Cogir at the Quarry.

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 800 NE 136th Ave Ste 200, Vancouver, WA 98684 Statement of Deficiencies License #: 2640 Compliance Determination # 67823 Plan of Correction Cogir at the Quarry Completion Date Page 1 of 22 Licensee: Cogir Management USA Inc 10/31/2025 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 10/27/2025 and 10/31/2025 of: Cogir at the Quarry 415 SE 177th Ave Vancouver, WA 98683 The following sample was selected for review during the unannounced on-site visit: 18 of 181 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Kyle Gehlen, ALF Licensor - LTC Jason Rose Jennifer Siharath, ALF Licensor From: DSHS, Aging and Long-Term Support Administration Residential Care Services, Region 3 , Unit E 800 NE 136th Ave Ste 200 Vancouver, WA 98684 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 #: 2640 Compliance Determination # 67823 Plan of Correction Cogir at the Quarry Completion Date Page 2 of 22 Licensee: Cogir Management USA Inc 10/31/2025 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-2466 Background checks Washington state name and date of birth background check Valid for two years National fingerprint background check Valid indefinitely. (1) A Washington state name and date of birth background check is valid for two years from the initial date it is conducted. The assisted living facility must ensure: (a) A new DSHS background authorization form is submitted to the department's background check central unit every two years for all administrators, caregivers, staff persons, volunteers and students; and (b) There is a valid Washington state name and date of birth background check for all administrators, caregivers, staff persons, volunteers and students. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure that a Washington state name and date of birth background check was completed every two years for 2 of 2 sampled staff (Staff E and F). This failure placed all residents at risk for harm by receiving care and services from staff whose criminal history was unknown. Findings included… On 10/28/2025 at 12:00 PM, the department received the requested staff documents. Record review for Staff E, Medication Technician, showed that Staff E was hired on 08/07/2020. Review of Staff E’s Washington State name and date of birth background checks showed that it was completed on 04/05/2024. No other Washington State name and date of birth background checks were provided to show that one had been completed at least every two years since Staff E was hired. 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 #: 2640 Compliance Determination # 67823 Plan of Correction Cogir at the Quarry Completion Date Page 3 of 22 Licensee: Cogir Management USA Inc 10/31/2025 Record review for Staff F, Medication Technician, showed that Staff F was hired on 06/07/2021. Review of Staff F’s Washington State name and date of birth background checks showed that one was completed on 06/04/2021 and another one completed on 01/11/2024. No other Washington State name and date of birth background checks were provided to show that one had been completed at least every two years since Staff F was hired. On 10/31/2025 at 11:00 AM, Staff A, Executive Director, acknowledged that the current Washington state name and date of birth background check for Staff E and F were either completed late and/or not completed at least every two years. 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, Cogir at the Quarry 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: (i) The resident's preadmission assessment; (ii) The resident's full assessments; (iii) On-going assessments of the resident; (b) The plan to provide assistance with activities of daily living, if provided by the assisted living facility; (c) The plan to provide necessary intermittent nursing services, if provided by the assisted living facility; (d) The plan to provide necessary health support services, if provided by the assisted living facility; (e) The resident's preferences for how services will be provided, supported and This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2640 Compliance Determination # 67823 Plan of Correction Cogir at the Quarry Completion Date Page 4 of 22 Licensee: Cogir Management USA Inc 10/31/2025 accommodated by the assisted living facility. (2) Clearly defined respective roles and responsibilities of the resident, the assisted living facility staff, and resident's family or other significant persons in meeting the resident's needs and preferences. Except as specified in WAC 388-78A-2290 and 388-78A-2340 (5), if a person other than a caregiver is to be responsible for providing care or services to the resident in the assisted living facility, the assisted living facility must specify in the negotiated service agreement an alternate plan for providing care or service to the resident in the event the necessary services are not provided. The assisted living facility may develop an alternate plan: (a) Exclusively for the individual resident; or (b) Based on standard policies and procedures in the assisted living facility provided that they are consistent with the reasonable accommodation requirements of state and federal law. (3) The times services will be delivered, including frequency and approximate time of day, as appropriate; (4) The resident's preferences for activities and how those preferences will be supported; (5) Appropriate behavioral interventions, if needed; (6) A communication plan, if special communication needs are present; (7) The resident's ability to leave the assisted living facility premises unsupervised; and (8) The assisted living facility must not require or ask the resident or the resident's representative to sign any negotiated service or risk agreement, that purports to waive any rights of the resident or that purports to place responsibility or liability for losses of personal property or injury on the resident. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to document, in the resident’s negotiated service agreements (NSA), the plan to provide specific resident identified care and service needs for 8 of 15 sampled residents (Residents 1, 2, 3, 6, 7, 8, 9, and 12). This failure to develop a complete NSA placed these residents at risk for unmet care needs and for care and services not being provided per the NSA. Findings included… Resident 1 (R1) On 10/28/2025 at 10:40 AM, R1’s records showed that they admitted to the facility on /2024 with various diagnoses including , and . This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2640 Compliance Determination # 67823 Plan of Correction Cogir at the Quarry Completion Date Page 5 of 22 Licensee: Cogir Management USA Inc 10/31/2025 Record review of the facility’s resident characteristic roster (RCR) documented that R1 has a medical device. Record review of R1’s assessments, showed an assessment dated 10/07/2025 that documented that R1 uses a medical device. Record review of R1’s NSA’s, showed an NSA dated 10/07/2025. No documentation was found on the NSA to show that R1 uses a medical device. On 10/29/2025, the facility confirmed that R1 has side rails. Resident 2 (R2) On 10/27/2025 at 12:50 PM, R2’s records showed that they admitted to the facility on 2022 with various diagnoses including and . Record review of R2’s NSA’s, showed a current NSA dated 10/27/2025. No documentation was found to show the type of diet that R2 was receiving. Resident 3 (R3) On 10/27/2025 at 1:20 PM, R3’s records showed that they admitted to the facility on /2025 with various diagnoses including and . Record review of R3’s NSA’s, showed a current NSA dated 10/03/2025. No documentation was found to show the type of diet that R3 was receiving. Resident 6 (R6) On 10/28/2025 at 12:50 PM, R6’s records showed that they admitted to the facility on /2023 with various diagnoses including , and . This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2640 Compliance Determination # 67823 Plan of Correction Cogir at the Quarry Completion Date Page 6 of 22 Licensee: Cogir Management USA Inc 10/31/2025 Record review of the facility’s RCR, documented that R6 receives nurse delegation. Record review of R6’s nurse delegation documents showed a consent signed on 03/01/2023 and a nurse delegation nursing visit completed on 10/01/2025 for capillary blood glucose (CBG) monitoring. Record review of R6’s NSAs, showed a current NSA dated 09/29/2025. No documentation was found to show that R6 receives nurse delegation services for CBG monitoring or the type of diet that R6 was receiving. Resident 7 (R7) On 10/28/2025 at 1:35 PM, R7’s records showed that they admitted to the facility on /2022 with various diagnoses including , and . Record review of the facility’s RCR documented that R7 has wounds, utilizes a medical device, and receives home health services. On 10/29/2025, the facility confirmed that R7 receives home health services and has a transfer pole. Record review of R7’s assessments showed a medical device assessment, dated 08/06/2025, for a transfer pole. Record review of R7’s NSAs, showed an NSA dated 08/17/2025. No documentation was found to show that R7 has any wounds, uses a medical device or receives home health services. Resident 8 (R8) On 10/28/2025 at 2:35 PM, R8’s records showed that they admitted to the facility on /2025 with various diagnoses including , and . Review of R8’s records, showed a hospice summary note, dated 10/14/2025, that documented under areas of decline, that R8 has a new stage two ulcer to the buttocks, was taking showers, but now bed baths only, and has difficulty swallowing, was eating all types of food, but now just soft mechanical diet. Record review of R8’s NSAs, showed a current NSA, dated 07/28/2025, that documented This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2640 Compliance Determination # 67823 Plan of Correction Cogir at the Quarry Completion Date Page 7 of 22 Licensee: Cogir Management USA Inc 10/31/2025 that R8 takes showers and has an “easy to chew” textured diet with thin liquids. No documentation was found to show that R8 has any wounds. Resident 9 (R9) On 10/29/2025 at 9:00 AM, R9’s records showed that they admitted to the facility on /2024 with various diagnoses including and . Record review of the facility’s RCR, documented that R9 receives home health services. Record review of R9’s assessments, showed an assessment, dated 06/09/2025, that documented that R9 receives home health services. Record review of R9’s NSAs, showed a current NSA dated 05/11/2025. No documentation was found to show that R9 receives any home health services. Resident 12 (R12) On 10/29/2025 at 10:05 AM, R12’s records showed that they admitted to the facility on /2024 with various diagnoses including , and . Record review of the facility’s RCR, showed documentation that R12 shows wandering behaviors. Record review of R9’s NSAs, showed a current NSA, dated 09/05/2025, that documented that R12 does not have a history of wandering. On 10/31/2055 at 11:00 AM, Staff A, Executive Director, acknowledged the department’s findings of pertinent information missing from the NSAs. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2640 Compliance Determination # 67823 Plan of Correction Cogir at the Quarry Completion Date Page 8 of 22 Licensee: Cogir Management USA Inc 10/31/2025 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, Cogir at the Quarry 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-2130 Service agreement planning. The assisted living facility must: (2) Complete the negotiated service agreement for each resident using the resident's preadmission assessment, initial resident service plan, and full assessment information, within thirty days of the resident moving in; This requirement was not met as evidenced by: Based on interview and record review, the facility failed to complete the negotiated service agreement (NSA) within 30 days of admission to the facility for 2 of 7 sampled residents (Resident 13 and 16). This failure placed these two residents at risk for proper care needs being unmet. Findings included… Resident 13 (R13) On 10/29/2025 at 10:10AM, R13’s records showed that they admitted to the facility on /2025 with various diagnoses including . Record review of R13’s NSAs showed that an initial NSA dated /2025 and another NSA dated 09/02/2025. No other NSA was provided to show that an NSA was completed within 30 days of R13 admitting to the facility. Resident 16 (R16) On 10/31/2025 at 10:00 AM, R16’s records showed that they admitted to the facility on /2025 with various diagnoses including . 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 #: 2640 Compliance Determination # 67823 Plan of Correction Cogir at the Quarry Completion Date Page 9 of 22 Licensee: Cogir Management USA Inc 10/31/2025 Record review of R16’s NSAs showed that an initial NSA dated 09/09/2025 and another NSA dated 10/23/2025. No other NSA was provided to show that an NSA was completed within 30 days of R16 admitting to the facility. On 10/31/2025 at 11:00 AM, Staff A, Executive Director, acknowledged that the 30-day NSAs were not completed for R13 and R16. 