Spring Ridge Retirement, Llc.

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

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: Spring Ridge Retirement, Provider Type: Assisted Living Facility LLC License/Cert.#: 2160 Intake ID: 123992 Compliance Determination #: 39424 Region/Unit #: RCS Region 3 / Unit D Investigator: Carol Gijima Investigation Date(s): 04/08/2024 through 06/12/2024 Complainant Contact Date(s): Allegation(s): 1. Residents had respiratory illness Investigation Methods: Sample: Total residents: Resident sample size: 5 Closed records sample size: 1 Observations: General environment Residents in their rooms Staff-to-resident interactions Resident behaviors Interviews: Staff Resident representatives Record Reviews: Resident Characteristic Roster Resident assessments and negotiated service agreements including the records of the named residents Medication administration records (MAR) Staff progress notes Medical records (lab reports, H & P summary) Incident log / reports Facility P & P- Infection control. Medication management Investigation Summary: Per record review and interviews with staff, the facility failed to investigate the causes of a respiratory outbreak or manage the spread of infection. The ALF demonstrated failed provider practice as documented in a Statement of Deficiencies dated 06/12/2024. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written . N/A . . . .

Findings Included .. on Facility and resident record reviews 01/11/2024 showed the following: Resident 1 Record review of Resident 1's (R1) documents showed that R1 admitted to AFL on /2019 With diagnoses to include . Review of the Negotiated Service Agreement dated 08/22/2023 showed that effective 08/01/2023, R.1 was to receive 2 showers per week and required physical assistance from .staff with showering. Review of the Memory Care shower schedule on 01/1112024 showed that R 1 was to receive showers on Mondays and Thursdays. There were no shower sheets for R 1 to review for December 2023 and :January 2024 review period. n1ere was no documentation in the progress notes to show that showers were given, attempted, or refused. Resident 2 Record teview of Resident 2's (R2) documents showed that R2 admitted to the ALF on /2023 with diagnoses to include . Review of the Negotiated Service Agreement dated 02i28/2024 showed that effective 08/18/2022, R2 was to receive 2 showers per week on Sunday and Thursday, and that R2 required total assistance from staff tc shower. Review of the Memory Care shower schedLtle on 01/11/2024 showed that R2 was to receive showers on Tuesdays. A negotiated service plan dated 09/18/2022 showed showers days were Sundays and Thursdays. There were no shower sheets for R2 to review . 04.05.2024 11 :18:06 State of 14ashington 517 Statement -0fDeficiencies License #: 2160 Compliance Determination # 35085 Plan of Correction Spring Ridge Retirement, LLC Completion Date Page3 of4 Ucensee: Spring Ridge Retirement. LLC 04./04/2024 for December 2023 and January 2024 review period. There was no documentation in the progress notes to show that showers were given, attempted, or refused, Resident 3 Record review of Resident 3's (R3) documents showed th~t R3 admitted to AFL on 2023 with diagnoses to include . Review of the Negotiated Service Agreement dated. /202:3 showed tha1 R3 was to receive 2 showers per week on Sundays and Wednesdays and required 2 person staff to be present. Revi.ewof the Memory Care shower schedule on 01/11/2024 did not show R3 to be scheduled for any showers. There were no shower sheets for R2 to review for December 2023. There was a progress noted on December 20, 2023, that stated R3 refused all care. January 2024 shower sheets showed that R3 received 2 showers on the 1st and 8th, There was no ott,er documentation in the progress notes to show that showers were given, attempted, or refused. During an interview on 01/11/2024 at 9:18 AM, Staff B, Medication Technician, stated that residents were given showers twice a week unless their service plan stated otherwise. Staff B stated that when residents refused showers or did not get. a shower, it would be documented in progress notes. Staff B. stated that staff would document showers or refusals on the "Caregiver Shower Review" sheet. 'M'len asked where the shower review sheets for Residents 1.2 and 3 were, Staff B stated they would be iri the shower binder. Staff B did not provide an. answer wheri asked why there would be no documentation in the binder. Staff Bwas asked if R3 had a shower during the review period since she was not on the shower schedule. Staff 8 did not provide an answer. When asked if showers were given or not. Staff B stated, "I do m;,t have an answer". During an interview on 01/11/2024 at 9:38 AM, Staff C, Caregiver, stated that resi:dents received showers according to their service plans and as. needed. Staff C stated that Residents 1 and 3 sometimes refused showers. Staff C stated that when residents refused showers,. they would document on the shower sheets and notify the Medication Technician to document in the progress notes. During an inte.rview on 01/11/2024 at 9:45 AM, Staff D, Registered Nurse. stated that showers were given according to service plans. Staff did