Hearthside Manor.

Statement of Deficiencies License #: 2142 Compliance Determination # 66429 Plan of Correction Hearthside Manor 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 the unannounced on-site full inspection on 10/01/2025 and 10/03/2025 of: Hearthside Manor 3615 Drexler Dr W University Place, WA 98466 The following sample was selected for review during the unannounced on-site visit: 7 of 31 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Shirley Grew, LTC Surveyor Cory Myers, NCI ALF Licensor From: DSHS, Aging and Long-Term Support Administration Lakewood, WA 98496 . . Statement of Deficiencies License #: 2142 Compliance Determination # 66429 Plan of Correction Hearthside Manor 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-2480 Tuberculosis Testing Required. (1) The assisted living facility must develop and implement a system to ensure each staff person is screened for tuberculosis within three days of employment. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to screen 1 of 3 sampled new staff (Staff B) for tuberculosis (TB), within three days of employment, as required. This failure placed all residents at risk for possible exposure and harm from a communicable disease. Findings included… Review of the facility's undated employee roster showed the facility hired Staff B, Caregiver/Med Aide, on 05/02/2024. Review of Staff B's personnel file showed no record that Staff B completed any TB testing. During an interview on 10/03/2025 at 3:30 PM, Staff A, Administrator, stated that they found no TB testing records for Staff B. This is a recurring deficiency previously cited on 04/11/2024 for subsection (1). . . Statement of Deficiencies License #: 2142 Compliance Determination # 66429 Plan of Correction Hearthside Manor 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, Hearthside Manor 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 . --- 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 Statement of Deficiencies License #: 2142 Compliance Determination # 66018 Plan of Correction Hearthside Manor 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 09/23/2025 of: Hearthside Manor 3615 Drexler Dr W University Place, WA 98466 This document references the following complaint number(s): 192458, 194385, 194501 The following sample was selected for review during the unannounced on-site visit: 0 of 0 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Woodetta Maulana, From: DSHS, Aging and Long-Term Support Administration Lakewood, WA 98496 . Statement of Deficiencies License #: 2142 Compliance Determination # 66018 Plan of Correction Hearthside Manor 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-2630 Reporting abuse and neglect. (1) The assisted living facility must ensure that each staff person: (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. This requirement was not met as evidenced by: Based on record review and interview, the Assisted Living Facility (ALF) failed to notify the department when suspected abuse occurred for 1 of 1 resident (Resident 1). Failure to report allegations of suspected abuse denied the state the opportunity to investigate and ensure resident safety and placed all 32 residents at risk for harm. Findings included… Review of the facility’s witness statement from an incident on 9/15/2025 documented: Resident 1 was sleeping on the loveseat. Staff asked Resident 1 to get up and when Resident 1 refused, staff made Resident 1 move from a laying position to a sitting upright position. Staff grabbed Resident 1 by the arms, between the shoulder and elbow on both sides and yanked Resident 1 up to their feet while resident was fighting. Resident 1 was grabbed and pulled so hard that they yelled out and then while staff held the left arm in the same place, they took Resident 1 to their room. On 9/23/2025 at 2:30 p.m., during an interview, Staff B, caregiver, stated that they witnessed the incident and immediately notified Staff A, Executive Director. . Statement of Deficiencies License #: 2142 Compliance Determination # 66018 Plan of Correction Hearthside Manor Completion Date On 9/23/2025 at 2:45 p.m., during an interview, Staff A stated that they immediately suspended Staff C, caregiver. Staff A stated that they did not notify the state of the allegation of possible abuse because the facility’s investigation did not substantiate any abuse. Staff A stated that they believed they only needed to notify the state if the investigation concluded that abuse occurred. 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, Hearthside Manor is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date .

This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website.