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, Cogir at the Quarry 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; (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 This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2640 Compliance Determination # 67823 Plan of Correction Cogir at the Quarry Completion Date Page 10 of 22 Licensee: Cogir Management USA Inc 10/31/2025 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. (8) Individual's level of personal care needs, including: (a) Ability to perform activities of daily living; (b) Medication management ability, including: This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2640 Compliance Determination # 67823 Plan of Correction Cogir at the Quarry Completion Date Page 11 of 22 Licensee: Cogir Management USA Inc 10/31/2025 (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 14 days of the resident admission to the facility for 4 of 7 sampled residents (Residents 3, 10, 11, and 13). The facility failed to include all necessary assessment topics in their full assessment for 5 of 15 sampled residents (Residents 1, 6, 8, 9 and 12). The facility also failed to assess other safety considerations that may pose a danger when they failed to complete self-administration of medication assessments for 2 of 5 sampled residents (Residents 2 and 10). These failures placed these residents at risk of their care needs not being met. Findings included… Resident 1 (R1) On 10/28/2025 at 10:40 AM, R1’s records showed that they admitted to the facility on /2024 with various diagnoses including , and . Record review of R1’s assessments showed a current assessment dated 10/07/2025 that documented that R1 receives nurse delegation. On 10/30/2025 at 11:55 am, Staff B, Director of Nursing Services, confirmed over the This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2640 Compliance Determination # 67823 Plan of Correction Cogir at the Quarry Completion Date Page 12 of 22 Licensee: Cogir Management USA Inc 10/31/2025 phone that R1 does not receive nurse delegation services. Resident 2 (R2) On 10/27/2025 at 12:50 PM, R2’s records showed that they admitted to the facility on /2022 with various diagnoses including and . Record review of R2’s negotiated service agreement (NSA) dated 10/27/2025 documented that R2 is independent with medication administration and receives assistance from family. Record review of R2’s assessments showed no documentation that a self-administration of medication assessment was completed for R2. On 10/29/2025 at 1:48 PM, the department requested a self-administration of medication assessment for R2. On 10/30/2025 at 11:55 AM, the department again requested a self-administration of medication assessment for R2. On 10/31/2025 at 9:00 AM, a self-administration of medication assessment dated 10/30/2025 had been provided for R2. Resident 3 (R3) On 10/27/2025 at 1:20 PM, R3’s records showed that they admitted to the facility on /2025 with various diagnoses including and . Record review of R3’s assessments showed a preadmission assessment completed on 08/20/2025 and another assessment dated 09/30/2025 for a change in condition. On 10/29/2025 an assessment dated 09/09/2025 was provided for R3. No other assessments were found to show that a full assessment was completed within 14 days of R3’s admission into the facility. Resident 6 (R6) This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2640 Compliance Determination # 67823 Plan of Correction Cogir at the Quarry Completion Date Page 13 of 22 Licensee: Cogir Management USA Inc 10/31/2025 On 10/28/2025 at 12:50 PM, R6’s records showed that they admitted to the facility on /2023 with various diagnoses including , and . Initial review of R6’s records, showed no full assessments completed for R6. On 10/30/2025 at 11:55 AM, the department requested a current full assessment for R6. By the completion of the onsite full inspection on 10/31/2025, no full assessments had been provided for R6. Resident 8 (R8) On 10/28/2025 at 2:35 PM, R8’s records showed that they admitted to the facility on /2025 with various diagnoses including , and . Review of R8’s records showed a hospice summery note dated 10/14/2025 that documented under areas of decline, that R8 has a new stage two ulcer to the buttocks and is now only receiving bed baths. Record review of R8’s assessments, showed an assessment dated 07/18/2025 that documented that R8 has no active wounds, receives showers, and uses a medical device. On 10/29/2025 at 1:48 PM, the department requested a medical device assessment for R8. On 10/30/2025 at 11:55 AM, Staff C, Health Services Director, confirmed that R8 does not have a medical device. Resident 9 (R9) On 10/29/2025 at 9:00 AM, R9’s records showed that they admitted to the facility on /2024 with various diagnoses including and . Record review of R9’s assessments, showed an assessment dated 06/09/2025 that documented that R9 has bed rails. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2640 Compliance Determination # 67823 Plan of Correction Cogir at the Quarry Completion Date Page 14 of 22 Licensee: Cogir Management USA Inc 10/31/2025 On 10/29/2025 at 1:48 PM, the department requested a medical device assessment for R9. On 10/30/2025 at 11:55 AM, Staff C, Health Services Director, confirmed that R9 does not have bed rails. Resident 10 (R10) On 10/29/2025 at 9:40 AM, R10’s records showed that they admitted to the facility on /2025 with various diagnoses including . Initial review of R10’s assessments showed an assessment labeled “initial” that was dated 06/27/2025. No other assessments were found. On 10/30/2025, two assessments were provided, one labeled “initial” with a date of 07/11/2025 and labeled “14-day” with a date of 08/13/2025. No other assessments were found or provided to show that a full assessment was completed within 14 days of R10’s admission into the facility. Resident 11 (R11) On 10/29/2025 at 9:44 AM, R11’s records showed that they admitted to the facility on /2025 with various diagnoses including . Record review of R11’s assessments showed a preadmission assessment dated 07/23/2025 and an assessment labeled 14-day assessment dated 08/24/2025. No other assessments were found to show that an assessment was completed within 14 days of R11’s admission to the facility. Resident 12 (R12) On 10/29/2025 at 10:05 AM, R12’s records showed that they admitted to the facility on /2024 with various diagnoses including , and . Record review of the facility’s resident characteristic roster documented that R12 has shown wandering behaviors. Record review of R12’s assessments, showed an assessment dated 08/25/2025 that did not document that R12 has any wandering behaviors. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2640 Compliance Determination # 67823 Plan of Correction Cogir at the Quarry Completion Date Page 15 of 22 Licensee: Cogir Management USA Inc 10/31/2025 Resident 13 (R13) On 10/29/2025 at 10:10AM, R13’s records showed that they admitted to the facility on /2025 with various diagnoses including . Record review of R13’s assessments showed a preadmission assessment dated 07/11/2025 and an assessment labeled 14-day assessment dated 08/05/2025. No other assessments were found to show that an assessment was completed within 14 days of R13’s admission to the facility. On 10/31/2025 at 11:00 AM, Staff A, Executive Director, acknowledged the departments findings. 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, Cogir at the Quarry 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; This requirement was not met as evidenced by: Based on interview and record review, the facility failed to complete an annual full assessment for 2 of 8 sampled residents (Residents 2 and 6). This failure placed these two residents at risk of their care needs not being met. Findings included… Resident 2 (R2) This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2640 Compliance Determination # 67823 Plan of Correction Cogir at the Quarry Completion Date Page 16 of 22 Licensee: Cogir Management USA Inc 10/31/2025 On 10/27/2025 at 12:50 PM, R2’s records showed that they admitted to the facility on /2022 with various diagnoses including and . No assessments were found during the initial review of R2’s records. On 10/29/2025 at 1:48 PM, the department requested a current full assessment for R2. On 10/30/2025 at 11:55 AM, the department again requested a current full assessment for R2. By the completion of the onsite full inspection on 10/31/2025, no current full assessment was provided for R2. Resident 6 (R6) On 10/28/2025 at 12:50 PM, R6’s records showed that they admitted to the facility on /2023 with various diagnoses including , and . No assessments were found during the initial review of R6’s records. On 10/30/2025 at 11:55 AM, the department requested a current full assessment for R6. By the completion of the onsite full inspection on 10/31/2025, no current full assessment was provided for R6. On 10/31/2025 at 11:00 AM, Staff A, Executive Director, acknowledged that there was no documentation to show that a current full assessment was completed for R2 and R6. 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 #: 2640 Compliance Determination # 67823 Plan of Correction Cogir at the Quarry Completion Date Page 17 of 22 Licensee: Cogir Management USA Inc 10/31/2025 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, Cogir at the Quarry 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-2290 Family assistance with medications and treatments. (3) If the assisted living facility allows family assistance with or administration of medications and treatments, and the resident and a family member(s) agree a family member will provide medication or treatment assistance, or medication or treatment administration to the resident, the assisted living facility must request that the family member submit to the assisted living facility a written plan for such assistance or administration that includes at a minimum: (a) By name, the family member who will provide the medication or treatment assistance or administration; (b) A description of the medication or treatment assistance or administration that the family member will provide, to be referred to as the primary plan; (c) An alternate plan if the family member is unable to fulfill his or her duties as specified in the primary plan; (d) An emergency contact person and telephone number if the assisted living facility observes changes in the resident's overall functioning or condition that may relate to the medication or treatment plan; and (e) Other information determined necessary by the assisted living facility. (4) The plan for family assistance with medications or treatments must be signed and dated by: (a) The resident, if able; (b) The resident's representative, if any; (c) The resident's family member responsible for implementing the plan; and (d) A representative of the assisted living facility authorized by the assisted living facility to sign on its behalf. This requirement was not met as evidenced by: This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2640 Compliance Determination # 67823 Plan of Correction Cogir at the Quarry Completion Date Page 18 of 22 Licensee: Cogir Management USA Inc 10/31/2025 Based on interview and record review, the facility failed to ensure a written plan was submitted including the minimum information required when 1 of 4 residents (Resident 8) had family assisting with medications. This failure placed this resident at risk for not receiving medications as prescribed due to missing documentation of the assistance family was providing with medications. Findings included… Resident 8 (R8) On 10/28/2025 at 2:35 PM, R8’s records showed that they admitted to the facility on /2025 with various diagnoses including , and . Record review of the facility’s resident characteristic roster showed documentation that R8 has family assisting with medication management. Record review of R8’s assessments showed an assessment dated 07/18/2025 that documented that family manages R8’s medications. No plan for family assisting with medications was found for R8. On 10/29/2025 at 1:48 PM, the department requested a family assisting with medication plan for R8. On 10/30/2025 at 11:55 AM, Staff H, Resident Care Coordinator, stated that all they could find was documentation on the assessment that stated R8’s “wife will do meds.” On 10/31/2025 at 09:25 AM, Staff C, Health Services Director, confirmed that they could not find documentation that a plan for family assisting with medications had been completed for R8. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2640 Compliance Determination # 67823 Plan of Correction Cogir at the Quarry Completion Date Page 19 of 22 Licensee: Cogir Management USA Inc 10/31/2025 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, Cogir at the Quarry 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-2390 Resident records. The assisted living facility must maintain adequate records concerning residents to enable the assisted living facility: (1) To effectively provide the care and services agreed upon with the resident; (2) To allow the resident to communicate with family, medical providers, and others; and (3) To respond appropriately in emergency situations, including, but not limited to, contacting the residents' emergency contact. