Hampton Special Care - Tumwater.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: HAMPTON SPECIAL CARE Provider Type: Assisted Living Facility - TUMWATER License/Cert.#: 1579 Intake ID: 200837 Compliance Determination #: 68883 Region/Unit #: RCS Region 3 / Unit E Investigator: Pamela Horlick Investigation Date(s): 11/18/2025 through 12/11/2025 Complainant Contact Date(s): Allegation(s): 1. Resident/Patient/Client Neglect: Report of resident not getting their medication. 2. Pharmaceutical Services: Report of resident not getting their medication. Investigation Methods: Sample: Total residents: 42 Resident sample size: 3 Closed records sample size: 1 Observations: Identified resident Residents Activities Dining Staff to resident interactions Resident to resident interactions Medication administration Interviews: Family members Nursing staff Health care provider executive director Record Reviews: State reporting log Incident investigation Facility policies Medication Administration records Progress Notes Care Plan Medication Orders Resident Handbook Packing/delivery slip After visit summary Staff List Investigation Summary: 1. Resident/Patient/Client Neglect: Facility failed to follow doctors orders by not . obtaining and administering the medication as prescribed. Failed practice identified. 2. Pharmaceutical Services: Facility failed to follow doctors orders by not obtaining and administering the medication as prescribed. Failed practice identified. 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 . I&] □ □ STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 800 NE 136th Ave Ste 200, Vancouver, WA 98684 Statement of Deficiencies License #: 1579 Compliance Determination # 57742 Plan of Correction HAMPTON SPECIAL CARE - TUMWATER Completion Date You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for an unannounced on-site complaint investigation on 04/07/2025, 04/02/2025 and 04/09/2025 of: HAMPTON SPECIAL CARE - TUMWATER 1400 Trosper Rd SW Tumwater, WA 98512 This document references the following complaint number(s): 172578, 172684, 173353 The following sample was selected for review during the unannounced on-site visit: 3 of 46 current residents and 1 former residents. The department staff that investigated the Assisted Living Facility: Phan Pham, Nurse Surveyor From: DSHS, Aging and Long-Term Support Administration 800 NE 136th Ave Ste 200 Vancouver, WA 98684 . Statement of Deficiencies License #: 1579 Compliance Determination # 57742 Plan of Correction HAMPTON SPECIAL CARE - TUMWATER Completion Date As a result of the on-site visit(s), the department found that you are not in compliance with the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. I understand that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. Administrator (or Representative) Date WAC 388-78A-2703 Safety of the built environment. The assisted living facility must provide a safe environment and promote the safety of each resident whenever the resident is on the premises or under the supervision of staff persons consistent with the resident's negotiated service agreement, and must maintain the premises and equipment used in resident care so as to be free of hazards, including: This requirement was not met as evidenced by: Based on observation, interview and record review, the assisted living facility failed to ensure staff members took necessary safety measures to promote safety and prevent avoidable injuries when assisting a resident with wheelchair mobility for 1 of 4 sampled residents (Resident 1) reviewed. This failure resulted in Resident 1 sustaining facial injuries requiring hospitalization and placed wheelchair dependent residents at risk for harm. Findings included… Review of Resident 1’s (R1) face sheet, dated /2025, showed R1 admitted to the facility on /2024 with diagnosis including . Review of R1’s negotiated service plan, dated 01/03/2025, showed R1 required staff assistance with his activities of daily living. R1 was independent with ambulation. Staff members were to monitor R1 for unsteadiness, safety, and assist R1 with the proper use of mobility assistive devices. On /2025 at 10:45 AM, R1 was observed in bed and covered with blankets. R1 had a skin injury on his left forehead. R1’s spouse was at R1’s bedside and stated R1 . Statement of Deficiencies License #: 1579 Compliance Determination # 57742 Plan of Correction HAMPTON SPECIAL CARE - TUMWATER Completion Date had passed away at 6:00 AM on /2025. Review of an incident investigation for R1, dated /2025 at 10:15 PM, showed staff documented R1 was being transported to his room via a wheelchair. R1 fell forward and R1 hit his face on the floor. R1 was bleeding from his nose and mouth. Review of R1’s progress notes, dated /2025 at 10:47 PM, showed staff documented R1 was transported to the hospital for further evaluation. On 03/24/2025 at 6:26 AM, hospital staff reported R1 sustained skin abrasion and bone fracture on