Memory Haven Sumner.

Conclusion / Action: . Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . I&] □ □ . 01.09.2025 14:24:48 state of Washington 5/10 STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEAL TH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION Statement of Deficiencies License#: 2421 Compliance Determination# 50838 Plan of Correction Memory Haven Sumner cornplelion Date You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for an unannounced on-site complaint investigation on 11/25/2024 and 11/2512024 of: Memory Have11 Sumner 5107 Parker Rd E Sumner, WA 98390 This document references the following complaint number(s): 155901 The following sample was selected for review during the unannounced on-site visit: 1 of 38 current residents and O former residents. The department staff that investigated the Assisted Living Facility: Nareet Bajwa, NCI-ALF Complaint Investigator From: DSHS, Aging and Long-Term Support Administration Lakewood, WA 98496 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. 01/0812025 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 . 01.09.2025 14:24:48 State of Washington 6/10 Statement of Deficiencies License#: 2421 Compliance Determination# 50838 Plan of Correction Memory Haven Sumner Completion Date Page 2 of3 Licensee: SSA VI, LLC 01106/2025 \_Jlx\ ~ Administrator (or Representative) WAC 388-78A-2630 Reporting abuse and neglect. (1) The assisted living facility must ensure that each staff pen;on: (a) Makes a report to the department's Aging and Disability Services Administration Complaint Resolution Unit hotline consistent with chapter 74.34 RCW in all cases where the staff person has reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred: and (b) Makes an immediate report to the appropriate law enforcement agency and the department consistent with chapter 74.34 RCWof all incidents of suspected sexual abuse or physical abuse of a resident. (2) The assisted living facility must prominently post so it is readily visible to staff, residents and visitors, the department's toll-free telephone number for reporting resident abuse and neglect. This requirement was not met as evidenced by: Based on interviews. observation and record review, the Assisted Living Facility (ALF) failed to call Law Enforcement and the Departments Complaint Resolution Unit (CRU) hotline as a mandatory reporter for 1 of 1 sampled resident (Resident 1[R1]) on an incident of physical abuse. The facility also failed to post the department's toll-free telephone number for reporting resident abuse and neglect. These failures placed all 38 residents in the ALF at risk for potential abuse. Findings Included ... Record review of the Abuse Reporting- Policy number: 6.0.608-07/2018 stated "(1i Notify the appropriate licensing or regulatory agency or Executive director for this community in accordance with specific state regulations. The hotline number is_, if applicable. The employee is a mandatory reporter, who will notify the state hotline (if applicable) without fear of retaliation and/or anonymously. During an observation on 11125/2024 at 12:10pm, The department's loll-free telephone number for reporting resident abuse and neglect was not posted in the facility During an inlerview on 11/25/2024 at 12:38pm, Staff C, Medication technician stated that Staff D, Caregiver notified her regarding the incident on 11/16/2024. Staff C stated that she reported to Staff 8, the Wellness Director, and asked Staff D to write a statement Staff C stated that she notified the doctor, family and administrator. Staff C stated that R 1 was placed on alert charting. Staff C was asked if hotline reporting was . 01.09.2025 14:24:48 State of Washington 7/10 Statement of Deficiencies License#: 2421 Compliance Determination# 50838 Plan of Correction Memory Haven Sumner Completion Date Page 3 of3 Licensee: SSA VI, LLC 01/06/2025 done. Staff C stated that she probably should have called the hotline, but she did not During an interview on 11/25/2024 at 1 :16pm, Staff 8. stated that the incident happened on 11/15/2024 evening and she was notified regarding the incident by Staff D on 11/16/2024 morning. Staff 8 stated that staff D said that she was terrified and did not want Staff E. Caregiver to know that she witnessed staff E abusing R 1. Staff 8 was asked who was notified. Staff 8 stated that Staff A. Administrator, Police, POA and doctor were notified Staff 8 was asked if Staff E was in the facility after the incident. Staff B stated that incident happened at 9: 15pm and Staff E was working in the facility with other residents after the incident and left when his shift ended at 10pm. Staff B stated that investigation was done, and Staff E was terminated. Staff 8 was asked if hotline reporting was done. Staff 8 stated that Staff D knows that she is mandatory reporter, but she did not called hotline. Staff B stated that she did the online reporting on 11/18/2024. Staff 8 stated that in.service education will be done for all staff and will post the posters of hotline number for reporting abuse and neglect During an interview on 01/03/2025 at 12: 11 pm, Staff A stated that if she witnessed abuse then she would intervene on the situation, move resident to safe area, call for help, call police and supervisor. Staff A stated that she would remove the alleged perpetrator from property and call state hotline. Staff A stated that all staff involved in the incident are supposed to report to state hotline individually. Staff A stated that staff D was shocked and forgot to call hotline. Staff A stated incident happened on 11/15/2024 evening, reported to Staff Bon 11/16i2024 morning and online reporting was done by Staff Bon 11/1812024. Staff A was asked if Staff E was in the facility after the incident Staff A stated that staff E was working in the facility after the incident and left after his shift ended. Staff A stated that in-service education was done with all staff and posted hotline posters in the building, 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, Memiry H!\ven §J,lrnner is or will be in compliance with this law and/ or regulation on (Date) I _I le I ~ IS . C In addition, I will implement a system to monitor and ensure continued compliance with ~~;;bL~'\ -····.\ \ i~LaL,>---- . January 14, 2025 Jody Just, Field Manager Region 3, Unit D Lakewood, Wa 98496 Re: Citation dated January 1, 2025 WAC 388-78A-2630 Reporting abuse and neglect. (1) The assisted living facility must ensure tha each staff person: (a) Makes a report to the department's Aging and Disability Serv ices Administration Complaint Resolution Unit hotline consistent with chapter 74.34 RCW in all cases where the staff person has reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred; and (b) Makes an immediate report to the appropriate law enforcement agency and the department consistent with chapter 74.34 RCW of all incidents of suspected sexual abuse or physical abuse of a resident. (2) The assisted living facility must be prominently posted so it is readily visible to staff, residents and visitors, the department's toll-free telephone number for reporting resident abuse and neglect. • Executive Director, Business Office Manager, and Wellness Director continue to in-service during on boarding, and in all staff as we have done in November & December with plans January 16, 2025. • Executive Director, Business Office Manager, and Wellness Director continue to ensure no reporting posters are taken down in all three cottages.

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.

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.