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to maintain a current characteristic roster accurately documenting resident care needs and services for 6 of 15 sampled residents (Residents 4, 5, 7, 9, 12, and 15). This failure placed these residents at risk for proper care needs not being met. Findings included… Resident 4 (R4) On 10/27/2025 at 1:35 PM, R4’s records showed that they admitted to the facility on /2022 with various diagnoses including , and . Record review of the facility’s Resident Characteristic Roster (RCR) documented that R4 receives nurse delegation and home health services. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2640 Compliance Determination # 67823 Plan of Correction Cogir at the Quarry Completion Date Page 20 of 22 Licensee: Cogir Management USA Inc 10/31/2025 Record review of R4’s assessments showed an assessment dated 09/02/2025. No documentation was found to show that R4 receives any nurse delegation or home health services. Record review of R4’s NSAs showed an NSA dated 09/18/2025. No documentation was found to show that R4 receives nurse delegation or home health services. Record review of R4’s notes, showed an outside provide note, dated 08/27/2025 from physical therapy, and 09/16/2025 from occupational therapy. On 10/30/2025 at 11:55 AM, Staff B, Director of Nursing Services, confirmed over the phone that R4 does not receive nurse delegation services. Staff C, Health Services Director, confirmed that R4 was discharged from home health and is no longer receiving services. Resident 5 (R5) On 10/28/2025 at 12:10 PM, R5’s records showed that they admitted to the facility on /2024 with various diagnoses including , and . Record review of the facility’s RCR, documented that R5 has a medical device. Record review of R5’s negotiated service agreements (NSA), showed an NSA dated 10/14/2025. No documentation was found to show that R5 has a medical device. On 10/30/2025 at 11:55 AM, Staff C confirmed that R5 does not have a medical device. Resident 7 (R7) On 10/28/2025 at 1:35 PM, R7’s records showed that they admitted to the facility on /2022 with various diagnoses including , and . Record review of R7’s NSAs showed an NSA, dated 08/17/2025, that documented that R7 has urinary incontinence. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2640 Compliance Determination # 67823 Plan of Correction Cogir at the Quarry Completion Date Page 21 of 22 Licensee: Cogir Management USA Inc 10/31/2025 On 10/29/2025 the facility confirmed that R7 has urinary incontinence. Record review of the facility’s RCR showed no documentation that R7 has any urinary incontinence. Resident 9 (R9) On 10/29/2025 at 9:00 AM, R9’s records showed that they admitted to the facility on /2024 with various diagnoses including and . Record review of the facility’s RCR showed documentation that R9 has a medical device. Record review of R9’s NSAs showed an NSA dated 05/11/2025. No documentation was found to show that R9 has a medical device. On 10/30/2025 at 11:55 AM, Staff C confirmed that R9 does not have a medical device. Resident 12 (R12) On 10/29/2025 at 10:05 AM, R12’s records showed that they admitted to the facility on /2024 with various diagnoses including , and . Record review of the facility’s RCR showed documentation that R12 has a medical device. Record review of R12’s NSAs showed an NSA dated 09/05/2025. No documentation was found to show that R12 has a medical device. On 10/30/2025 at 11:55 AM, Staff C confirmed that R12 does not have a medical device. Resident 15 (R15) On 10/29/2025 at 11:40 AM, R15’s records showed that they admitted to the facility on /2025 with various diagnoses including . 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 #: 2640 Compliance Determination # 67823 Plan of Correction Cogir at the Quarry Completion Date Page 22 of 22 Licensee: Cogir Management USA Inc 10/31/2025 Review of the facility’s RCR showed documentation that R15 was receiving home health services. Record review of R15’s NSA dated 08/03/2025 showed no documentation that R15 was receiving home health services. On 10/30/2025 at 11:55 AM, Staff G, Resident Care Coordinator, confirmed that R15 was no longer receiving home health services. On 10/31/2025 at 11:00 AM, Staff A, Executive Director, acknowledges the departments findings of the discrepancies on the RCR. 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, Cogir at the Quarry 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. STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEAL TH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 800 NE 136th Ave Ste 200, Vancouver, WA 98684 Cogir Management USA Inc Cogir at the Quarry 415 SE 177th Ave Vancouver, WA 98683 RE: Cogir at the Quarry License# 2640 Dear Administrator: This letter addresses Compliance Determination(s) 37494 (Completion Date 03/08/2024) and 34671 (Completion Date 01/08/2024). The Department completed a follow-up inspection of your Assisted Living Facility on 03/08/2024 and found no deficiencies. Your facility meets the Assisted Living Facility licensing requirements. The Department found that deficiencies for the following licensing laws and regulations were corrected: WAC 388-78A-2260-1, WAC 388-78A-2260-2-d, WAC 388-78A-2400-2, WAC 388-78A-2950-6, WAC 388-78A-2466-1, WAC 388-78A-2466-1-a, WAC 388-78A-2466-1-b, WAC 388-78A- 24642-1, WAC 388-78A-2484, WAC 388-78A-2484-1, WAC 388-78A-2484-2, WAC 388-78A- 2474-2-a, WAC 388-78A-2474-2-c, WAC 388-78A-2140, WAC 388-78A-2140-1, WAC 388-78A- 2140-1-a, WAC 388-78A-2140-1-a-i, WAC 388-78A-2140-1-a-ii, WAC 388-78A-2140-1-a-iii, WAC 388-78A-2140-1-b, WAC 388-78A-2140-1-c, WAC 388-78A-2140-1-d, WAC 388-78A- 2140-1-e, WAC 388-78A-2140-2, WAC 388-78A-2140-2-a, WAC 388-78A-2140-2-b, WAC 388- 78A-2140-3, WAC 388-78A-2140-4, WAC 388-78A-2140-5, WAC 388-78A-2140-6, WAC 388- 78A-2140-7, WAC 388-78A-2140-8, WAC 388-78A-2070, WAC 388-78A-2070-1, WAC 388- 78A-2070-2, WAC 388-78A-2070-3, WAC 388-78A-2090, WAC 388-78A-2090-1, WAC 388- 78A-2090-1-a, WAC 388-78A-2090-1-b, WAC 388-78A-2090-1-c, WAC 388-78A-2090-2, WAC 388-78A-2090-2-a, WAC 388-78A-2090-2-b, WAC 388-78A-2090-2-c, WAC 388-78A-2090-3, WAC 388-78A-2090-4, WAC 388-78A-2090-4-a, WAC 388-78A-2090-4-b, WAC 388-78A-2090- 5, WAC 388-78A-2090-5-a, WAC 388-78A-2090-5-b, WAC 388-78A-2090-5-c, WAC 388-78A- 2090-6, WAC 388-78A-2090-6-a, WAC 388-78A-2090-6-b, WAC 388-78A-2090-6-c, WAC 388- 78A-2090-6-d, WAC 388-78A-2090-6-e, WAC 388-78A-2090-7, WAC 388-78A-2090-7-a, WAC 388-78A-2090-7-b, WAC 388-78A-2090-7-c, WAC 388-78A-2090-7-c-i, WAC 388-78A-2090-7- c-ii, WAC 388-78A-2090-7-d, WAC 388-78A-2090-8, WAC 388-78A-2090-8-a, WAC 388-78A- 2090-8-b, WAC 388-78A-2090-8-b-i, WAC 388-78A-2090-8-b-ii, WAC 388-78A-2090-9, WAC 388-78A-2090-10, WAC 388-78A-2090-11, WAC 388-78A- This document was prepared by Residential Care Services for the Locator website. Cogir at the Quarry# 2640 03/08/2024 Page 2 of2 2090-11-a, WAC 388-78A-2090-11-b, WAC 388-78A-2090-11-c, WAC 388-78A-2130-1, WAC 388-78A-2130-1-a, WAC 388-78A-2130-1-b, WAC 388-78A-2130-1-c, WAC 388-78A-2130-2 The Department staff who did the on-site verification: Jennifer Siharath, ALF Licensor If you have any questions, please contact me at (360)450-1218. Sincerely, Region 3, Unit I Residential Care Services SSSSSSSSSSSSSTTTTTAAAAAAAAAAATTTEEEEOOOOOOOOOOOOOOOOOFFFWWWWWWWWWWWWWWWWWWWWAAAAAAAAAAAASSSSSSSSSSSSSSSSHHHIIINNNNNNNNNGGGGGGGGGTTOOOOOOOOOOOOONNNNNNNNNNNNN DDDDEEEPPPPPPPPPPPAAAAAAAAAAAAAAAAARRRRRRRRRRRRRRRRTTMMMMMMMMMMMMMMMEEEENNNNNNNNNNNNNTTOOOOOOOOOOOOOOOOFF SSSSSSSSSSSSSSSSSOOOOOOOOOOOOOOCCCCCCCCCCCCCCCIIAAAAAAAAAAAAALL AAAAAAAAAAAAANNNNNNNNNNNNDDDDDDD HHHHEEEEAAAAAAAAAAAAAAALLLTTHHHH SSSSSSSSSSSSSSSSSEERRRRRRRRRRRRRRRRVVVVVVVVVVVVIIICCCCCCCCCCCCCCEEEESSSSSSSSSSSSSSSSSSSS AAAAAAAAAAAGGGGGGGGIIINNNNNNNNNNNNNGGGGGGGGGAAAAAAAAAAANNNNNNNNNDDDDDDDLLLLOOOOOOOOOOOOONNNNNNNNNNNNNGGGGGG---TTTEEERRRRRRRRRRRRRMMMMMMMMMMMMMMMMMSSSSSSSSSSSSSSSSUUUUUUUUUUPPPPPPPPPPPPPPPPPPPPOOOOOOOOOOOOOOOOORRRRRRRRRRRRRTTTTT AAAAAAAAAAADDDDMMMMMMMMMMMMMIINNNNNNNNNNNIISSSSSSSSSSSSTTRRRRRRRRRRAAAAAAAAAAAAATTIIIOOOOOOOOOOOONNNNNNNNNNN 8888888888888888880000000000000000000000000000000000NNNNNNNNNNNNNNNNNNEEEEEEEEEEE1111111111133333333333333666666666666666ttttttttttttthhhhhhhhhhhhh AAAAAAAAAAAAAAAAAvvvvvvvvvvveeeeeeeeeeeeSSSSSSSSSSSSSSSSttttttttttttteeeeeeeeeeeeee22222222220000000000000000000000000000000,,,, VVVVVVVVVVVVVVaaaaaaaaaaaaannnnnnnnnccccccccccccooooooooooooouuuuuuuuuuuuvvvvvvvvvvvveeeeeeeeeerrrrrrrrrr,, WWWWWWWWWWWWWWWAAAAAAAAAAAAAAAAAAA9999999999999998888888888888888886666666666666666888888888888888888444444444444444 SSSSSSSSSSSSSSStttttttttaaaaaaaaaaaaaaaaatttttttteeeeeeeeeeeeeeemmmmmmmmeeeeeeeeeeeennnnnnnntttttttt ooooooooooooooffffffffDDDDDDDDDDDeeeeeeeeeeeeffffffffffiiicccccccciiiiieeeeeeeeeeeeeennnnccccccccccccciiieeeeeeeeeeesssssssssssss LLLLLiiiiiccccccccccccceeeeeeeeeeeeeennnnnnnnsssssssssssssssseeeeeeeeeeee ##################::::::2222222222222266666666666666644444444444400000000000000 CCCCCCCCCCCCCCCCCooooooooooooommmmmmmmmmmmppppppppppppppllliiiiaaaaaaaaaaaannnnnnnnccccccccccccceeeeeeeeeeeeeeDDDDDDDDDDDeeeeeeeeeeetttttttttteeeeeeeeeeerrrrmmmmmmmmiiinnnnaaaaaaaaaaaaaaaatttttttttiiiiioooooooooooooooonnnn ################ 33333333333334444444444446666666666666667777777777111111 PPPPPPPPPlllaaaaaaaaaaaaannnnnnnnooooooooooooooffffffff CCCCCCCCCCCCoooooooooooooorrrrrrrreeeeeeeeeeeeecccccccccccccttttttttiiiiooooooooooooonnnnnnnn CCCCCCCCCCCCCCCoooooooooooooooooggggggggggggggiiiirrrr aaaaaaaaaaaaaaaattttttttttttttttttthhhhhhhhhheeeeeeeeeeeeeeQQQQQQQQQQQQQQQQQQQQuuuuuuuuuuaaaaaaaaaaaaarrrrrrrryyyyyyyyyyyyyyyy CCCCCCCCCCCCCCCCCooooooooooooooommmmmmmmmmmmppppppppppppplleeeeeeeeeeettttttttttiiioooooooooooooonnnnnnnnDDDDDDDDaaaaaaaaaaaaattttttttteeeeeeeeeeeeee PPPPPPPPPaaaaaaaaaaaaggggggggggggggggeeeeeeeeeeeeeee1111111 ooooooooooooooffffffff 1111119999999999999999999 LLLLiiiccccccccccccceeeeeeeeeeeeennnnnnnsssssssssssseeeeeeeeeeeeeeeeeeeeeeeeeeee::CCCCCCCCCCCCCCCCCooooooooooooooogggggggggggggiiirrr MMMMMMMMMMMMMMaaaaaaaaaaaannnnnnnaaaaaaaaaaaaggggggggggggggggggeeeeeeeeeeeeeemmmmmmmmmmmeeeeeeeeeeeeeeennnnnnnttttttttttUUUUUUUUUUUUUUSSSSSSSSSSSSSSSSAAAAAAAAAAAAAAAAAAAAIIInnnnnnnccccccccc 00000000000000000111111//////////////000000000000000888888888888888888////////////////2222222222222222000000000000000222222222222444444444444 YYYYYYYYYooooooooooooouuuuuuuuuaaaaaaaaaaaaarrrreeeeeeeeeerrrreeeeeeeeeeeeqqqqqqqqqqqqquuuuuuuuuuuiiiiirrrrrreeeeeeeeeeeeeedddddddddddddddd tttttttttttoooooooooooooobbbbbbbbbbbbbbeeeeeeeeeeeeeeee iiinnnnnncccccccccccooooooooooooommmmmmmmmmpppppppppppppppllliiiiaaaaaaaaaaannnnccccccccccceeeeeeeeeeeeeeaaaaaaaaaaaaaattttttttttttt aaaaaaaaaaaallllltttttttttiiiiiiiimmmmmmmeeeeeeeeeeeesssssssssssswwwwwwwwwwwwwiiiiitttttttttthhhhhhhhhhhhhhhhh aaaaaaaaaaaalllllllliiicccccccccceeeeeeeeeeeeeennnnnnnsssssssssssssiiiiinnnnnnggggggggggggggggglllaaaaaaaaaaaaawwwwwwwwwwwwwwwsssssssssssss aaaaaaaaaaaaaaaannnnnndddddddddddddddddrrrrreeeeeeeeeeeeeggggggggggggggguuuuuuuullaaaaaaaaaaaaaattttttttttttiiiiiiooooooooooooonnnnssssssssssss tttttttttttooooooooooooooo mmmmmmaaaaaaaaaaaaiiinnnnnnnttttttttttttaaaaaaaaaaaiinnnnnnyyyyyyyyyyyyyooooooooooooouuuuuuuuurr AAAAAAAAAAAAAAAsssssssssssssssssssssssssssssiiisssssssssssssttttttteeeeeeeeeeeeeeddddddddddddddddLLLLiiivvvvvvvviiinnnnnnngggggggggggggggFFFFFFFFFaaaaaaaaaaaacccccccccciilliiittttttttyyyyyyyyyyyyyyy llliiicccccccccceeeeeeeeeeeeeennnnnnssssssssssssseeeeeeeeeee. TTThhhhhhhhhhhhhheeeeeeeeeeeeddddddddddddddddeeeeeeeeeeeeeeeeeepppppppppppppppaaaaaaaaaaaarrrrrrrtttttttttttttttmmmmmmmmmmmeeeeeeeeeeeennnnnnnnnnttttttttttttcccccccccccccccoooooooooooooommmmmmmmmpppppppppppppllleeeeeeeeeeeeeeeeeetttttttttttttteeeeeeeeeeeeeeeeedddddddddddddddd ddddddddddddddddaaaaaaaaaaaaaaaaattttttttttttaaaaaaaaaaaaaa ccccccccccccoooooooooooooolllleeeeeeeeeeeeeeeccccccccccctttttttttttttiiiiiiooooooooooooonnnnnnn fffffoooooooooooooorrrrrtttttttttttthhhhhhhhhhhhheeeeeeeeeeeeeeeuuuuuuuuunnnnnnnaaaaaaaaaaaaaannnnnnnnnnnnnooooooooooooooooouuuuuuuuunnnnnnnccccccccccceeeeeeeeeeeeeeeeeeddddddddddddddddd ooooooooooooonnnnnnn-sssssssssssssiiiiittttttttttteeeeeeeeeeeeeeeee fffffffffffuuuuuuuuullll iiiinnnnnnnnsssssssssssssspppppppppppppeeeeeeeeeeeeeeeccccccccccccttttttttttiiioooooooooooooonnnnnnooooooooooooonnnnnnn 000000000000000111111///////////00000000000000000333333333333333////////////////2222222222222220000000000000000022222222222222244444444444444 aaaaaaaaaaaaaaaannnnnnnnnnndddddddddddddd 000000000000000111111///////////000000000000000000888888888888888888/////////////////222222222222222000000000000000002222222222222224444444444444 ooooooooooooooffffffffff::: CCCCCCCCCCCCCCCCCCooooooooooooooooggggggggggggggggggiiiiirraaaaaaaaaaaaaatttttttttttttttttttttthhhhhhhhhhhhheeeeeeeeeeeeeeeQQQQQQQQQQQQQQQQQuuuuuuuuuuaaaaaaaaaaaaaaaarrrrrrrryyyyyyyyyyyyyyy 444444444444444111111555555555555555SSSSSSSSSSSSSSSSSSSEEEEEEE 111111777777777777777777777777tttttttttttthhhhhhhhhhhhhAAAAAAAAAAAAAAAAAAvvvvvvvvvvvvvveeeeeeeeeeee VVVVVVVVVVVVVVVVVVaaaaaaaaaaaaannnnnnncccccccccccoooooooooooooouuuuuuuuuuuvvvvvvvvvvvvveeeeeeeeeeeerrrr,,,WWWWWWWWWWWWWWWWWWWWAAAAAAAAAAAAAAAAAAA 9999999999999988888888888888888666666666666666666688888888888888888333333333333333 TTThhhhhhhhhhhheeeeeeeeeefffffffffooooooooooooolllllloooooooooooowwwwwwwwwwwwwwwiiinnnnnngggggggggggggssssssssssssaaaaaaaaaaaammmmmmmppppppppppppllleeeeeeeeeeeeeewwwwwwwwwwwwwaaaaaaaaaaaaaaaassssssssssssssssssssssssseeeeeeeeeeeeellleeeeeeeeeeeeeecccccccccccctttttttttteeeeeeeeeeeeedddddddddddddddd ffffffffffoooooooooooooorrrr rrrreeeeeeeeeeeeevvvvvvvvvvviiieeeeeeeeeeeewwwwwwwwwwwwwwww