his forehead and injured his front tooth. On 03/24/2025 at 3:38 PM, Staff A, Health Service Director, documented on /2025, a staff member was transporting R1 to bed in his wheelchair when R1’s feet got caught under his wheelchair and fell forward. R1 hit his face on the floor and sustained an abrasion to his forehead and nosebleed. R1 was transported to the hospital and diagnosed with a . In an interview on /2025 at 12:23 PM, Staff C, Caregiver, said she had been trained to check to ensure the resident was safe, feet off the floor and fitted in the wheelchair when assisting residents with wheelchair mobility. Staff C stated she had assisted R1 with wheelchair mobility and was able to transport safely. In an interview on 04/09/2025 at 10:31 AM, Staff B, Charge Nurse, stated R1 was in his wheelchair and staff members were assisting R1 to his room. Staff B said R1’s feet got caught on the carpet and R1 fell out of his wheelchair. Staff B stated staff members had been trained in resident safety and wheelchair transport. Staff B said staff members who were assisting the residents were responsible for ensuring the residents fit in their wheelchair and feet were off the floor. Staff B stated she routinely observed staff members assist residents with mobility and wheelchair transport to ensure the residents were safe. In an interview on 04/09/2025 at 4:06 PM, Staff D, Caregiver, said on /2025 she observed R1 was in his wheelchair in the television room and Staff E, Caregiver, was assisting R1 by pushing the wheelchair to his room. Staff D stated she witnessed the resident’s feet got caught under his wheelchair and R1 fell forward. Staff D said she had been trained in how to assist transport residents in wheelchairs. Staff D stated she would make sure the resident was safe to transport and feet off the floor. In an interview on 04/10/2025 at 12:31 PM, Staff E said on /2025 R1 was sleeping in his wheelchair and Staff D assisted the resident to his room by pushing R1’s wheelchair. Staff E stated R1’s feet got caught on the carpet and the resident fell forward. Staff E said she had been trained to check and ensure the resident fit in the wheelchair, feet off the floor and walk slowly to prevent falls. . Statement of Deficiencies License #: 1579 Compliance Determination # 57742 Plan of Correction HAMPTON SPECIAL CARE - TUMWATER 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, HAMPTON SPECIAL CARE - TUMWATER 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 HEALTH SERVICES Home and Community Living Administration PO Box 45600, Olympia, WA 98504-5600 December 23, 2025 ELECTRONIC-FACSIMILE Administrator HAMPTON SPECIAL CARE – TUMWATER 1400 Trosper Rd SW Tumwater, WA 98512 Assisted Living Facility License # 1579 Licensee: TROSPER ROAD LIMITED PARTNERSHIP IMPOSITION OF CIVIL FINE Dear Administrator: On December 11, 2025, the Department of Social and Health Services (DSHS), Residential Care Services completed a Complaint Investigation at your facility. This letter constitutes formal notice of a civil fine on the license for your assisted living facility, also known as HAMPTON SPECIAL CARE - TUMWATER, located at 1400 Trosper Rd SW, Tumwater, 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 fine on the license is based on the following violation of the RCW and/or WAC as described in the attached Statement of Deficiencies (SOD) report dated December 11, 2025. Civil Fine WAC 388-78A-2210 (1)(b)(2) Medication services. $600.00 The licensee failed to ensure resident’s medications were administered as ordered for two residents. This failure resulted in residents not receiving medications as prescribed and contributed to one resident having altered mental status and being hospitalized and another resident for medical complications. This is a recurring deficiency previously cited on January 24, 2025, and March 25, 2024. NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Administrator HAMPTON SPECIAL CARE – TUMWATER License # 1579 December 23, 2025 Page 2 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: Clinton Fridley, RN, Field Manager Region 3, Unit E 6639 Capitol Blvd SW Point Plaza West Tumwater, WA 98501 Phone: (360) 450-1218/ Fax: (360) 664-8451 rcsregion3email@dshs.wa.gov Appeal Rights: You have two appeal rights: Informal Dispute Resolution (IDR) and an Administrative Hearing. Each has a different request timeline. Informal Dispute Resolution [RCW 18.20.195] You have an opportunity to challenge the deficiencies and/or enforcement actions through the state's IDR process. All IDR requests must be in writing and include: • The deficiencies you are disputing; and • The method of review you prefer (face-to-face, telephone conference or documentation review). The written request must be received by the 10th working day from receipt of this letter. During the IDR process, you will have the opportunity to present written and/or oral evidence to dispute the deficiencies. You can make