not provide an answer when asked why there was no documentation showing that residents either received or refused a shower. When asked if Residents 1, 2, and 3 received or refused showers, Staff D stated -that there was no way to know without documentation. at During an interview on 04/02/2024 2:00 PM, Staff E, Resi.dent Care Coordinator, stated that resident showers were dependent on the service plan, bl..!t typically they received 2 showers a week and as needed. Staff Estated that caregivers had "run sheets" and ~shower books" which showed when residents were scheduled for showers. Staff E stated that when residents refused or were not given their showers, it would .be documented in th.e progress notes by the Medication Technici.an. Staff Estatedlhere should be no reason that resident do not receive their showers unless they were ill. . 04.05.2024 11:18:06 State of washington 617 Statement of Deficiencies License#: 2160 Compliance Determination # 35085 Plan of Correction Spring Ridge Retirement, LLC Completion Date Page4 of4 Licensee: Spring Ridge Retirement, LLC 04/04/2024 During an interview on 04/03/2024 at 10:09 AM , Staff A, Administrator, stated that resident showers were given according to their service plans and need. Admi11ist(ator stated that caregivers have a shower schedule wh.ich lists residents' shower days and times {day or ev.ening). When asked if resident showers. were documented if given or refused, Administrator stated that they were documented on the shower log but not in progress notes. Admi11istrator was asked why there were no shower logs to review. Administrator stated that shower logs were an "internal document'', were .not consic:!ered part of the resident's record and were not retained .. When asked how one would know if residents were getting showers per service plan, Administrator stated that if there was no "exception documentation" then they would assume that residents received their showers. Administrator was asked if residents received their showers per service plan, Administrator stated "I don't ·know the answer to that honestly", and that it would be a good conversation lo have with the team. In a separate interviaw on 04/04/2024 at 1 :05 PM, Administrator stated that their process for ensuring residents were showered was not working. This is an uncorrecte.d deficiency previously cited on 10/23/2023. Plan/Attestation Statement- I hereby certify that I have reviewed this report and have taken or Will take active measures to c.orrect this deficiency. By taking this action, Spring Ridge Rptirement, LLC is 05t t::±( ·?'2-~ or will be in compliance with this law and/ or regulation on (Date} In addition; I will implement a system to monitor and ensure contin~ed compliance with this reqLJirement. ........... qJ.\u.b.02-± ..... Administrator (or Representative) Date . Investigation Summary Report Provider/Facility: Spring Ridge Retirement, Provider Type: Assisted Living Facility LLC License/Cert.#: 2160 Intake ID: 88645 Compliance Determination #: 27 429 Region/Unit#: RCS Region 3 J Unit o Investigator: Carol Gijima Investigation Date(s ): 07/31/2023 through 10/23/2023 Complainant Contact Date(s): Allegation(s): 1. Resident developed a pressure ulcer Investigation Methods: Sample: Total residents: Resident sample size: 4 Closed records sample size: Observations: General environment Resident wounds Residents in their rooms Staff-to-resident interactions Interviews: Resident representatives Staff Record Reviews: Resident Characteristic Roster Resident assessments and negotiated service agreements including the records of the named resident Staff progress notes Incident log / reports Shower schedules Investigation Summary: 1. Per observation, record review and interviews with staff, the facility failed to investigate circumstances of the pressure ulcer development, assess and implement interventions to prevent recurrence. The ALF demonstrated failed provider practice as documented in a Statement of Deficiencies dated 10/23/2023. Conclusion/ Action: ~ Failed Provider Practice Identified/ Citation(s) Written D Failed Provider Practice Not Identified / No Citation Written □ N/A . Investigation Summary Report Provider/Facility: Spring Ridge Retirement, Provider Type: Assisted Living Facility LLC License/Cert.#: 2160 Intake ID: 87716 Compliance Determination #: 27 429 Region/Unit#: RCS Region 3 J Unit o Investigator: Carol Gijima Investigation Date(s ): 07/31/2023 through 10/23/2023 Complainant Contact Date(s): Allegation(s): 1. Injury of unknown source Investigation Methods: Sample: Total residents: Resident sample size: 4 Closed records sample size: Observations: General environment Residents in their rooms Staff-to-resident interactions Interviews: Resident representatives Staff Record Reviews: Resident Characteristic Roster Resident assessments and negotiated service agreements including the records of the named resident Staff progress notes Incident log / reports Shower schedules Investigation Summary: 1. Per record review and interviews with staff, the facility failed to investigate circumstances surrounding injuries of unknown origin. The ALF demonstrated failed provider practice as documented in a Statement of Deficiencies dated 10/23/2023.