dddddddddddddddduuuuuuuuurrrriiinnnnnnnggggggggggggggg tttttttthhhhhhhhheeeeeeeeeeee uuuuuuuuuuunnnnnnaaaaaaaaaaannnnnnnnooooooooooooouuuuuuuuuuunnnnnncccccccccccceeeeeeeeeedddddddddddddddd ooooooooooooonnnnnn--sssssssssssssiiiiiitttttttttttteeeeeeeeeeee vvvvvvvvvvviiissssssssssssiiiiiitttttttttttt::::: 11119999999999999oooooooooooooffffffffff1111177777777777744444444444 cccccccccccuuuuuuuuurrrrrrrrrreeeeeeeeeeeeeennnnnnntttttttttttt rrrrreeeeeeeeeeeeeeessssssssssssssiiiddddddddddddddddeeeeeeeeeeeeeeeeeennnnnnnnnnttttttttttttttsssssssssssss aaaaaaaaaaaaaaaannnnnnnddddddddddddddddd00000000000000000 fffffoooooooooooooorrrrrmmmmmmmmmeeeeeeeeeeeeeerrrrrrrrrreeeeeeeeeeeeeesssssssssssssiiiiiddddddddddddddddeeeeeeeeeeeeeennnnnnnttttttttttttssssssssssssssss. TTThhhhhhhhhhhhhheeeeeeeeeeddddddddddddddddeeeeeeeeeeeeeeeeepppppppppppppppaaaaaaaaaaarrrrrrrttttttttttttttmmmmmmmmmmmeeeeeeeeeeeennnnnnnnntttttttttttsssssssssssstttttttttttttttaaaaaaaaaaaaaaffffffffffffffff ttttttttttthhhhhhhhhhhhhaaaaaaaaaaaaaaattttttttttttt iiiiinnnnnnssssssssssssppppppppppppppeeeeeeeeeeeeeecccccccccccttttttttttttteeeeeeeeeeeedddddddddddddddd ttttttttthhhhhhhhhhhhhhhhheeeeeeeeee AAAAAAAAAAAAAAAAAAAssssssssssssssssssssssssssssiiiisssssssssssssssstttttttttttteeeeeeeeeeeeeeeeedddddddddddddddddLLLLLiiiiivvvvvvvviiiinnnnnnnggggggggggggggg FFFFFFFaaaaaaaaaaaaacccccccccciiiillliiittttttttttttyyyyyyyyyyyyyyy::: JJJJJJJJJJJJeeeeeeeeeeeeennnnnnnnniiiiifffffffffffeeeeeeeeeeeeerrrrrSSSSSSSSSSSSSSSiiiihhhhhhhhhhhhhhaaaaaaaaaaaaarrrraaaaaaaaaaaaaattttttttttthhhhhhhhhhhh,, AAAAAAAAAAAAAAAAALLLLFFFFFFF LLLLiiiiiiccccccccccceeeeeeeeeeeeennnnnnssssssssssssoooooooooooooorr KKKKKKKKKKKKKKKyyyyyyyyyyyyyyyyllleeeeeeeeeeee GGGGGGGGGGeeeeeeeeeeeeeeeehhhhhhhhhhhhhhllleeeeeeeeeeeennnnnn,,,,AAAAAAAAAAAAAAAALLLLFFFFFFF LLLLiiiiiiccccccccccceeeeeeeeeeeennnnnnssssssssssssooooooooooooorr - LLLLTTTCCCCCCCCCCCCCCCCC JJJJJJJJJJJJaaaaaaaaaaaaaasssssssssssssooooooooooooonnnnnnRRRRRRRRRRRRRRRRoooooooooooooosssssssssssseeeeeeeeeeeee FFFFFFFrrrrrrrooooooooooooommmmmmm:: DDDDDDDSSSSSSSSSSSSSSSHHHHHHHHSSSSSSSSSSSSSSSSSSS,,, AAAAAAAAAAAAAAAAAggggggggggggggiiinnnnnnnggggggggggggggggggaaaaaaaaaaaannnnnnndddddddddddddddd LLLLooooooooooooooooonnnnnnggggggggggggggg-TTTeeeeeeeeeeeeeeerrrrrmmmmmmmmmm SSSSSSSSSSSSSSSSSSSSuuuuuuuuuuuppppppppppppppppppppppppppppppoooooooooooooorrrrrttttttttttt AAAAAAAAAAAAAAAAAddddddddddddddddmmmmmmmmiiiinnnnniiisssssssssssssssttttttttttttrrrrraaaaaaaaaaaaaattttttttttttttiiiiioooooooooooooonnnnnn RRRRRRRRRRRRRRRReeeeeeeeeeeeeeesssssssssssssiiiiidddddddddddddddddeeeeeeeeeeeeeennnnnnnnnttttttttiiiiiiaaaaaaaaaaaaaaaalllCCCCCCCCCCCCCCCaaaaaaaaaaaaaaarrrreeeeeeeeeeeeee SSSSSSSSSSSSSSSeeeeeeeeeeeeeerrrrrvvvvvvvvvvviiicccccccccceeeeeeeeeeeeeessssssssssss, RRRRRRRRRRRRRReeeeeeeeeeeeegggggggggggggggiiiooooooooooooonnnnnn3333333333333,,, UUUUUUUUUUUUUnnnnnnnnnniiitttttttIII 8888888888888888800000000000000000000000000000000NNNNNNNNNNNNNNEEEEEEE 11113333333333333666666666666666666tttttttttttthhhhhhhhhhhhhh AAAAAAAAAAAAAAAAvvvvvvvvvvvveeeeeeeeeeSSSSSSSSSSSSSSSSStttttttteeeeeeeeeeeee 2222222222222220000000000000000000000000000000000 VVVVVVVVVVVVVVVVaaaaaaaaaaaaaaaannnnnnnccccccccccccooooooooooooouuuuuuuuuvvvvvvvvveeeeeeeeeeeeeerrrrr,,,WWWWWWWWWWWWWWWWWWWWAAAAAAAAAAAAAAAAAAA 9999999999999999888888888888888886666666666666666666888888888888888844444444444444 AAAAAAAAAAAAAAAAssssssssssssssaaaaaaaaaaa rrrrreeeeeeeeeeeeesssssssssssssuuuuuuuuulllltttttttttttt oooooooooooofffffttttttttttthhhhhhhhhhhheeeeeeeeeeeeeeeooooooooooooonnnnnn-sssssssssssssiiittttttttttteeeeeeeeeeeeeeeee vvvvvvvvvvviiissssssssssssiiiittttttt(((((((((((((ssssssssssssss)))))))))),,,ttttttttttthhhhhhhhhhhheeeeeeeeeeeeeedddddddddddddeeeeeeeeeeppppppppppppaaaaaaaaaaaaaaaarrrrttttttttttttmmmmmmmmmmeeeeeeeeeeeeeennnnnntttttttttttt fffffoooooooooooouuuuuuuuunnnnnndddddddddddddddddttttttttthhhhhhhhhhhhhhhaaaaaaaaaaaaaattttttttttt yyyyyyyyyyyyyyyooooooooooooouuuuuuuuu aaaaaaaaaaaarrrreeeeeeeeeennnnnnoooooooooooooottttttttttttiiinnnn ccccccccccooooooooooooommmmmmmpppppppppppplliiiaaaaaaaaaaannnnnncccccccccceeeeeeeeeeeewwwwwwwwwwwwwwwiiiittttttttttthhhhhhhhhhhttttttttthhhhhhhhhhhhhhheeeeeeeeee llliiiiiccccccccccceeeeeeeeeeeeeeennnnnnsssssssssssssiiinnnnnngggggggggggggggggglllaaaaaaaaaaaaaaawwwwwwwwwwwwwwwsssssssssssss aaaaaaaaaaaaaannnnnnnnndddddddddddddddddrrrrreeeeeeeeeeeeeeeggggggggggggggguuuuuuuuullaaaaaaaaaaaaaaaaatttttttttttttiiiiiioooooooooooooonnnnnnnssssssssssssss aaaaaaaaaaaaaasssssssssssss sssssssssssssssttttttttttttttaaaaaaaaaaaaaaaatttttttttttttteeeeeeeeeeeeeeeeddddddddddddddd iiinnnnnnntttttttttthhhhhhhhhhhhhhheeeeeeeeeeeeeee ccccccccccccciiiiittttttttttttteeeeeeeeeeeeeeeddddddddddddddd ddddddddddddddddeeeeeeeeeeeeeeeeefffffffffiiiicccccccccccciiieeeeeeeeeeeeeennnnnnccccccccccccccciiieeeeeeeeeeeeeesssssssssssssiiiiinnnnn tttttttttttthhhhhhhhhhhhheeeeeeeeeeeeeeeeeeeeeeeeeeeeeennnnnnncccccccccccccllloooooooooooooooossssssssssssseeeeeeeeeeeeeeeeedddddddddddddddd rrrrreeeeeeeeeeeeeepppppppppppppppooooooooooooorrrrrrttttttttttttttt. 01/12/2024 RRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRReeeeeeeeeeeeessssssssssssiiiiiiiidddddddddddddddddddddddeeeeeeeeeeeeeennnnnnntttttttttttttttttiiiiiiiiiaaaaaaaaaaalllll CCCCCCCCCCCCCCCCCCCCaaaaaaaaaaaarrreeeeeeeeeeeee SSSSSSSSSSSSSSSSSSSSSSSSSSSeeeeeeeeeeeeerrrrrvvvvvvvvvvvviiiiiiiiccccccccccccceeeeeeeeeeeeesssssssssssss DDDDDDDDDaaaaaaaaaaaaaaaatttttttttteeeeeeeeeeeeeeeee IIIuuuuuuuuunnnnnnnddddddddddddddddeeeeeeeeeeeeeeeeerrrrrrssssssssssssstttttttttttaaaaaaaaaaaaaannnnnnnnnnndddddddddddddddd tttttttttttthhhhhhhhhhhhhaaaaaaaaaaaaaaatttttttttttt ttttttttttooooooooooooo mmmmmmmmmaaaaaaaaaaaaaaaaaiiiiinnnnnnnnnnttttttttttttttaaaaaaaaaaaaiiinnnnnnnaaaaaaaaaaaaaannnnnnn AAAAAAAAAAAAAAAAAsssssssssssssssssssssssssssiiiiisssssssssssssstttttttteeeeeeeeeeeeddddddddddddddddLLLLiiiivvvvvvvvvvvvvviiiiinnnnnnggggggggggggggggggFFFFFFFFFaaaaaaaaaaaaccccccccccciiilliiiiitttttttyyyyyyyyyyyyyy llliiiiiccccccccccceeeeeeeeeeeeeennnnnnssssssssssssseeeeeeeeeeeee,,, tttttttttttthhhhhhhhhhhhheeeeeeeeeeeeeeefffffffffffaaaaaaaaaaaaccccccccccciiillliiiiittttttttyyyyyyyyyyyyyyy mmmmmmmmuuuuuuuuusssssssssssssssttttttttttttt bbbbbbbbbbbbbbbeeeeeeeeeeeeeee iiiiinnnnnnn cccccccccccccccoooooooooooooommmmmmmmpppppppppppppllliiiiiaaaaaaaaaaaaaannnnncccccccccccceeeeeeeeeeeeeeewwwwwwwwwwwwwwiiiiiiiiitttttttttthhhhhhhhhhhhhhhhh aaaaaaaaaaaaaallllltttttttttttttthhhhhhhhhhhhhhhhheeeeeeeeeeee llliiiicccccccccccceeeeeeeeeeeennnnnnnsssssssssssssiiiiinnnnnnnggggggggggggglllaaaaaaaaaaaaaaawwwwwwwwwwwwwwwsssssssssssssaaaaaaaaaaaannnnnnnnnnndddddddddddddddd rrrrreeeeeeeeeeeegggggggggggggggguuuuuuuuuuulllaaaaaaaaaaaattttttttiiioooooooooooooonnnnnnsssssssssssss aaaaaaaaaaaaaattttttttttttaaaaaaaaaaaaaaaallllll ttttttttiiiiimmmmmmmmeeeeeeeeeeeeeeesssssssssssss. This document was prepared by Residential Care Services for the Locator website. STATIE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALT H SERVII CES AGING AND l OINIG-TIERMI SUPPORT ADMINISTRATION 1@9 NE 136th Ave Ste 20'0, Vancouver, WA 91614 Statement of Deficiencies license #:. 2640 Compliance Determination # 34671 Plan of Correction Cogir at the Quarry Completion Date Page 1 of 19 Licensee: Cogir Management USA Inc 01J08/2024 You are required to be in compliance at all bimes with all licensing laws and regulations to maintain your Assisted Living IF acility license. The department completed data collection for the unannounced on-site full inspection on 01 /03:/2024 and O1 /08/2024 of Cogir at the Quarry 415 SE 177th Ave Vancouver, WA 98683 The following sample was selected for review dming the unannounced on-site visit: 19 of 174 current residents and O former residents. The depa1rtme111t staff that inspected the Assisted Living Facility: Jennifer Siharath, ALF Licensor Kyle Gehl en, ALF Licensor - LT C Jason IRose From: DSHS, Aging and Long-Term Support Administrabion Residential Care Services, Region 3 , Unit I 800 NE 136~h Ave Ste 200 Vancouver, WA 986,84 As a result of the on-site visiit(s), the department found that you are not in compliance with the licensing llaws and regulations as stated in the cited deficiencies in the enclosed report. Date I understand that to maintain an Assisted Living Facility liicense, the acility must be in compliance with all the licensiing laws and regulations at all times. This document was prepared by Residential Care Services for the Locator website. .12.2024 11 :57:25 State of Washington 6, Sl:"t~m,~nt M DMici~nde!:: u,~e~1$!(\ #: 2640 GC i n-1plii-'l n,~a Deteu1:1in«tic-n #-3457"1 Phm oi C Gffedio11 Cog\:· ~1th~ Quarry C'tJmptefa1-n Oat~ Pags 2 0•f H~ 1. ' 1,1, ("!} The assisted liV1f1$l fodUl.y must ,~etLWc medk:1ttions for re-slrients 1;.,vhr1 -,.~re rwt s::~~pable d safol:/ sto~k~:9 tf1eir own rnedicathm~. (2) The c1s:sistE."d liv1n~i fodllty rm..ist. i:!ns1.,iri::; {irn ITkH.ik;;iti1ms tmd·er the as~isbsd llving fo:dHt-y's confn:ir ar6 pr,Jp~1.1y· sto:red: This rs.quir.e.m-entwas n~t met as. evidenced by: B.:!Sed 0:n obstiV~ltkH1: and interview, the fadity foiled ta en,stm~ that rrmdil~tions for St oi' 31 residents in medkatic,n cait seven it,'Bre locked and aci::e·s.s[tlle on~ tr1 designated responsible :staff. ·rhis failur~ p~at:~fl i~~H Ji ll:ien10:t1.1 t~r~ rsslct~:fits i~f fi$·k cf ~clvers~ r~;acJ!cn,s :frorn c.anst1n1fJ:tion of rmn.ik:aticns not i:lS int,-::-ncled Dr :presGribed to thern. Flndtngs tnc.luded ... Durin~1 ;:m m-i.~t1t10lm,::ed !k~i1sin-g lt1$f-11?-di~n -an Cl-UH:1/2024 'iJt '.] DAf> A'rl, m·, Witltif.tl'lded rn~dic,~tkH1 cart, tabded ···rnecHc.i:iti0-n e:mt sv€ en'' r \l\,,'i:lS ~ihs\'Jrvect ti:~ b-e iod<ed tiut tne dep;:.1rtrrnrnt \'\-'as 0ble ta open the 1-r1edk~th:m c:~irt <lr~w-ers and access tfH medicatio1,1s. On GU03i2D24 at W:4-1 AM durin.g an intcrvi-ew, Staff F, Resident Cani .Assodate, st.ater.1t hat they hmd r:',,pmted the tm.1ken m:edkatio11 cmt to m~n,~gernent t<NG v11~eks p~far. Owmg an exit intr~rvk-w tm Dll'08l2024 at !ll :ao PM, l:,ta~f B_, Director or N 11r-sin.g Service-s, .:id,nCT'f'iedged tl'1;:tt rnedkal\on Ci:lft S)ijven tNas bri:ike:n. Plan/Attestation Statement In ~ddititm, I wilt irnp!etw.mt a syste,m to rn::mitor and enm.tr<= rnntlnued f:'.oniplitmce-wm1 this requiren,ent Statement of Deficiencies License #: 2640 Compliance Determination # 34671 Plan of Correction Cogir at the Quarry Completion Date Page 2 of 19 Licensee: Cogir Management USA Inc 01/08/2024 Administrator (or Representative) Date WAC 388-78A-2260 Storing, securing, and accounting for medications. (1) The assisted living facility must secure medications for residents who are not capable of safely storing their own medications. (2) The assisted living facility must ensure all medications under the assisted living facility's control are properly stored: (d) In a locked compartment that is accessible only to designated responsible staff persons; and This requirement was not met as evidenced by: Based on observation and interview, the facility failed to ensure that medications for 31 of 31 residents in medication cart seven were locked and accessible only to designated responsible staff. This failure placed all 31 memory care residents at risk of adverse reactions from consumption of medications not as intended or prescribed to them. Findings included… During an unannounced licensing inspection on 01/03/2024 at 10:45 AM, an unattended medication cart, labeled “medication cart seven”, was observed to be locked but the department was able to open the medication cart drawers and access the medications. On 01/03/2024 at 10:47 AM during an interview, Staff F, Resident Care Associate, stated that they had reported the broken medication cart to management two weeks prior. During an exit interview on 01/08/2024 at 01:30 PM, Staff B, Director of Nursing Services, acknowledged that medication cart seven was broken. 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, Cogir at the Quarry 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. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. .12.2024 11: 57:25 State of Uashington 7, Stat<:'t1}\liit ;;i·f Defid,H1de"S: U,~\'mS!l\ #: 2641..) Gc,nipli.f'l~,:~ Oeten1:1in~tiN1 #346/1 Plan oi Co rre.ction GGgir at the OLl~r~y Caff~p!eii~-r~ Dals· r,n Mah1tnin resident reumfa and pre.serve: their c:onfo:ientta!it)-' in accordance ."v~th ;app-:licable state i~nd fad.sral sfaluti!!s ~nd r11h,-s 1 indudmg .:.:rrniµt~rs ·nH12 ;and 70 ..n ·B; RCV\ 1; Gas!:!d cff~ observeiti'on and inte·rvr:evv tile facility failed ta rnaintain resident reoJrds <rnd pre:s.etVB rnt1fafontiaHtv for •i of ·/ rt1sident ('Rtsi,:hnt 20). Thi::, foi~ur~ pla,c~d tlfrs. resident at risk ol' theif penrn11al lnfri'.nni:ltinn beinn disdt1sad to t:m,~i..1th1orfred pe.,n,ple. Dur/ng an un~rmounced Hcer1;sing visit or1 OHU4/2824 c.it 9:53 AM., the depHrtrnent ~b$NVed ~n Lmnftende.d maijitation cart Gutside of rn,(1,i-ri 4[-iO viith the. cornputer screen vis\bh?. and -cpen kt R~ulder~t :?O's chart. On {HfG4.!2G24 at 9:~,e AM, during an interview, Staff G, Resident Care .AssGdat~, ~ate1:Hi1at itis not· okay fnr th& rnmpufor t.t) be ,Jpen ~-1,1ith pn1ted.ed he~1ffi'l info-rn,atlan. Owing an -exit interview on Ol:'lt8/21J24 at {H ::HJ F'l\11. Staff B, Director of Nursing 8.etvk::e~. stated that Staff G rBpm:t.ed the indd,mt t,J ·ihem 3fter it hap-pe:ned. fn ,,dditi,:}r tl1ls requi:. Statement of Deficiencies License #: 2640 Compliance Determination # 34671 Plan of Correction Cogir at the Quarry Completion Date Page 3 of 19 Licensee: Cogir Management USA Inc 01/08/2024 Administrator (or Representative) Date WAC 388-78A-2400 Protection of resident records. The assisted living facility must: (2) Maintain resident records and preserve their confidentiality in accordance with applicable state and federal statutes and rules, including chapters 70.02 and 70.129 RCW; This requirement was not met as evidenced by: Based on observation and interview the facility failed to maintain resident records and preserve confidentiality for 1 of 1 resident (Resident 20). This failure placed this resident at risk of their personal information being disclosed to unauthorized people. Findings included… During an unannounced licensing visit on 01/04/2024 at 9:53 AM, the department observed an unattended medication cart outside of room 450 with the computer screen visible and open to Resident 20’s chart. On 01/04/2024 at 9:56 AM, during an interview, Staff G, Resident Care Associate, stated that it is not okay for the computer to be open with protected health information. During an exit interview on 01/08/2024 at 01:30 PM, Staff B, Director of Nursing Services, stated that Staff G reported the incident to them after it happened. 