an IDR request and find directions on the IDR web page at: http://www.dshs.wa.gov/altsa/idr. Administrator HAMPTON SPECIAL CARE – TUMWATER License # 1579 December 23, 2025 Page 3 Formal Administrative Hearing You may contest the civil fine by requesting a formal administrative hearing to challenge the deficiency, which resulted in the civil fine. All hearing requests must be in writing and include: • A copy of this letter; and • A copy of the Statement of Deficiencies. The written request must be received within twenty-eight (28) calendar days of receipt of this letter. Send your written request to: Office of Administrative Hearings PO Box 42489 Olympia, Washington 98504-2489 Payment: If you do not request a formal administrative hearing, the civil fine is due to the Office of Financial Recovery twenty-eight (28) calendar days after receipt of this letter. Mail a check for $600.00 payable to the ‘Department of Social and Health Services’, and if you have or have had a Medicaid resident(s), please include your ProviderOne ID Number # on the check, to: DSHS Office of Financial Recovery PO Box 9501 Olympia, WA 98507-9501 (360) 664-5919 / FAX: (360) 664-8401 OFRMMISVendor@dshs.wa.gov If the Office of Financial Recovery has not received your payment within twenty-eight (28) days after receipt of this letter, interest will begin to accrue immediately on the balance, at the rate of one percent per month. If you do not submit a hearing request or make payment within twenty-eight (28) days, the balance due will be recovered. Administrator HAMPTON SPECIAL CARE – TUMWATER License # 1579 December 23, 2025 Page 4 NOTICE: State and federal law provide protections to defendants who are in military service, and to their dependents. Dependents of a service member are the service member’s spouse, the service member’s minor child, or and individual for whom the service member provided more than one-half of the individual’s support for one hundred eight days immediately preceding an application for relief. One protection provided is the protection against the entry of a default judgment in certain circumstances. This notice pertains only to a defendant who is a dependent of a member of the National Guard or a military reserve component under a call to active service, or a National Guard member under a call to service authorized by the governor of the state of Washington, for a period of more than thirty consecutive days. Other defendants in military service also have protections against default judgments not covered by this notice. If you are the dependent of a member of the national guard or a military reserve component under a call to active service, or a national guard member under a call to service authorized by the governor of the state of Washington, for a period of more than thirty consecutive days, you should notify the Department in writing of your status as such within twenty days of the receipt of this notice. If you fail to do so, then a court or an administrative tribunal may presume that you are not a dependent of an active duty member of the national guard or reserves, or a national guard member under a call to service authorized by the governor of the state of Washington, and proceed with the entry of an order of default and/or a default judgment without further proof of your status. Your response to the Department about your status does not constitute an appearance for jurisdictional purposes in any pending litigation nor a waiver of your rights. If you have any questions, please contact Clinton Fridley, Field Manager, at (360) 450-1218. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 3, Unit E RCS Regional Administrator, Region 3 HCS Regional Administrator, Region 3 DDA Regional Administrator, Region 3 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW HP

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

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 September 25, 2024 ELECTRONIC-FACSIMILE Administrator Hampton Special Care - Tumwater 1400 Trosper Rd SW Tumwater, WA 98512 Assisted Living Facility License # 1579 Licensee: Trosper Road Limited Partnership IMPOSITION OF CIVIL FINE Dear Administrator: On September 13, 2024, the Department of Social and Health Services (DSHS), Residential Care Services completed a Complaint Investigation at your facility. This letter constitutes formal notice of a civil fine on the license for your assisted living facility, also known as Hampton Special Care - Tumwater, located at 1400 Trosper Rd SW, Tumwater, 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 fine on the license is based on the following violation of the RCW and/or WAC as described in the attached Statement of Deficiencies (SOD) report dated September 13, 2024 Civil Fine WAC 388-78A-2610(1)(2)(a)(d)(c)(f) Infection control. $800.00 The licensee failed to implement infection control practices by staff not performing hand hygiene and not wearing correct personal