Conclusion / Action: O Failed Provider Practice Identified / Citation(s) Written � Failed Provider Practice Not Identified/ No Citation Written 0 N/A . Investigation Summary Report Provider/Facility: Spring Ridge Retirement, Provider Type: Assisted Living Facility LLC License/Cert.#: 2160 Intake ID: 65369 Compliance Determination#: 23146 o Region/Unit#: RCS Region 3; Unit Investigator: Woodetta Maulana Investigation Date(s): 04/20/2023 through 05/01/2023 Complainant Contact Date(s): Allegation(s ): 1) Injury of unknown source Investigation Methods: Sample: Total residents: 100 Resident sample size: 2 Closed records sample size: 0 Observations: staff to resident interaction residents general observation of the facility Interviews: staff residents Record Reviews: resident records facility incident report Investigation Summary: The assisted living facility failed to thoroughly investigate to determine the circumstances of the event for named resident. Conclusion / Action: � Failed Provider Practice Identified / Citation(s) Written D Failed Provider Practice Not Identified / No Citation Written □ N/A . .'''l ll> , S1Ar'E OF WA�l-1 iNC3lOl\l DEPARTMENT OF S0.CIAL AND HEAL TH SERVICES C A.C;(NG ANJ LONG-lE:RM SUP.POIH ADMINIST-RA"rtON Stateiinent. of Deficiencies LiCerlSa #: 2·160 Cmnplianco Deterrriinatiorl #.23146 Pl an of Corr-ection Spring Ridge Retiremen�. Ll.C ·C.omplelion Date Pag.e.1 of 3 Licensee� Spring Ridge Retirement. LLC 05/01/2023 You are required to be in compliance at.all times with all licensing laws and regulations to maintain your A·ssist.ed Living Facility license. The department completed data collecti.on for an u11announced on-site complaint investigation on 04/20/2023 and 04I.20i2023 of: SprinQ Ridge Retirement, LLC 6856 E PorUand Ave Tacoma WA 98404 1 This dCicument references the fallowing complaint numoer(s.): 64481, 653.69 The following sample was.selected for revie-w dur'.ing.the unannounced on�site visit: 2 of 100 current residents and O former residents. The department staff that investigated the·Assisted Living Facir.ty: From: DSHS, Aging and Long-Term Support' Administration Residential Car-e Services, Region 3 , Unit O Lakewood, WA 98496 As· .a result of the on-site visit(s), the departmentfou,nd that you· ar.e not in compfi.ance with the licensrng laws and regulations as stated in the cited deficiencies in the enclosed report ·- !�4j-, Li-- 5/1/2023 ResLdential Care Services Date I understand that to maintain an Ass1sted Livin.g Facility license, the facility must be in compliance with all ·the licensing laws· and regulations at all times. . Statement of Deficiencies License#: 2160 Compliance Determination# 23146 Plan of Correction Spring Ridge Retirement, LLC Completion Date 05/01/2023 Administrator (or Representative) Date WAC 388-78A-2371 Investigations. The assisted living facility must: (2) Determine the circumstances of the event; This requirement was not met as evidenced by: Based on observation, interview, and record review the assisted living facility (ALF) failed to thoroughly investigate to determine the circumstances of the event for 1 of 2 sample residents (Resident 1 ). This failure placed residents at risk for harm. Findings included ... Review of the facility's incident report dated 01/09/2023 described the injury as "resident lips swollen and bottom lip had bruising .. .front bottom teeth loose, swelling." This same incident report documented "Resident top and bottom lips swollen with small bruising to bottom lip, both RCC and AM Medtech noticed around 8a.m. Resident had been up all-night wandering halls and in and out of door. Resident denied falling or hitting mouth of any sort when asked. Resident states she bites her lips when they are dry." On 04/20/2023 at 11 :20 a.m., Resident 1 (R 1 ), who resided in a memory