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, Cogir at the Quarry 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. .12.2024 11:57:25 State of Washington 8, 8l:at~t1i~nt ,;:rt D~tld~t~de-s Phm ~i Co rre.;:.tion Cngi:~ at th.e Quar~y Pags 4 .::f t9 Ur.s::}s;i,e: Gogir ~km.igement USA.foe: OiJOB/2024 WAC 388--7SA-:'2950 Wat-e:r s.u~Jdy. The assisted living facHity must: (&} Prnvide ail illnk·s. in rtf3"ident ,rornns, tcdli:otrGGn1s and l:iathrcim,s, arK~ bathing fi;<tur~s wred by r:~gid~nts wi!tt ht~t \/\•al:er 1:.~et\/.\'e~m ·: Gf,: F mKi ·! 2Q F ~tall fones; ~ml GasBd ,J;n obse-rvJt1\m and inte·rviev,,•, the radH~' failed tn en:sur"B that thB hot \¾'c1t:er temperature for the sink us.ed b~.t t·estct .1. nt~ ~n the t'f1e:rr1~t~i can:: un~t v.. t ~·s: bet\~e.en t a5~F .aruj ·120*F .. 1-ni~ faHttre· pl.n,~ed ~lit n~~tden.t~ at risk for ln_jtny due tc1 Wot.er t!?.ti:lp~r-~~~r:es being t.co high. Oiiring an un.anrn:iunced Hcensing inspection :cm Ol}D3i2024 ~~t :J 0:45-.MAI, the d£!!}~rtrrn=.mtreo.:.,rded thiz fernpernture ~1Hhe c~Jm1m1n bathrot:.1m sin¾ in th:~1 rnerrmry carel unit to fa~ ·i '1.7 .S ifogre~s Fahrenrielt. Durin~J an exit intervie11;,• r1n D"ll08WJ24 at GLSO PM, $:wfr A, Executive Dired{l,r, ac:hno~'\.~edged tt~at th1z w,,iter farnp~rature \•1,1as <lbove the rn;nximurn tl?.111p~rntum of ·12.D 1:h~gree~ Fahr·~r1l1Bit. Plan/Attestation Statement !n ntklltbr m"' 1 · · -~ l&tern ta n1::initar imd ensur~ continued o,mpHan:ee with tt1is f">J!'.tll!·· ' WAC 388•78.A-24.t-6 B,i.td:ground e:h-ecks Washfngton ~tate 11am e and da~ of b-irth baekground check VllHd ·for twl) years Nation;nl flngerprint baekgrO'und chei:k Valid lnd@finitely. ( 1) .A. V\•mshi.ngtan stBte name and date af bi:t:h b;:i;.:ki~round chei:,i~: is val!-d for tv,J::! years from the inihgil date it is rnnctuct~ti. The as~isteci lt1/kltl r:adW.y must ensure: fa_l .A. ne>,,,QSHS bar:kgro@d aut!lorlrntion farm,ls subrnitted to the depBrtrnent1s bach:grmmd ,:::he-~k central unit every t\e\'0 years far .all administrat8rs., caregivers, staff persons:, vglunteers ami students; ,,nd Statement of Deficiencies License #: 2640 Compliance Determination # 34671 Plan of Correction Cogir at the Quarry Completion Date Page 4 of 19 Licensee: Cogir Management USA Inc 01/08/2024 WAC 388-78A-2950 Water supply. The assisted living facility must: (6) Provide all sinks in resident rooms, toilet rooms and bathrooms, and bathing fixtures used by residents with hot water between 105 F and 120 F at all times; and This requirement was not met as evidenced by: Based on observation and interview, the facility failed to ensure that the hot water temperature for the sink used by residents in the memory care unit was between 105°F and 120°F. This failure placed all residents at risk for injury due to water temperatures being too high. Findings included… During an unannounced licensing inspection on 01/03/2024 at 10:45 AM, the department recorded the temperature of the common bathroom sink in the memory care unit to be 127.5 degrees Fahrenheit. During an exit interview on 01/08/2024 at 01:30 PM, Staff A, Executive Director, acknowledged that the water temperature was above the maximum temperature of 120 degrees Fahrenheit. 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, Cogir at the Quarry 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-2466 Background checks Washington state name and date of birth background check Valid for two years National fingerprint background check Valid indefinitely. (1) A Washington state name and date of birth background check is valid for two years from the initial date it is conducted. The assisted living facility must ensure: (a) A new DSHS background authorization form is submitted to the department's background check central unit every two years for all administrators, caregivers, staff persons, volunteers and students; and This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2640 Compliance Determination # 34671 Plan of Correction Cogir at the Quarry Completion Date Page 5 of 19 Licensee: Cogir Management USA Inc 01/08/2024 (b) There is a valid Washington state name and date of birth background check for all administrators, caregivers, staff persons, volunteers and students. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure a Washington State name and date of birth background check was completed prior to employment for 2 of 5 sampled staff (Staff A and Staff C) and/or a current Washington State name and date of birth background check was documented in the staff’s personnel file for 2 of 5 sampled staff (Staff D and Staff E). These failures placed all residents and staff at risk by possibly employing staff with disqualifying criminal convictions or pending charges for a disqualifying crimes. Findings included… During an unannounced licensing inspection on 01/05/2024 at 11:00 AM, the department received the requested staff records. Staff A Record review for Staff A, Executive Director, showed Staff A was hired on 04/21/2023. Review of Staff A’s personnel file showed no Washington State name and date of birth background check for Staff A. Staff C Record review for Staff C, Resident Care Associate, showed Staff C was hired on 02/26/2023. Review of Staff B’s Washington State name and date of birth background check showed that it was completed after their hire date on 03/03/2023. Staff D Record review for Staff D, Medication Care Tech, showed Staff D was hired on 08/16/2018. Review of Staff D’s Washington State name and date of birth background check showed an expiration date of 06/11/2023. Staff E Record review for Staff E, Medication Care Tech, showed Staff E was hired on 03/30/2018. Review of Staff D’s Washington State name and date of birth background check showed an expiration date of 11/03/2022. On 01/08/2024 at 1:00 PM, no additional background checks were provided for Staff A, C, D, and E. During an exit interview on 01/08/2024 at 01:30 PM, Staff A, Executive Director, acknowledged that the Washington State name and date background check for Staff A and C were not completed prior to their employment and that the Washington State name and This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. .12.2024 11:57:25 State of Washington 10, Stattim:ei~t of Defid~rtcies U<~~msie #: 2640 Phm t~f Co rrectlon 01.:.'gir M t'1~ Cwar~y Pags6 cf 1:~ Ur.er.1se,e: Gogir Manag_sm~nt US.1-\lm: Plan/Attestation St~terit~"t f fwreby· c;;ntify tht~t I ~lsJVf~ rtwitJto\1ed tt1i\l rf;:pmt i\.\tld h~M-~ isiken twv. .• iH t;;ike ~~di'v1;5 rneasures t-G co.rrect this defieiern::y. fly taking this actkm,, C .gir at th~e Qiu-a-rry. i -s or \NW b~ iri cc,rr1f.llim•Ke vvlth hiis l~w~• ~rnd I t'H regul.ation-on {D.ate}__k__,._...__. ....... In .~-d11ltk1n, I \'\•iH i1T1pl-> , :.r.t a svstf:-!rn tti mtJnitor :a.nd en~Lffa continued o:m1pHance with this requlrerm t WAC 388-.78A,24-Ei.42 B,ad1:g_r~mnd thttks Natlnnar fingerprint background ch&ck. ( 1) A.::frninistrt~trJrn and au careg}..-i:!rs '.-\ho are- l1ired .~~bw-,.larwary 'r.. 2!:H 2 arni ~r~ nat dh;qu~lifif:!d by the Vhshin~1ton state name and date of blrth back9rmmd check, must cc.imp!e-te a nationa~ fingerpdnt bads:fJrnund che(~; (;]rfd fo!lol$V dep·attrnent procetiutes. Thb r~quire:tnent was :n~t met .ts eviderte-ed by: GastHl on interview and record reviev.\', (he f-adity faifed to cGrnplete a rrntk:nal fingerprint biud,gi-ound ched-,: for ·1 of 5 s~1tnpl@d itt~f'f (Sh'lllf .Al Thl'.s ·f-afa1re placet! .~a residents m·id stlllr at rh;ik by-p-a·ssfoiy efnp.l,;1~-iir~g ·staff Mtith disqualit)-'ing e:r1,rninai Gonvii::tic-n~ or pending d1arg:cs for a disqu,,ilif)"ing c1irne$. FindITTgs induded ... Outing m1 tm~nntitmcecl 1k:en~ing inspection tm Cl'f l'nB/2024 at J ·l :·OD AM, the ctef}~rirmmt rnc~ived thi;; re;:peskd s,lafl r~rnrcis. Staff A Re·z:ard revh,,\N'for Sfa3ff 1-\ E:•{ec:utiv~ Dini:dor, '5hc1N~d Sfaff .Aw-as hin?-d -011 04r2 H:1Cl2J. Review t:sf Staff A's ~ersonne! file shm¾•ed no Natinn:al nngerprint bad-;:grnund c:hecl\ for ~~taff A Ckiring an ~x.it int~rvie\"<' on OH USl2tl24 :ilf. Gi :80 Prv1. Bt..i.ff A, Ex.tlc.Ufale Dired-:..·ir, ad,na1hfadged fh,~t the there was tJD ~latkm.al fingerpr1nt t>ackJnnmd cher::k for Staff A. Statement of Deficiencies License #: 2640 Compliance Determination # 34671 Plan of Correction Cogir at the Quarry Completion Date Page 6 of 19 Licensee: Cogir Management USA Inc 01/08/2024 date of birth background checks for Staff D and E were not current. 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, Cogir at the Quarry 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-24642 Background checks National fingerprint background check. (1) Administrators and all caregivers who are hired after January 7, 2012 and are not disqualified by the Washington state name and date of birth background check, must complete a national fingerprint background check and follow department procedures. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to complete a national fingerprint background check for 1 of 5 sampled staff (Staff A). This failure placed all residents and staff at risk by possibly employing staff with disqualifying criminal convictions or pending charges for a disqualifying crimes. Findings included… During an unannounced licensing inspection on 01/05/2024 at 11:00 AM, the department received the requested staff records. Staff A Record review for Staff A, Executive Director, showed Staff A was hired on 04/21/2023. Review of Staff A’s personnel file showed no National Fingerprint background check for Staff A. On 01/08/2024 at 1:00 PM, no additional background checks were provided for Staff A. During an exit interview on 01/08/2024 at 01:30 PM, Staff A, Executive Director, acknowledged that the there was no National fingerprint background check for Staff 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. .12.2024 11:57:25 State of Washington 1I , Sl:~tiirc~~t)t M Defici;et'J.de-s: U,;;e11S):I #'. 2640 Gon-ipli;H'!,~~ Datett'l-:lint.!Mn #346/1 Plat.1 vi Correction -Gog!!' at thl:- Qu,~rty Co:n1p~e!tfl'n D.at.s· Plan/Attesfaticn Statement f hen~bv cernfv th~t I have reviewed this report i\md h~vt faken: t:.r·wm taht ~~ctVe l ' t " n i ) ~ • c - ' ! ' .. , .< ~ ( ,; , i V ,. > r · L n J p r:A .. l .~ > i ;; a " .; ' , ' n t" . c ..._, e (, ~ · . · v , ' , - l v } ,_ ( \ , t , - h • ~ ., , , . , _ · t \ t . . h . t i - t s ' 1 ·r . ~ , l . ~ . - V U .~ \ _ ~ ' , , - .t < · : , 1 ~ • t . . 1 - • : • t ~ - i • ' t f 1 · w i '' ' \ r i , r 8 e \ g ,. u .r:-.. , l , , - a > ~ ~' t - 'i i f o 'l• " t : ' _ 1 \ 1 . : , , i ; . l : '" m ! i. : { '" ~ ' - ' { C D : - t • > a , . · .- t t ·, f . , \ · . 1 ! ' } - ~ - . , · , , ) . . - . - ,• ,, \ , . , .J . . 'r · < ~ ~ .~ t ~ ~ ,, " . ' . ~ ,-- U ,~ C • . ·: : : t i r- 1 •~. · \ · ' ' 1 ,- ~ ...:, •o. I ~ ~ · - :. - ~ ~ i 1~H, k~• 1 .,.,-, f n .additinn, I -,,,,~1;, lrn · ~rnenf a ~y~te.,m to manifor .&mi ~rmm'lt cs:mtfou~d ct:.implitrni::~ ~-\•ith thls requirnf et WAC 388·'1'8A~24.a4 Tube:rculosls Two: step s-kln t.esdngi. Unless th.e staff J:}erson meets the raqui:t~m-enHor h.wfalg no-skin testing: or l')nly one test~ th~ ass~s.ted. living -r~eiHty c.h:oos.tng t~ -do skin testfng, must -ensa,re that eaeh: staff person has the-foUowing two.step s,kin testing: This requirement was n~t met as evidenced by: Eh~sed {l;n intetv11::\N .Hnd r~ccrd review·.. tl·ie t'adi!ity foif:ed b:i cGrnpf:ete tuberwiosb, (T8} (sn inf{;i:;tiolrn bad;eriai ufaease tlut cfti::·11 Jtta-:::ks the fung.sJ t~stln] on 1 r,f. ::} satr1p~~d srnff (Staff .A) :j:\cr r~gut~tions. This f~:ilun~ rl,~cd ~11!: sfatf: itnct resid~nts-~l: tfal~ for po~sfole ~xp,:i~ure and hrn-rn frntn ~1 cornn1unicable diseas.:e. Our/n9 an tlnarmm.ff1Ge.d !k:~nsing inspeclior. -on O·l/tJ5./2tl24 ~t 11 JW Ml., the de~i,~rtrnent rnceived the re~u;e~ted i.,.taH re·i::t:.,rzfa. Staff A R~i:ord review for St~ff .A. Ex~c:ut.iwi Dir~dGr, ~ho1.-•,md Shif A was hirnd M 04/2 'l.120'.23. 