protective equipment (PPE) in two areas (north and south side of memory care unit) during an infectious disease outbreak. The licensee failed to report an infectious disease outbreak to the Local Health Jurisdiction (LHJ). The licensee failed to follow and implement the Centers for Disease Control and Prevention (CDC) guidance for use and storage of PPE. These failures placed 38 residents and all staff members, and visitors at risk of being infected and continuing the spread of COVID-19 (Corona Virus Disease 2019-an infectious disease caused by a virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, sore throat, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste Administrator Hampton Special Care – Tumwater License # 1579 September 25, 2024 Page 2 or smell, and in severe cases difficulty breathing that could result in severe impairment or death) during a COVID-19 outbreak. This is a recurring deficiency previously cited on July 31, 2023, and February 17, 2022. NOTE: This is the violation, which resulted in the fine; 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: Cory Cisneros, Field Manager Region 3, Unit E 6639 Capitol Blvd SW Point Plaza West Tumwater, WA 98501 Phone: (253) 254-3190 / Fax: (360) 664-8451 rcsregion3email@dshs.wa.gov Appeal Rights: You have two appeal rights: Informal Dispute Resolution (IDR) and an Administrative Hearing. Each has a different request timeline. Informal Dispute Resolution [RCW 18.20.195] You have an opportunity to challenge the deficiencies and/or enforcement actions through the state's IDR process. All IDR requests must be in writing and include: • The deficiencies you are disputing; and • The method of review you prefer (face-to-face, telephone conference or documentation review). The written request must be received by the 10th working day from receipt of this letter. During the IDR process, you will have the opportunity to present written and/or oral evidence to dispute the deficiencies. Administrator Hampton Special Care – Tumwater License # 1579 September 25, 2024 Page 3 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 fine by requesting a formal administrative hearing to challenge the deficiency, which resulted in the civil fine. All hearing requests must be in writing and include: • A copy of this letter; and • A copy of the Statement of Deficiencies. The written request must be received within twenty-eight (28) calendar days of receipt of this letter. Send your written request to: Office of Administrative Hearings PO Box 42489 Olympia, Washington 98504-2489 Payment: If you do not request a formal administrative hearing, the civil fine is due to the Office of Financial Recovery twenty-eight (28) calendar days after receipt of this letter. Mail a check for $800.00 payable to the ‘Department of Social and Health Services’, and if you have or have had a Medicaid resident(s), please include your ProviderOne ID Number # on the check, to: DSHS Office of Financial Recovery PO Box 9501 Olympia, WA 98507-9501 (360) 664-5919 / FAX: (360) 664-8401 OFRMMISVendor@dshs.wa.gov If the Office of Financial Recovery has not received your payment within twenty-eight (28) days after receipt of this letter, interest will begin to accrue immediately on the balance, at the rate of one percent per month. If you do not submit a hearing request or make payment within twenty-eight (28) days, the balance due will be recovered. Administrator Hampton Special Care – Tumwater License # 1579 September 25, 2024 Page 4 If you have any questions, please contact Cory Cisneros, Field Manager, at (253) 254-3190. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 3, Unit E RCS Regional Administrator, Region 3 HCS Regional Administrator, Region 3 DDA Regional Administrator, Region 3 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW HP

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: HAMPTON SPECIAL CARE Provider Type: Assisted Living Facility - TUMWATER License/Cert.#: 1579 Intake ID: 111980 Compliance Determination #: 34645 Region/Unit #: RCS Region 3 / Unit E Investigator: Paul Aube Investigation Date(s): 01/03/2024 through 01/03/2024 Complainant Contact Date(s): Allegation(s): Quality of Care/Treatment: Facility report of a resident-to-resident altercation in the community. Investigation Methods: Sample: Total residents: 46 Resident sample size: 3 Closed records sample size: 1 Observations: Residents Dining Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Nursing staff Family members Management Record Reviews: Facility policies Incident Log Incident investigation Progress Notes/Alert Charting Care Plans Investigation Summary: Quality of Care/Treatment: Facility investigated incident, and monitored residents per policy. Facility failed to follow policy and notify law enforcement after one resident physically assaulted another resident. Failed practice identified. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written . N/A . . .