care unit, was observed in their room. The resident was not a good historian and continued to talk of their past when asked if they remembered anything about the incident. On 04/20/2023 at 11 :40 a.m., during an interview, the Resident Care Coordinator (Staff B) stated, during shift change, it was reported that R 1 had an injury to their mouth. Staff B stated she did not get witness statements from the staff. Staff B confirmed she did not interview night shift and stated day shift staff did not know how the injury occurred. On 04/20/2023 at 11 :40 a.m., during an interview, the Corporate Nurse (Staff C) stated she was there when the incident was reported. Staff C confirmed she did not get witness statements from staff and stated the day shift staff was unaware of how the resident sustained the injury. When asked, Staff C stated she did not interview staff from the previous shift. On 04/20/2023, at 11 :50 a.m., during an interview, the Executive Director (Staff A) stated the incident report documented the resident stated they did not fall. Staff A was unable to show how the facility further investigated to determine the circumstances of the event. . Statement of Deficiencies License#: 2160 Compliance Determination# 23146 Plan of Correction Spring Ridge Retirement, LLC Completion Date Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Spring Ridge Retirement, LLC 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 . STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEAL TH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 05/01/2023 Licensee: Spring Ridge Retirement, LLC Spring Ridge Retirement, LLC 6856 E Portland Ave Tacoma, WA 98404 RE: Spring Ridge Retirement, LLC License# 2160 Dear Administrator: The Department completed a complaint investigation of your Assisted Living Facility on 05/01/2023 and found that your facility does not meet the Assisted Living Facility licensing requirements. The Department: • Wrote the enclosed Statement of Deficiencies (SOD) report; and •May take licensing enforcement action based on any deficiency listed on the enclosed report; and •May inspect the facility to determine if you have corrected all deficiencies. You Must: • Begin the process of correcting the 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 the enclosed 'Plan/Attestation Statement'; oSign and date the enclosed report; o For each deficiency, indicate the date you have or will correct each deficiency; o Next to each deficiency, sign and date certifying that you have or will correct each cited deficiency; and oMail the Plan/Attestation Statement and report with original signatures to: . Spring �idg.a Retirement, LLC Spring RiQge Retirement, LLC License# 2160 05/01/2023 Page2 of2 Manfay Ghan, Field Manager Region 3, Ut1it D Lakewood, WA 98496 -� Complete correction(s) within 45 days, or sooner if directed by the Department, after review of your proposed correction dat�s. • Have your plan approved by the Department. Yqu Mi!ly: - Receive a letter of enforcement action based on any deficiency lrsted on the enclosed report . . lnA dditioni You M.ay: • Request an Informal Dispute Resolution {IDR} review within 10 working days after you receive this lefter. Your IDR request must include: o What specific deficiency or deficiencies you disagree with; oWhy you disagree with eacti deflciency; and. o \Nhether you want an IOR to occur in:person, by telephone or as a paper review. oSend your request to: IDR Program Manager Department of Social and Health Services R�siqential Care S\9rvic�s Olympia, WA 98504 560.0 If You Have Any Questio.ns: • Please contact me. at -(253)442�3013 .. Sincerely, ?4.,._t, L 1.. ._, Manfa/ehan, Field Manager Region 3, Unit D Enclosure .

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

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