'Revfow ,1t Staff' A's TB rncmifa t#~OV<ied that Staff A. had their fir~t step TB te~t t.omp!e.t~d (in 03t2S/1023 ar~d r<;!su/ts read 1Jn CJ3,i3·i,c202:~. No second step TB ksh\•r:~s: fmmd for Sfa!'f A. On 01/08/2024 at ·t 2:55 PM, during an inte-r:;_,fow, St,aff A :stated, Trn ~}Uilty cit th~t ~ }ust t~wught t.•-VD ~tepr; rne,mt tJO ing 'in tvvi ,.;~ ." Statement of Deficiencies License #: 2640 Compliance Determination # 34671 Plan of Correction Cogir at the Quarry Completion Date Page 7 of 19 Licensee: Cogir Management USA Inc 01/08/2024 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, Cogir at the Quarry 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-2484 Tuberculosis Two step skin testing. Unless the staff person meets the requirement for having no skin testing or only one test, the assisted living facility choosing to do skin testing, must ensure that each staff person has the following two-step skin testing: (1) An initial skin test within three days of employment; and (2) A second test done one to three weeks after the first test. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to complete tuberculosis (TB) (an infectious bacterial disease that often attacks the lungs) testing on 1 of 3 sampled staff (Staff A) per regulations. This failure placed all staff and residents at risk for possible exposure and harm from a communicable disease. During an unannounced licensing inspection on 01/05/2024 at 11:00 AM, the department received the requested staff records. Staff A Record review for Staff A, Executive Director, showed Staff A was hired on 04/21/2023. Review of Staff A’s TB records showed that Staff A had their first step TB test completed on 03/29/2023 and results read on 03/31/2023. No second step TB test was found for Staff A. On 01/08/2024 at 12:55 PM, during an interview, Staff A stated, “I’m guilty of that. I just thought two steps meant going in twice.” Plan/Attestation Statement This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. .12.2024 11 :57:25 State of Washington 12, Stat{¾rn:ent cf Detici~nde"&: Li,;<.1nse. #: 2640 Gcrr.~pfamc-e D~tett'l:'linaMn #345Ti Phm Correr.tion ·Cl:\gfr at the Ousrny c·an1ptetbn Oats t'l'f Fags 6 0f 1:9 D%XJ8/2D24 ln adrllti,'.l-n, I • · · · ~\,:nt a: :£ystl!::rn ta n,~::initor ~nd e.n~ur~ contlntJed 01rnplicinc1r. \,\Mh th is requiret WAC 388-1:SA-247.4 Training 1ind hc1n-e care aide -eertffleatlon r-equirementi. l. · • .:. ) . \ J Tl" ~ e · . - ! · ;. 1 , s - ~ -= 1~. l . . - . , ' - - , - . ' ~ U livfrv ~ , - f .: " t~ , ,. v .. ~ f i L " ~ ' , ' ~ " 'l ~ ' , ' St " ....., " :i; ' :~ ~ .... Ure a ·. l! ,; )I, q :, ~, ,. - ! ; I, ~ :\~ 't - ;t ' . - . d jj, " , 1 . : ; 1 r ·1 -,,·~~ hv "' i - li~ '!i.) " ' ?·:,._,:j, 1 ' - \': . l- 1 ; 1 ,i n1-,,• t. · 1 • ~ ·: . 1 $ i: : t L ·1 1rn :,, (y ~ · a, , e· t r designeBs, anf~ cm.egivern h~red <:m or after Janwuy 7. 2,0·12 1-rseet the fong-tenT: ,:aHi \N"G~·/,-;ertraining r'ltquirements: iJf ch;npter :?BB-112/\ VlA C, imjudk,1 bnf t.'b'}t lirr,iz~cl fo: . (a} Orientation and tmfety-; (,:) Spedalty for dem<?.ntfa, iT1ental illness :am.' . l/or developrr1ent'al disabi;iti,e!:rlt\t~en serving r,e·s.idents v~ith any ,:if th,ose prirn«l'V sp~dal ni?.-ectl:>; Based o,n interview and record reviev,...-, th,~ ftllci'!ity··faifed to ensure that :3 i:If 5 sarnp!ed st11ff (Braff :A., St~ff 8, eind S.tatf C:) cl)mpl,eted requkf:,d tmlning per r~gu!ati:ons.. Thi£ failure pbced <~f'I reddents at risk of b;eing c:::irn{1 for by untminBd staff. During an ti:n.Jnnntm(:ed lii:erwing inspection on Ot iH5/2D2.4 ~t ,i i JJ{l AM, the dep:arttnent rci,:•:eived the re.~~e~:ted staff rntl':lt"6s. St<~ff A Record revie~-vfor Staff A, Exec.,utive Directi:ir, sh{:;v~•eti Staff A 'i>\'.fls hired on 04/2 ~/2023. Docurnani:atkm of Or!entatirJr~ ;-irid S~fot_v Trnining \N~s ni'.lt foum:l h;r.r Sfalff A. . St~~ff 8 Record revie'¥v for Staff B, Dire,ctor fi Nursing Ser1ic1:;.s, s~1m•v~d that Staff 8 \NBS hired r.:ri 08i2:B/2D23. Dtiwmznt;ntiun of Orlenfaitfon and Safety Trnlnlnii \•va-s not foumi for St.~1ff 8. Statement of Deficiencies License #: 2640 Compliance Determination # 34671 Plan of Correction Cogir at the Quarry Completion Date Page 8 of 19 Licensee: Cogir Management USA Inc 01/08/2024 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, Cogir at the Quarry 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-2474 Training and home care aide certification requirements. (2) The assisted living facility must ensure all assisted living facility administrators, or their designees, and caregivers hired on or after January 7, 2012 meet the long-term care worker training requirements of chapter 388-112A WAC, including but not limited to: (a) Orientation and safety; (c) Specialty for dementia, mental illness and/or developmental disabilities when serving residents with any of those primary special needs; This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure that 3 of 5 sampled staff (Staff A, Staff B, and Staff C) completed required training per regulations. This failure placed all residents at risk of being cared for by untrained staff. Findings included… During an unannounced licensing inspection on 01/05/2024 at 11:00 AM, the department received the requested staff records. Staff A Record review for Staff A, Executive Director, showed Staff A was hired on 04/21/2023. Documentation of Orientation and Safety Training was not found for Staff A. Staff B Record review for Staff B, Director of Nursing Services, showed that Staff B was hired on 08/28/2023. Documentation of Orientation and Safety Training was not found for Staff B. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. .12.2024 11 :57:25 State of Washington 13, 81:~hm~nt {rf D~t!d,:H'lciEl'fi Phu, oi Corre.;:.tion {:-Q.gi~ at th~ Quar~y Pags9 di§ Ur.ense,e: C:ogir ().·}~nagem-t>nf U:SA)nc Oi.10812024 St~ff C Re~onJ rnviev-t for Staff C, 'Re-sitfor,t C-ar,~-Ass.odatt"[;. shov1.,ed Staff C ~,.,•~s hlr-e-d on 02/2Bf202.:3. Dor.:un-ient~tion of Dernenti,a ;,md Mcni.:11 He<itH, v\ias nut found kir Sh1il C. In nn e;dt intetvle~<\• tm OW:J8i2D24 ,~t ·t;rn PM, Sfa~t'f .n. .. Ex-ecuhv~ O!r&ctrw. ,.~,::-l<nmf\'~edgcd Hmt th~ required trnining for: Staff .A, B, and C v,.<asn13t c:0mµ.leted. Plan/Atteitatitrn Statem-ent In ~~dditioi~, I -~·\•in in-ipl· .YHrnt a sv~t~n1 ta mrmit~r ~rtd en·m.ff-e t:onfo1ued {~11r-r1pli~na v,&h this requirernent WAC 383-18A-214{l N-$:QOtiat~-d service agreement eeormmts. The: assfned living facmtv must develop, arid document i'n th~ t'esident'~ record,. the agreEd ,upon pfan ta addr-ess and support e~eh r~tident's asussed eapcab-ifities, n~~ds and prefe:re:ne-es. inctudingfuefuHowing: {.&} The pfan to. tr1Mittlr th1: resident and .&·ddress lnte1ventic:ms for ct.nrent 11sfolt to \fo3· residen-l's l·walth ,md g~f-e-ty tf·mt v~'~l'tt- idn€ tif led in nn-e c.~r rrmrn fJf th~ fr1Ho\i\M·1~r (i) The re-uicfont<s pn:.~adtt1i~siun zis:sessrne·r,it: (b) Til~ plan fo pmvid~ assistance \>',ith act~vit\~g of daitv li\11ng, if prnvlded b}~ the a:ssigted livhig: fadlity; (r) The. p~~m fo providB nei::e,ssary lntinmltt!?.'l'lt m.1rS-1t1~J ~ervicss, ff provided by t'Ms ,:.1ssist~d lhting fud!ity; {~) Til~ r~sidenfs p-rererenc,,% kw hi'.>\·V .~eivi:::es ~-">Im h~ pr~vtded, ·m1ppmfod and ;1;:;.cm11motfated ty the assisted fivin:J fi:idlity. (2) C!eirb/ d-e:fined :respia;:Nve trl-les imd r&Sf.h':lnsibmt&s of the re»M~nt, foe i-'lS5'i~t~d living fridlitt staff', and residentsfarnH_y or other si9nifirnnt pet$Uns in rne.eting the re!:{idenfg 'needs and pn~f'er£!m:::s·s.. Except .m~ spedfh.:tl in \.'VAC: 38B-78A-:129D m~d 3SS-7BA-2S40 {5), lf a per$1,m oth:er tf1an a rnregi'ver is to b-:: r~spons.i!Jl;e for p.rcvfdin!fl care or services tc, th:e Statement of Deficiencies License #: 2640 Compliance Determination # 34671 Plan of Correction Cogir at the Quarry Completion Date Page 9 of 19 Licensee: Cogir Management USA Inc 01/08/2024 Staff C Record review for Staff C, Resident Care Associate, showed Staff C was hired on 02/26/2023. Documentation of Dementia and Mental Health was not found for Staff C. In an exit interview on 01/08/2024 at 1:30 PM, Staff A, Executive Director, acknowledged that the required training for Staff A, B, and C was not completed. 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, Cogir at the Quarry 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: (i) The resident's preadmission assessment; (ii) The resident's full assessments; (iii) On-going assessments of the resident; (b) The plan to provide assistance with activities of daily living, if provided by the assisted living facility; (c) The plan to provide necessary intermittent nursing services, if provided by the assisted living facility; (d) The plan to provide necessary health support services, if provided by the assisted living facility; (e) The resident's preferences for how services will be provided, supported and accommodated by the assisted living facility. (2) Clearly defined respective roles and responsibilities of the resident, the assisted living facility staff, and resident's family or other significant persons in meeting the resident's needs and preferences. Except as specified in WAC 388-78A-2290 and 388-78A-2340 (5), if a person other than a caregiver is to be responsible for providing care or services to the This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. . 12. 2024 11 :57:25 State of Washington 14, Stt.t~ttHii'lt irf D~ftd*i)cies Uc~ms~ #: 2640 Pfan o-f C c:irrectioli CQgfr at the 0!.lM[)' Pags n-f 1:§ Lk.~nsiJ,e: C:ogir M<1n.icg;m,~nt USA.Joe msid-ent in th~ assistB:-d living fadlit')", the asss~t~d Jiving f~<::-tfrty must specify in the n~goh~ted s~Nit:a agreement an aft,:,rrrnte. pi~~n for prnvh:H:ng cam m' service to the rssidentin the e~le:nt the neces.~a,y sctvkes. <'H"ir notpr<:.ivid>c"d. The as.~isfod li~.,in~l fod!:ity m~~✓ de.vek:1p m1 aftem~~te plftrt (3} The times services will be detl'vered, including frequen,._:j•· and .aµpn::,xiim.lte time of day, as ~Jpprop::-j~~te; [:3} .Appr-opriate beh«viora! Interventions, it needed; (S} Th~ ~rssisted living facility rnu~ m:i :n,iquire {i-l' .t1s'k th~ r-esident tir the reski-en:t's reprns.~nhitive tti sign any negotiated -service ur r:lsk agreern-t!nt, that rtffports tr, \:•1raive :illlY right; of the res-itlent or that pur;:wrts fo plafe resp{lnsiMlty ar liability for lasse~ nf personal prnp1:Ht)r or:-injury on the rtsk:knt. This r~quire.ment wa~ net m:~t as evhfenced by: 8nse.d un intervie\.:V -~nd record re•\f.'iew·, th<'.: facility fai!f.:d to do.curn~nt in the re$:ident'$-Negcfaited Se1vk:-e Agra-,ernents {t~S.A) tt,e p!an to providB spf!dfic resident identified c.:tre arlid service ne.e1.fo tnr rn ~ ,:if 5'>Jn1p1ed resid.,;nfa (R~:!:cidents 1f l, ·l ·\, ·1 r~, HJ}. Failur~ h~ cfovdop ;,1 cc;rnplete N~~A t(li:ic:ad thes:e-reBkients at li:sll: for unme.t care rre:e-ds and fm· Gare ~nd services not be1ng pn:ivids.J per the f\JSA. Rs€ ident i O{ Rl CQ On tH/0412{}24 at L·W PM, RH:ts n::·con:Js sho\A;,'fd tlrnt ern ,~drriHtecl b:i t"l:e fadlify ,:m l2023 w~tt-i a physkal tn(}Ve in date of .l2.G23. Rm was dm::umenteti to have v-srious diagnoses ir<cfudi"" ,,• . ,:,. !-)1,: Rv€ i:ev.,i ot R·1O 's f\!SA, datBd ·1O l05l202J, showtd n.o dowrner.tatirn, of the type !Jf ciiet R-·10 ViJss re(:1~\ling. Rtlsid.ent 1,1 (R~i) On fH/05./2024 at '1:33 PM, R·J fl's records ·tshav-te:d that r~-rn ~dmrtte-d tCI the-facility c~n l2023 \l\1U1 ~~ pi}~/sbt:al rnc~\ie it~ -di~te ,1t 2(}23. R-i Gv vas docun,~nte·d ~ls t1Evi:r~g vsritlt~~ tH~gt1ris-Bs Statement of Deficiencies License #: 2640 Compliance Determination # 34671 Plan of Correction Cogir at the Quarry Completion Date Page of 19 Licensee: Cogir Management USA Inc 01/08/2024 resident in the assisted living facility, the assisted living facility must specify in the negotiated service agreement an alternate plan for providing care or service to the resident in the event the necessary services are not provided. The assisted living facility may develop an alternate plan: (a) Exclusively for the individual resident; or (b) Based on standard policies and procedures in the assisted living facility provided that they are consistent with the reasonable accommodation requirements of state and federal law. (3) The times services will be delivered, including frequency and approximate time of day, as appropriate; (4) The resident's preferences for activities and how those preferences will be supported; (5) Appropriate behavioral interventions, if needed; (6) A communication plan, if special communication needs are present; (7) The resident's ability to leave the assisted living facility premises unsupervised; and (8) The assisted living facility must not require or ask the resident or the resident's representative to sign any negotiated service or risk agreement, that purports to waive any rights of the resident or that purports to place responsibility or liability for losses of personal property or injury on the resident. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to document in the resident’s Negotiated Service Agreements (NSA) the plan to provide specific resident identified care and service needs for 4 of 19 sampled residents (Residents 10, 11, 16, 19). Failure to develop a complete NSA placed these residents at risk for unmet care needs and for care and services not being provided per the NSA. Findings included… Resident 10 (R10) On 01/04/2024 at 1:10 PM, R10’s records showed that R10 admitted to the facility on /2023 with a physical move in date of /2023. R10 was documented to have various diagnoses including . Review of R10’s NSA, dated 10/05/2023, showed no documentation of the type of diet R10 was receiving. Resident 11 (R11) On 01/05/2024 at 1:33 PM, R16’s records showed that R16 admitted to the facility on /2023 with a physical move in date of /2023. R16 was documented as having various diagnoses This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. .12.2024 11:57:25 State of Washington 15, St~te:rM!1t ,rf D~fid~tide-s: lk,~ms~ #: 2640 Plan oi C: orrectiort C~gi~ ~t the Quar~y P.ags 11f 1:13 Ur.ens~,e: Cogir ~hmi-gsm{;nt USA!m'.: Re{~ord revlew of Rt i's assessments. shri•Ned .a rnedkal dev·iee asses-srnent dated '! 1lD9i2023 for tt11:: tme of ~1 tran~for wiie and sid~ mils. . RNiew of R·1 :1 's !\JS.A dat::d ·1 li'nHl2D23 shnwecl na ducurn~·nt~tion ot the i11:e-,:ika:i devices R1 t Vfas usll'W for tratH,lers and su,foty or fhB dlet R1 'l \i\,m~ receiving. Resident l8 {RH:i) On CH/0.512024 ~(1:1a PM. RH>'~ rni.:.orcis show!);d that R•i$ adrni·tt.M ta ~"<e ·fodlitv m, ·f ·flHV10n v~it11 v21rl1J1...rn: rliagnast:~s lndi1&ng Cl-(D. · R~'iew of R ·1 6'~ [\JS.A d;;it~d 12/1 n. .Q iJ:13 shn\Ned t1(l dncurn~·t.tatim, of the type ,Jf rliet R ·I 8 v\f<i~ receiving and no dGcument:::ikm af a h,m1ilV plan far medk:~tion. ·rn F~eskfor~t {RHl} C)n u·it1J5l2.D:24 ~lt 1 t:(HJ .l\~·~, R·1 Efs rectird~ shtt\·Vedi th~~t R19 ~d~11~tt:-~,j to the f:~l~~~Hty t}n /202~3 w~'tt1 varfous dfa~moses indud\nfl . Rt1VieW oi' R·l 8's NS.A dilkd 08/'IH/1D2:3 showed t)() ducurr1e·ntatlon of the type or ctid R·l 9 iN~lS rei::e\vi~1g and no dm::urnentaticn of a f~mji/ plan for rnedict~tlans. In an le!>::.it lnt.~r\;fa~.v on Q 1/tlS/2024 :at. 1: 30 PM, Sttlff A,. Exet:.ufr-.re Oired◊r, ~c.knowtedg\!l•~Hh~t H,~ f'-J:£-.\As fo,r R'W, 'ii, ·rn,, mid ·1 r i v.'i?>re 1-r1~s£\ng jp edfa:: rnside.nt Me.ntt%ed need~ am~ services. Plan/Attestation Statement f h~rnby.-ceitify thtlt I t'klV~ revi~W~ti thi~ rr-pGrt .~~nd h~Vff fak~rt t,f"WiH tak.f! tldN~ rne.-i,sures to i::orr~;:-;t thi£; d:aficiem:y. By t-a§<ing this <l.::tion, Cot_ ·r ~t t ,. Quarry\$ tH' v1irn he in corr1µliEmce v\lifr-1 tl·1is l;:t\•\ii illrtd / or r:egubtion trn (Oatej 2. ~ Statement of Deficiencies License #: 2640 Compliance Determination # 34671 Plan of Correction Cogir at the Quarry Completion Date Page of 19 Licensee: Cogir Management USA Inc 01/08/2024 . Record review of R11’s assessments showed a medical device assessment dated 11/09/2023 for the use of a transfer pole and side rails. Review of R11’s NSA dated 11/09/2023 showed no documentation of the medical devices R11 was using for transfers and safety or the diet R11 was receiving. Resident 16 (R16) On 01/05/2024 at 1:33 PM, R16’s records showed that R16 admitted to the facility on /2023 with various diagnoses including . Review of R16’s NSA dated 12/10/2023 showed no documentation of the type of diet R16 was receiving and no documentation of a family plan for medication. Resident 19 (R19) On 01/05/2024 at 11:00 AM, R19’s records showed that R19 admitted to the facility on /2023 with various diagnoses including . Review of R19’s NSA dated 08/19/2023 showed no documentation of the type of diet R19 was receiving and no documentation of a family plan for medications. In an exit interview on 01/08/2024 at 1:30 PM, Staff A, Executive Director, acknowledged that the NSAs for R10, 11, 16, and 19 were missing specific resident identified needs and services. 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, Cogir at the Quarry 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. .12.2024 11:57:25 State of Hashington 16, St~t~t1~;ent gi t:.hific/,,tlde-;, lkimS!il ,ff 264{.) Pl-w ;J-f Correction Cogir ~t the- Quarry Pags of 1'~ Lk:.e11s,i,e: Gogir Mang:gsm@t USAlnc Di ,{18/202-4 WAC 388-1:SA-2-07-0 Timing o-f pr~a-d1nission assessmE!nt. {0 Unless them is ~n ernBrge.nc~-✓, the assisted-~tving fodlity rnust cornp!ete. th~ pre·.m:lmission ~~~5~~srnent ti the pro~}':Jct:H::hve.: resid-emt bek~r:e e~ch :prti~pectiv~ r~£ident t11ove~ hto th~ ,iss\.~t\:\d living focmty. c:n TtH." ;assisted living fa{.::.i!ily n1(i~t i!nsure !h~ pr~mknrs~i<Jn i\8Sf;;S.Stnent i'S. cornp;eted \,\•Hhfrl five c..~l~nd~~r ifays otth~ ri?,sk!ent n,cvin~}-~ntc, foe assisted living faidli'fy' when the rnsident nmve-s: in ur·ider ernergency conditions. p1F ~r the purp{~~es of this ~ection. . ''isrrHatgency•· met~ns m1y drcun--r.-1tm1ces whe~1 the prosp<?.dlve r~3sid~J1t 'Ji'V13uld other-,\•ise need to re.nuit1 'in an wn~~fo se.tt:ng er b~ without atfoquat~ .:.1nd sate:~ hmrnlng. lhfa requir-e:mentwns not met as evidenced by: B""tse.cl a-n inh·:tvie1,•v -~nd record revievftl1e fadity foiled to ensure. ::1 preadmis's.ion ~ss-~ssm£:nt 1t"l--as L" ... l . ' , " J 'f ~ ) ""' J ' ., j 1 , 1 : •, - , 1 • • , t; " > '" < ' i : , ~ ;, \ . ,, - : • , I , ' ,. s " , o s i : • ; /- : ) i ~ ~ 't ►A " l "'M l:ij: i -- _ <C. ; ~1 - ,,. : - .r .. \ . r·1 .... ~ ( ~ ~. ' . t ~ tl 1 ~ . ' . < .• l" lh l/ • • .J ,., t5'i:·:~>. ..-..- . ~ -" h '' . • { '{ ' » -• ~ l· 1t ~ "" \ - ~ " -: ·1 t"a ._ . ' , (: ., :l , :~ • ·t .. { ..... ' . l ti ·1 C l~. . .1 l ) • ~ 1 ~ •·1 · l • ), ' ; W ., t ;L 1 .:\. , ~ tt,, .p , • · . , , , . . f - ' c - > , < t1 ~ . < , 1 l, ·; ) ° 1 ~ s- - e .... : .. 1 '1· . ) ,i, n ; 4 ~ o !,; t l l, ·J , ',., . ,. facility. This failure placed these three residents. at rish o-f their c:a!~~ ne-ecls not belng tdennfied am:! rnst. Ffoding~ indw:.ifJtL. Resktent 15 . {R-15} Ourh~fl an unarmounce.d full lnspection >1n rJ'llOS/2024 ,,~t "!.2:00 PM, RVi'~ r~CG:fits shmv~dthaJt Rm adrr,!tt~d to t:'te fadJity on l2023 \Nith varirn.Js diagnoses incimHng Rt:.,•iew or R-1 S'~ f'fjGQn:ts sht.nN~i.:.t an ~--ms-essmf.Jnt c1;,rnpld~ct un 0.9l-H.:ll202~J. f\l~i ~~~s~~sments d~tecl on or p-rfor tn adntis-slon vvere fOLmd. Residtnt ·t 6 {R·.~'-1) On QHG5i2D24 at ·1 ::n F~M, R.W's r,€::ords.show,ed that Rl6 adn1itted to th: € f'ae:lrn.y an 1(123 \N~tts vt1:ri~,u~ r.Hm~1no·st;~ ii~clLtd~ng Revie,,-\' of R-1 Ws P::i:.:oE$s sho1Ned: an Jss-essrne-nt complet-ed o.n ·t I/24l202J,. 1·--i0 asse.ssrnents d~ted on rn- ft-rk,r tn ~-idrnissh:m {•\iisra found. Rf:sident 18 {Ria) On G-U05.!2G24 at. ·1: 3(~ PM; RH:fs recon:18 ·st10vved that R1B sdrnrtt.e-ct to the· facility cm !2023 \~it~··l \re1:rioL~~ di~s~Jtltlses ~ncllttiin£J Rfvi;sW of R·l B's rio.;con:Jcs sha,Ne:d assessirt1:enh, ~{)n-ipldea on rl'li-07/2(}23 Hnd 071'27!2023. .. No tlSSt~£f>trkints d~ted on tsr prior trJ. adrni~-~km V-i1im,) frH.ind. Statement of Deficiencies License #: 2640 Compliance Determination # 34671 Plan of Correction Cogir at the Quarry Completion Date Page of 19 Licensee: Cogir Management USA Inc 01/08/2024 WAC 388-78A-2070 Timing of preadmission assessment. (1) Unless there is an emergency, the assisted living facility must complete the preadmission assessment of the prospective resident before each prospective resident moves into the assisted living facility. (2) The assisted living facility must ensure the preadmission assessment is completed within five calendar days of the resident moving into the assisted living facility when the resident moves in under emergency conditions. (3) For the purposes of this section, "emergency" means any circumstances when the prospective resident would otherwise need to remain in an unsafe setting or be without adequate and safe housing. This requirement was not met as evidenced by: Based on interview and record review the facility failed to ensure a preadmission assessment was completed for 3 of 9 sampled residents (Resident 15, 16, and 18) prior to their admission to the facility. This failure placed these three residents at risk of their care needs not being identified and met. Findings included… Resident 15 (R15) During an unannounced full inspection on 01/05/2024 at 12:00 PM, R15’s records showed that R15 admitted to the facility on /2023 with various diagnoses including . Review of R15’s records showed an assessment completed on 09/10/2023. No assessments dated on or prior to admission were found. Resident 16 (R16) On 01/05/2024 at 1:33 PM, R16’s records showed that R16 admitted to the facility on /2023 with various diagnoses including . Review of R16’s records showed an assessment completed on 11/24/2023. No assessments dated on or prior to admission were found. Resident 18 (R18) On 01/05/2024 at 1:35 PM, R18’s records showed that R16 admitted to the facility on /2023 with various diagnoses including . Review of R18’s records showed assessments completed on 07/07/2023 and 07/27/2023. No assessments dated on or prior to admission were found. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. .12.2024 11:57:25 State of Washington 17, St-at~(ll',,nt {rf D~tid~t'lcie~ Gor.:)pltM,~~ Det~tt'l:1int.Htn # 34671 Pl-an oi Corre.ction c·~n1p~etkN1 Dlte: Pags ,:}f i9 In an t?.xit intervisvv on: H1ltl8/2H24 ~t. i'.-~W PM, St~ff A,. Executive Oired;1r, ~cl<nm,'.fodgect that UH preadrrilsskm a:ssessrrn::nt:,nvr€n not corn,nlefoa for RiS. Rl6, t111ti RH} Plan/A tiest~tion Statement WAC 388-18A.,'20SO FuU ~~S~:§St'iterit t~lilts. Thi!. ttsslst:i!d livlttgfaeility mu~tobt.iin sufffoient information to be able to aue.is the e~pabitlti~s;, needs:, and preferences: for eac,h resldent~ and must complete~ -fuU assessment address.irig the follawin~., within fourteen d;ay,s o-fthe r-~s.ident's move-in date, unles-s-eimmcle,d by the departmmtfor good cause: (~} A ik::ensBd rnedi,cal or hea!U't prore~sionai':s diawwsis, 1-mlBs:s·U1e resident abjed& for ri€i~Jious re-as.ans; (a} .A.n•/ pre~crib-:l·d :me.dkt1tkms, and GVeHhe-counter meffa::a:lkm.s corrnnDnly takm by the bdividm1f, Hrnt the indi1lidtml is able to in.dependent.iv se1f-administer, ar safely -and ~cr:urntel)' :dired 0H·1t,rn k1 administer tl) hin-~her; (.".,:.:.ih-1l > ..~ ~ , <t .- ! ~ l , p• ~ - e{ . ' . • !-~ ~ ... - ,-·,t:):· . » .... . < ... · .i ~ · :. t ~ " ~ ' ' > -- " > 'l ~ •· .: • ~ ··· u ,·t ·, S , J " ~ '" , - .: " : " > : ·~•>,~;>rS<1 .,, o ss ~ , t :' " !: " -, " :- tt :; ,. 1 , \ , i - • • . . " . U \ "'llt J '• t f.- ~ ., t .. • ~ -t \ ·, ! o V ,, U •l : l " -'' " '" ~ -i~ ,: O . f • .1 . ° :: ' , · .• ,. '" ., ) u • , " 1Jo'·:•:·:1:,'•-''''~l'·'I Y t \ - :~ ,~ :n o : , v , r, l ~ ~~ ''t t1 -: 1 < "" > '' ; ~ . ~ , ~ . J 1. : J ·,-~-,J;-u 4 ua.c,.,i..i),, 1 th;,it the indivldu.ai is able. to seff-admit,i:st~r vvhen helshe has th!l! a~~istan{:c GTa {:are;Jivt'ir; and f.c) Anv presc:ri:ti~d rnedit;,itions, and civ~v-th,':!-count~w m~ciie.,tkms etltnnicmly t~,ken t}y th@ individuai, that the individtu1! is rwt able to se!f-adrn!niste.r, ~nd nee-<:ls to ll~'fe adn1ini&tl:'!red te< hirn ar her. (s-} Th~ individual's n:t.::rsing :needs 1Nhen the individual reqt.iir.es the ~erv~ces i;:if a nurse on 'tl':e assistt:ia living fodmv premise~. Statement of Deficiencies License #: 2640 Compliance Determination # 34671 Plan of Correction Cogir at the Quarry Completion Date Page of 19 Licensee: Cogir Management USA Inc 01/08/2024 In an exit interview on 01/08/2024 at 1:30 PM, Staff A, Executive Director, acknowledged that the preadmission assessments were not completed for R15, R16, and R18 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, Cogir at the Quarry 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; (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: This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. .12.2024 11:57:25 State of Washington 18, Sl:~ts"ml:<.ent M Defid~ncie-s: Ccm~pli.in,~::, Deteu1:1in~t:~m # 34£T1 Phm oi Corrnr.tion C.an1pl~t~Qn Oat.~· Pags ofH D1 .00.12024 (:8) SignitkimUmGvw1 b~h~viorn i:~r·~ym:ptrnwi of the \,nciivh:iua~ causing cone.em or rnquiring spedal care, indtKEn~r (a) H!-stmv of suhst~m~::a B:b1..1se; (.ic'} Other saf;1:;ty c:-anside.r~1ticm, that rnay pose ~~ danger fo the indivi:duaf: GI' c~tt·if.:r-5, ~uch ~~ use Gf rnedical dB-vices or the indivkh..1~!1-s: ability fo snmke Llnsup,srvist:1d, if smcil~1~19 is ~'l-errnittea in the il.1~.misted Uving fodlit).:. (7} lndividuat'-s spedal ,needs:, hy evah;.1ating avait:atile intcHmatiG:n, t:.n-if avatls:!ble inforrnation tkies. not indh::atti the pres-en-t~ cf spt,d.:11 n~i:!tfa, selettinq :~nd us.~ fo ng r ~n appr,cprt~t~-te101i. to ctetermint~ the pres~nrn ,;f symptoms c::.n~lstent wit'"< and irnplic;utions •::::<ire ·and service)l ~f: (a} M er1ta! illntc'~s-, m needs for psfd,nlagic.:sl or ment.~l h~.a:lth s.ervi,tBS, e~<cepf vvhf.ffe }Jrot~:-J;,:d by cDnfaientiality !aws;. ti) B.:i:se ~mi· deterrn!nst-on that 'the re.siadent has shmt-te:rm memory Josi:,; upon i:Jhj;ective e\.'fdeni::e~ and (.1ij Hc~w the lt1dlvirlusl ,..vm obtain prescribed rnedkatii:.ms f-or :use h1 th,~ ns~isted living fadi~-;. Statement of Deficiencies License #: 2640 Compliance Determination # 34671 Plan of Correction Cogir at the Quarry Completion Date Page of 19 Licensee: Cogir Management USA Inc 01/08/2024 (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. (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. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. .12.2024 11:57:25 State of Washington 19, Sl:~tf!l"il,rnt c·f D~fici;sl'lde-e; Uc~ms~ iff 264D Phm o1 Co n-al:'.tiort CQgfr at the Qu::my Pags of B U,r.ense,~: Cogir M<1n.i::gement US..A.!nc: ('! G} I r.dividui1ll's p~tsan~!, identity imd !lfiil§t;yle,. tG the ~xtent. the indi,,...idual is \·\•irnn,g t{\ ~!'l,m~ thf.: infonnation. . and tr1e rmmn,~r in 11Nhkrtthev are. expressed, including prefon::nc:es re-garciint} foxld, wrnrrn. m. i~-' umtacts, hobbiel:,, sp\rJtucil prMen;,;nc{s's, or other sources of p/e:1.tm.ire. and con1fmt. (a,l The pre~;:;r,c-a· uf any adv;,'Jnce. dfredi'-/e, or other h:igjl cti:H::wr1ent thatv.