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 August 7, 2023 ELECTRONIC-FACSIMILE Administrator Hampton Special Care - Tumwater 1400 Trosper Rd SW Tumwater, WA 98512 Assisted Living Facility License #1579 Licensee: Trosper Road Limited Partnership IMPOSITION OF CIVIL FINE Dear Administrator: On July 31, 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 a civil fine on the license for your assisted living facility, also known as Hampton Special Care - Tumwater, located at 1400 Trosper Rd SW, Tumwater, 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 fine on the license is based on the following violation of the RCW and/or WAC as described in the attached Statement of Deficiencies (SOD) report dated July 31, 2023. Civil Fine WAC 388-78A-2610 (1)(2)(c) Infection control. $300.00 The licensee failed to provide the necessary handwashing supplies in one common bathroom. This failure placed all 46 residents, staff, and visitors at risk for spread of infectious disease. This is a recurring deficiency previously cited on February 17, 2022, and February 4, 2021. NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Administrator Hampton Special Care – Tumwater License #1579 August 7, 2023 Page 2 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: Cory Cisneros, Field Manager Region 3, Unit E 6639 Capitol Blvd SW Point Plaza West Tumwater, WA 98501 Phone: (253) 254-3190 / Fax: (360) 664-8451 rcsregion3email@dshs.wa.gov Appeal Rights: You have two appeal rights: Informal Dispute Resolution (IDR) and an Administrative Hearing. Each has a different request timeline. Informal Dispute Resolution [RCW 18.20.195] You have an opportunity to challenge the deficiencies and/or enforcement actions through the state's IDR process. All IDR requests must be in writing and include: • The deficiencies you are disputing; and • The method of review you prefer (face-to-face, telephone conference or documentation review). The written request must be received by the 10th working day from receipt of this letter. During the IDR process, you will have the opportunity to present written and/or oral evidence to dispute the deficiencies. Send your written request to: Informal Dispute Resolution Program Manager Residential Care Services PO Box 45600 Olympia, Washington 98504-5600 Administrator Hampton Special Care – Tumwater License #1579 August 7, 2023 Page 3 Formal Administrative Hearing You may contest the civil fine by requesting a formal administrative hearing to challenge the deficiency, which resulted in the civil fine. All hearing requests must be in writing and include: • A copy of this letter; and • A copy of the Statement of Deficiencies. The written request must be received within twenty-eight (28) calendar days of receipt of this letter. Send your written request to: Office of Administrative Hearings PO Box 42489 Olympia, Washington 98504-2489 Payment: If you do not request a formal administrative hearing, the civil fine is due to the Office of Financial Recovery twenty-eight (28) calendar days after receipt of this letter. Mail a check for $300.00 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 rate of one percent per month. If you do not submit a hearing request or make payment within twenty-eight (28) days, the balance due will be recovered. Administrator Hampton Special Care – Tumwater License #1579 August 7, 2023 Page 4 If you have any questions, please contact Cory Cisneros, Field Manager, at (253) 254-3190. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 3, Unit E RCS Regional Administrator, Region 3 HCS Regional Administrator, Region 3 DDA Regional Administrator, Region 3 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW HP