facility must: (1) Investigate and document investigative actions and findings for any alleged or suspected abuse, neglect, or financial exploitation; or accident or incident jeopardizing or affecting a resident health or life; During the full licensing inspection, it was determined that the facility did not document their investigations following incidents that required emergency medical interventions. During the inspection, the administrator began to create a new incident report template that included their investigation documentation. You Are Not: • Required to submit a plan of correction for the consultation deficiency or deficiencies stated in this letter and not listed on the enclosed report. You May: • Contact me for clarification of the deficiency or deficiencies found. In Addition, You May: • Request an Informal Dispute Resolution (IDR) review within 10 working days after you receive this letter. Your IDR request must include: o What specific deficiency or deficiencies you disagree with; o Why you disagree with each deficiency; and o Whether you want an IDR to occur in-person, by telephone or as a paper review. o Send your request to: 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. This document was prepared by Residential Care Services for the Locator website. Willow Grove # 2399 04/19/2024 Page 3 of 3 Sincerely, Stephanie Jenks, Field Manager Region 1, Unit B Residential Care Services Enclosure This document was prepared by Residential Care Services for the Locator website.

This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: Willow Grove Provider Type: Assisted Living Facility License/Cert.#: 2399 Compliance Determination #: 34293 Intake ID: 108904 Investigator: Sylvia Shauvin Region/Unit #: RCS Region 1 / Unit B Investigation Date(s): 12/21/2023 through 01/02/2024 Complainant Contact Date(s): Allegation(s): 1 - Facility staff don't allow resident(s) to have access to their snacks Investigation Methods: Sample: Total residents: 18 Resident sample size: 4 Closed records sample size: 0 Observations: Residents' well-being Any unmet residents' needs Staff's interactions with residents and response to their needs Interviews: Four residents, including alleged victim Four facility caregivers Dietary Supervisor Two Collateral Contacts Director of Care/Administrator Designee Record Reviews: Sampled residents' Face Sheets, assessments, care plans, and Progress Notes Behavior monitoring sheets for sampled resident House Rules Admission Agreement Staffing schedule Three sampled staff credentials Investigation Summary: 1 - Snacks purchased by residents, including named resident, were observed stored in a locked room which was also used to store medications and supplies. Alleged victim (AV) stated the staff sometimes did not allow them to have the snacks they bought. Staff interviews and review of Progress Notes pertaining to AV showed staff sometimes did not allow AV to have the snacks they bought because the AV stood in the doorway of the room where medications were stored, or because staff was concerned about the resident eating snacks containing too much sugar. A counselor and the Administrator Designee stated the facility did not allow the AV to keep snacks in their apartment because of sanitation concerns. The facility failed to allow AV's access to snacks they This document was prepared by Residential Care Services for the Locator website. bought (i.e. their personal property). Failed facility practice was found and documented in a Statement of Deficiencies under Washington Administrative Code 388-78a-2660(1)(2)(4)(6) Resident rights with reference to Revised Code of Washington 70.129.100 Personal property. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A This document was prepared by Residential Care Services for the Locator website. 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 #: 2399 Compliance Determination # 34293 Plan of Correction Willow Grove Completion Date Page 1 of 4 Licensee: Legacy1864, LLC 01/02/2024 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 complaint investigation on 12/21/2023, 12/21/2023 and 01/02/2024 of: Willow Grove 1620 E Mead St Spokane, WA 99218 This document references the following complaint number(s): 108904 The following sample was selected for review during the unannounced on-site visit: 4 of 18 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Sylvia Shauvin, Complaint Investigator 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. Statement of Deficiencies License #: 2399 Compliance Determination # 34293 Plan of Correction Willow Grove Completion Date Page 2 of 4 Licensee: Legacy1864, LLC 01/02/2024 Administrator (or Representative) Date RCW 70.129.100 Personal property -- Storage space. (1) The resident has the right to retain and use personal possessions, including some furnishings, and appropriate clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. WAC 388-78A-2660 Resident rights. The assisted living facility must: (1) Comply with chapter 70.129 RCW, Long-term care resident rights; (2) Ensure all staff persons provide care and services to each resident consistent with chapter 70.129 RCW; (4) Promote and protect the residents' exercise of all rights granted under chapter 70.129 RCW; (6) Reasonably accommodate residents consistent with applicable state and/or federal law; and This requirement was not met as evidenced by: Based on observation, interview and record review, the facility failed to provide a resident with snacks they had purchased for 1 of 4 sampled residents (Resident 3). This failure resulted in a violation of the resident’s right to retain their personal property. Findings included… Resident 3’s Behavior Support Plan (BSP), dated 07/03/2023, showed they experienced anxiety. The BSP further showed Resident 3 made unhealthy food choices, and their issues around eating could trigger constant need for reassurance and problems with aggression. Review of Resident 3’s Progress Note, dated 11/07/2023 at 9:15 PM, showed that Staff B, Caregiver, documented that Resident 3 voiced feeling that staff did not like them because staff did not give them their own snack consisting of “sugary cookies”. The note further showed staff explained “we needed to make healthier choices for [Resident 3’s] body.” Review of Resident 3’s Progress Note, dated 11/14/2023 at 6:30 PM, showed that Staff B documented that Resident 3 yelled at staff members and stated staff did not like [Resident 3] when staff did not give the resident their “personal snack due to the sugars in them”. The note further showed staff explained to Resident 3 why the snacks were unhealthy. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2399 Compliance Determination # 34293 Plan of Correction Willow Grove Completion Date Page 3 of 4 Licensee: Legacy1864, LLC 01/02/2024 Review of Resident 3’s Progress Note, dated 11/24/2023 at 8:15 PM, showed that Staff D, Caregiver, documented that due to Resident 3’s behaviors that day, such as sleeping through an activity, swearing, and yelling, the resident could have the “house snack” instead of their “personal snack”. Review of Resident 3’s Progress Note, dated 12/18/2023 at 9:00 PM, Staff C, Caregiver, documented that staff would “hold off” on giving Resident 3 their personal snack and gave the resident the “facility snack” instead because the resident “overstepped a boundary” by being in the medication room. Staff C noted this resulted in the resident getting upset and raising their voice at staff. In an interview on 12/21/2023 at 11:05 AM, Resident 3 stated they sometimes bought their own snacks which the staff kept locked up. Resident 3 stated staff did not allow them to have the snacks if they were “rude to [staff]” and looked in the medication room. Resident 3 further stated staff limited access to personal snacks because of concern that the resident could become diabetic. Resident 3 stated, “It made me cry” when staff took chocolate away from them. Observation on 12/21/2023 at 11:35 AM showed snacks, such as boxes of honey-oat bars and juice, were labelled with Resident 3’s name and kept locked up in the medication room. In an interview on 12/21/2023 at 11:35 AM, Staff C stated residents, whose own snacks were kept locked up in the medication room, were not allowed to independently access the snacks there, because of safety concerns since medications and care supplies were also stored in the room. In an interview on 12/21/2023 at 12:50 PM, Staff C stated they did not allow Resident 3 to have their personal snacks on 12/18/2023, because the resident entered the medication room. In an interview on 12/20/2023 at 8:30 AM, Collateral Contact 1 stated that snacks purchased by residents were considered the residents’ personal property and they were concerned that prohibiting residents’ access to their snacks could be a resident rights issue. In an interview on 12/28/2023 at 1:15 PM, Collateral Contact 2 stated the facility did not negotiate Resident 3’s access to the snacks they purchased related to the facility’s concerns over the resident’s problem behaviors and poor blood sugar control. In an interview on 01/02/2024 at 11:35 AM, Staff C stated staff limited Resident 3’s access to their personal snacks due to concerns of the resident’s risk for developing diabetes, and the resident’s history of storing food in their apartment in an unsanitary manner. Staff C stated the facility previously allowed Resident 3 access to the snacks they purchased and This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2399 Compliance Determination # 34293 Plan of Correction Willow Grove Completion Date Page 4 of 4 Licensee: Legacy1864, LLC 01/02/2024 was uncertain when the practice was changed and who initiated limiting the resident’s access to their snacks. In an interview on 01/02/2024 at 11:45 AM, Staff D stated they did not recall Resident 3’s physician or counselor providing the facility with specific instructions regarding the resident’s access to their personal snacks. 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, Willow Grove 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.

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 October 12, 2023 ELECTRONIC-FACSIMILE Administrator Willow Grove 1620 E Mead St Spokane, WA 99218 Assisted Living Facility License #2399 Licensee: Legacy1864, LLC IMPOSITION OF CIVIL FINES Dear Administrator: On October 5, 2023, 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 Willow Grove, located at 1620 E Mead St, 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 October 5, 2023. Civil Fines WAC 388-78A-2600(1)(a)(2)(j)(i)(ii)(iii) Policies and procedures. $200.00 The licensee failed to develop, implement policies, and provide training on what staff must do to address aggressive behavior related to a medical condition for one resident. These failures contributed to the resident being manually and physically restrained by untrained staff, transferred to the emergency room, and placed the resident at risk of physical and psychological harm. WAC 388-78A-2660(3) Resident rights. $500.00 The licensee failed to ensure a resident was not restrained by untrained staff for one resident. These failures contributed to the resident being manually and physically Administrator Willow Grove License #2399 October 12, 2023 Page 2 restrained by untrained staff on multiple occasions and needing to be transferred to the emergency room. WAC 388-78A-2130(1)(c) Service agreement planning. $200.00 The licensee failed to monitor and address a health and safety issue identified in one resident’s assessment and document behavioral interventions in the service agreement (service plan) for one resident. These failed practices resulted in the resident having subsequent encounters with law enforcement requiring emergency department treatment and placed the resident at risk of harm due to a lack of interventions for behaviors and contributed to being restrained. 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 Willow Grove License #2399 October 12, 2023 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. Send your written request to: Informal Dispute Resolution Program Manager Residential Care Services PO Box 45600 Olympia, Washington 98504-5600 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 $900.00 payable to the ‘Department of Social and Health Services’, and if you have or have had a Medicaid resident(s), please include your ProviderOne ID Number # on the check, to: DSHS Office of Financial Recovery PO Box 9501 Olympia, Washington 98507-9501 1-800-562-6114 (extension 45919) OFRMMISVendor@dshs.wa.gov If the Office of Financial Recovery has not received your payment within twenty-eight (28) days after receipt of this letter, interest will begin to accrue immediately on the balance, at the Administrator Willow Grove License #2399 October 12, 2023 Page 4 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. 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