•m estatli'~h ~i sat~~titute dedsion rrmker in the fofore; Based on int£:tview snd !\'3rnrd rev\e\N, the fad~ity fai!ed to c-Grnp!ete a tun assessrnent vvith\n fourteen days af the resident's tTHJv.e-m date for 8 Qf S sarnpled r,t;sidents (Reside.nts 4, S, -~ O, '14, 1g , ·f 8}. This faf.!urr,; pf<l.c"'d th~s,., five re~ld,mts ~t rish of their car~ nili::d~ not be.inn met Residen:t4 (R4) During an u:nanno ...m ct,H.l fiiH 1m,pe;:::t.ian tsn Oti'04./2:J:l24 at t 2:00 PM. R-4's. rec\":irds shc-\•<Jed th~t R4 ;:.drn\Hed to the f'adliity· on /20:23 v.,:ith a ~'lhysic~i lll0Vt';· in d[tte of 2028. K~ \-'1i.tlS r.k1curnented to f1av,1; varinus diagnoses including Rf:f;ident 9 (RS} Dtidng an unarm,nunc~d fuH insptcth:m c,n; 0·1/04J2fl24 at UJ:45 .~M, R8'·s rec,nrds sh,:i\o\!ed that R9 ,~drnltted ta thE: f~t.Jlity ,:lf1 l2Gl:23 ~-\'ith a phy·sii::<ll f'li()Vf; in iht~ of t}023. R~=! V,f.m,. doci.rmented to hav=t various diagnoses including . R .,c-,·,.i:.,.,,1. < fl tRH1) N~ U~~ h ~ .:.. -\ ~ U On D1/G4J2024 2t ·r·.-rn PM, RW's r~cords shovved that RHL,1ctrnrtt.ect tu th~ facHit~/ t:~n ·u2023 v~~th ~~ physkal move in i:fote ot 201:.3. R'~ Ow as dtH:un'Hl1t~d t,;j h.:M~ v,~ritiu:s dl::Jfln0s~~ in~_Judfng . Statement of Deficiencies License #: 2640 Compliance Determination # 34671 Plan of Correction Cogir at the Quarry Completion Date Page of 19 Licensee: Cogir Management USA Inc 01/08/2024 (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 6 of 9 sampled residents (Residents 4, 9, 10, 14, 18, 19). This failure placed these five residents at risk of their care needs not being met. Findings included… Resident 4 (R4) During an unannounced full inspection on 01/04/2024 at 12:00 PM, R4’s records showed that R4 admitted to the facility on /2023 with a physical move in date of /2023. R4 was documented to have various diagnoses including . Record review showed an assessment for R4 labeled “14-day” with a date of 10/16/2023. Resident 9 (R9) During an unannounced full inspection on 01/04/2024 at 10:45 AM, R9’s records showed that R9 admitted to the facility on /2023 with a physical move in date of /2023. R9 was documented to have various diagnoses including . Record review showed an assessment for R9 labeled “14-day” with a date of 12/06/2023. Resident 10 (R10) On 01/04/2024 at 1:10 PM, R10’s records showed that R10 admitted to the facility on /2023 with a physical move in date of /2023. R10 was documented to have various diagnoses including . This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. .12.2024 11: 57:25 State of Washington 20, 81:at~m:,int (rf Ddld;.:ncies Plw oi C@ ffEH'.tion CQgf.r at th~ Quiwy Pags of B U:.ense,e: Cogir M~na::gem~n{ US.A.inc ResidBn:t 14 (R14} On tHlOSl2.t124 ;,it 1· ~::1f .AM. R14's ri€::m ·ds s~1~NWHith~t Rl4 Jdn11tt~d to th~ far.;ili~/ Gl:J 202:3 wHh a 9hyskal rr10\,e in rl;ate of :2G2:3. RM \i'\,'aS documented ta hav~ v1~rk1us dbgrn..s(:,s induding Resid1:~t ·18 (R·1 B) On l.H/G6/2-iJ24 at t ·.;35 PM, RiS's re·~cwds sl-1ow·ed that Rts ~dmitttd to the· fad!ity-on f2D23. RHl vv.;:-is documented to haV<'.: vari:oLm di.sgnoses tndutiing . Rfskfont rn {Rm) On D-U05.l2G2.4 at ·1 i:00 .A.M, 1~-19's records shov,·ed that RH) admitted tri the fodlit<;' 011 /202:3 v~ilh veidm.m dfognases induding In an ex.it \ntef'\.'ie\;v on 01 /tlS/2024 ;11t ~: 30 PM, Staff A,. Exu.cufr.-..re Ofred.;'.}r, ackrH::lW~ed9ed ~hJ:t tl1~ ·i4~day assessrn~ntsv~·t:.re net comp~eted v,1ithin 14 {fays Gf adrnisskm for R4,. R9, R·!O, R-1+( R'f:2, sndRW. Plan/Attestation S~ tement I hereby: certify thr:~t I ~1~w~ rev\~v\1ed thi~ rnpmt mid h~~vB tlk~n twwm tak!~ t~div~ rn~;:isures ki i:::;:;rrni:t thi~ d~ficierKy. By t-al<ing ~hi~ actkiri:., C 1glr ~ . th~ 0Lmny ls or wrn he ·u. . ~ --- . in 1:on-1p!iance v\<ifri this li1v11 and tor regulation un (DateLl. Statement of Deficiencies License #: 2640 Compliance Determination # 34671 Plan of Correction Cogir at the Quarry Completion Date Page of 19 Licensee: Cogir Management USA Inc 01/08/2024 Record review showed an assessment for R10 labeled “14-day” with a date of /2023. Resident 14 (R14) On 01/05/2024 at 11:25 AM, R14’s records showed that R14 admitted to the facility on /2023 with a physical move in date of 11/21/2023. R14 was documented to have various diagnoses including . Record review showed an assessment for R14 labeled “14-day” with a date of 12/07/2023. Resident 18 (R18) On 01/05/2024 at 1:35 PM, R18’s records showed that R18 admitted to the facility on /2023. R18 was documented to have various diagnoses including . Record review showed an assessment for R18 labeled “14-day” with a date of 08/12/2023. Resident 19 (R19) On 01/05/2024 at 11:00 AM, R19’s records showed that R19 admitted to the facility on /2023 with various diagnoses including . Record review showed an assessment for R19 labeled “14-day” with a date of /2023. In an exit interview on 01/08/2024 at 1:30 PM, Staff A, Executive Director, acknowledged that the 14-day assessments were not completed within 14 days of admission for R4, R9, R10, R14, R18, and R19. 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, Cogir at the Quarry 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. .12.2024 11:57:25 State of Washington 21, St.at,nn;,int trf Detici~t)da-s Gcirl'\pli.a~,':'-\': Datett'l:lin<1titt1 # 345?1 Plan ;.1-f Cofrnction c· u:-rlp~e1kN1 0 at.s· P·ags of 1:§ (1} Devel,Jt1 sn inlti. .1 ! resh:lent service phrn, b:nsed up-~n discussions lNith th€ res~dent nnd tl.'1e r~side:nt's rnpr~i:;.enfabve H the rn~id•;smt has on~. ~Hld th~ pre,~dm~2.~i-on ~ssessn~a:nt uf ~~ qmiWieci as5essG:r; upon admitting a resident into an :a·ssi-sted !hdng fad!ity. The as.sist.ed living faci!~tf must ensure the i:nltiuJ t;:lE,ident servlc;a µ!atr. (a) lntegr.,tas the ~ss~ssment info.rmmfon i1n:1vided t~iy' ·thr::· d@p:mtrrrent's c~s.1 mQm~~g'c'r for s~ch resident whose c.me is pmtf~lly ~r 1-vho!ly funded by the d~·pmtr:rient ar the ~ltaitb cme .Huthut\W,, (c) F'f,avides dfredian to st~ff «nd CEWe£§i'<lers relating ta ~t,e residenl's irrtnedh=.ttfJ ne.;:Jd:ii, capabilities, and p,-eforet1tf!£:. f ~ - .: ' . ' . i ) r •.- '- - , u ,, ~ ,· ~ 1 · ,. • ... ' . , ' , - . ' , ' $ -'- ,, " t l · . 1 , ~ ; ... , .- r-, t . : , .- · - ~ " r " -~ ·t · , ,. ~ •., t, \ , ,, , \ . , ~ (' · ~ •· " .... t '' v · , ' - ; -. , _ . . . , .. , . ~ ,, - : . : , 1 \ .) ,. . . - ,, L •· - q ,: · - " ! " - " v r ~ {" t 1 ~'",-,~,, ,....,. t- ~- ,-...-. l 1 : , t . - , ~ . ' ., C _ , . . , ~ 1· , U _ . , .. , . , .. : - : - -~ ~ ~ l.. , . ~ · D L t,. ' : " ,.: t ; ' ,{ . - , i ti· ~ • ' , \ , , , ; f'" 'v '" , ' . . · d ' , ... ; .. ; . c .,. , . , , .. . p .. o ,. , Y 1,, \ ,. t'" C: ' , ' t " 1- d ...;I • , 1- l • -.. l . ~ \· ~ ~ ~ -• • .• • ' •n ' ·' ~ " a~me'.!mment, lnltia:! resfd,;<>.~t. servlce p-h:ir1, anti ful! asses~ment ink~rn1ation, v1Mh!n thirty' days of the resident mav\ng h Bas?d ,111 interview <~ml recrm.-1 revie,.,v, ttie: fadfrtyfailed to corrip!eh:: the Ne.go-Hated Se.rvke .A.greern~nt :(t•;!:S~4} upon adrnis:s$rtr1 tc the fa(;~J~ty.·· for 5 of 9 re~§ctc.nt£ {Fteu~{t~nts ~ 0~ 14;, ·t 5, '16~=· ·}tl} ;~t'ldl{ft v~•ifoin Ji} days fri'ikw~1nfl adrnis~i0n ta thi:! fodtlty T{H' 3-d 8 r~i>iidenis (Ri:!slid&.nt~ 4, £1, ~ 8). TMs fofaJre pbced lh£:se rnsh:l~nhl ~rt rish of fr1.e~r care needs rwt being met. R~I~id1nt4 (R4} Ow~ng an un.ar-1trnrn1red n.i!l lnspe.ftion ~n a H H4/2D24 at ·; 2: 00 PM, R4's records gh◊V<Jtd Hmt R4 adrnitta:;d t-o the focrni:y Qt1 !202,3 -v•.-ith fil physic-a! rrn:Ne in date tif l2iJ23. R4 \l'l~ls do.curnented to ~1ave v-ar-iuus diagrmses hduding Resident 9 (R9} Durtr~g an t::nannounced full insp~ftkHt an Otl04V2:f}2-4 ;~! ~0:4t-; .Atv1, R@:•s ric:tirds shnv-ied ~h~t R!~ adm~tteci to the fm:!1itt on 2023 vvith a ph:v-s,c.al m1Dve ir1 date of /2023. RB '\-\•ES clo,:umente!d to hc1v~ vi1ti0us di.;,1gnosf?.s induding Re<::ord revlm,v shtiwed iarl MS.ti_ for R9 labeled "SO-day'· w~th B date of /2U23: snd signed rm l2021~. Statement of Deficiencies License #: 2640 Compliance Determination # 34671 Plan of Correction Cogir at the Quarry Completion Date Page of 19 Licensee: Cogir Management USA Inc 01/08/2024 WAC 388-78A-2130 Service agreement planning. The assisted living facility must: (1) Develop an initial resident service plan, based upon discussions with the resident and the resident's representative if the resident has one, and the preadmission assessment of a qualified assessor, upon admitting a resident into an assisted living facility. The assisted living facility must ensure the initial resident service plan: (a) Integrates the assessment information provided by the department's case manager for each resident whose care is partially or wholly funded by the department or the health care authority; (b) Identifies the resident's immediate needs; and (c) Provides direction to staff and caregivers relating to the resident's immediate needs, capabilities, and preferences. (2) Complete the negotiated service agreement for each resident using the resident's preadmission assessment, initial resident service plan, and full assessment information, within thirty days of the resident moving in; This requirement was not met as evidenced by: Based on interview and record review, the facility failed to complete the Negotiated Service Agreement (NSA) upon admission to the facility for 5 of 9 residents (Residents 10, 14, 15, 16, 18) and/or within 30 days following admission to the facility for 3 of 9 residents (Residents 4, 9, 18). This failure placed these residents at risk of their care needs not being met. Findings included… Resident 4 (R4) During an unannounced full inspection on 01/04/2024 at 12:00 PM, R4’s records showed that R4 admitted to the facility on /2023 with a physical move in date of /2023. R4 was documented to have various diagnoses including . Record review showed an NSA for R4 labeled “30-day” with a date of /2023. Resident 9 (R9) During an unannounced full inspection on 01/04/2024 at 10:45 AM, R9’s records showed that R9 admitted to the facility on /2023 with a physical move in date of /2023. R9 was documented to have various diagnoses including . Record review showed an NSA for R9 labeled “30-day” with a date of /2023 and signed on /2023. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. .12.2024 11:57:25 State of Washington 22, St<itl:ft11?-nt M [Mfici~ncie~ Go~)pli,rnc~ Detet111in~W$n # 345T1 Phm tYf Correction c·crn"::ptet~Qn Oat.s· Pags oft'§ R,flsidt:lnt H1 {RH1) On DHG-4/20-2-4 at Utl PM, RW's l'l:}Wrds shciv,i'td that Hlu 8dmitte;J to th~-fotHity (m 2r.l23 1,•\<~th a physk.~I mo,1e in Jate or ,Qg,n O=.i2M3. R 10 V'.J~1:s di.Jc.t1ment1::d to h~vi1 v~1ric,us diagncsc::s inc~utUn£t Reskknt i4 (R·!4) On 01/05/20-24 at n:25 .AJ.%, RJ4's re1::on.1s sho;,,vedthat R-~4 admitted tu th!:! facility an 2023 w~th a p~tyskal m01...-~ inflate of·! ·U2't/W23. R~4 wag d,JCumented tt) h<l'l~ viwimrn. diagnl,Sf!-f; inducfo:-£\ . Resident ·l S {R15) On Ot/05/2024 ~~t ·J 2:00 PM. R1 f~'s rnetwds sht.nN~d th,Jt Ri:3 ~:dmHtf.d to tl'rn fodlitv , ~n 202~l. ' RW 1Nas duwrnt::nte-d tc~ r1ave vaifous dhi9110s.~s including , .. Rfsid{mt q {R1 i} On 0Ut]5i2024 tlt ·1 :83 F)M, r~-i !Is re-c,ords -~howed fh,Jt Rf6 adrnitt.tH.i to t):e-fadlity m1 ncu:i ,1viih a ilJhisit~I rnove. k~ ,ck1t£J of i U2t/20'.l:l RH:: \'\:'as ducurnrntecl a~ h~~v~r~g varkius diagrw.ses induding Resident ·18 (R-16) C)n {H!05J2.02A at 13f:i Pt-.•~, R Hfs nH:ards sf,rn,1\/'frd thtlt RtS ~dmitfirl to the· fodmy cm /1023. RIB \•V~s ck1curnentcd to hav~:: vari,oLm diagtrnSf!S inducting _ Resord revie\.vshav:1·e:d an initial NS:A aat-2:d 7l2021 and sl-gned nn 2-023 and£~ 30-d,,w f\1:S..t\ l2023 and s~gned .on 12023. In an exit interview im O· 1 /[18/2024 at ·t: '.W PM , St,d A, Ex-~cutiv~ Di f!;;Ct~r. . sd<nm"-lfod~Ni thi~t the inRbl NSA:s for Rm, RliJ, RH\ R16, Rm were tb'.:it uwnpleteci up-on admission t(1 (hg fad!ity .1nd fl1at the 30-.day-NSA·s. for R4, FW, RH.t wiire not canwleteti and sf:gned wifuin 3D days C<f m:lrn~ssion. Statement of Deficiencies License #: 2640 Compliance Determination # 34671 Plan of Correction Cogir at the Quarry Completion Date Page of 19 Licensee: Cogir Management USA Inc 01/08/2024 Resident 10 (R10) On 01/04/2024 at 1:10 PM, R10’s records showed that R10 admitted to the facility on /2023 with a physical move in date of /2023. R10 was documented to have various diagnoses including . Record review showed an initial NSA dated 09/06/2023 and signed on 09/14/2023. Resident 14 (R14) On 01/05/2024 at 11:25 AM, R14’s records showed that R14 admitted to the facility on /2023 with a physical move in date of /2023. R14 was documented to have various diagnoses including . Record review showed an initial NSA dated 11/28/2023 and signed on 11/29/2023. Resident 15 (R15) On 01/05/2024 at 12:00 PM, R15’s records showed that R15 admitted to the facility on /2023. R15 was documented to have various diagnoses including . Record review showed an initial NSA dated 09/11/2023. Resident 11 (R11) On 01/05/2024 at 1:33 PM, R16’s records showed that R16 admitted to the facility on /2023 with a physical move in date of /2023. R16 was documented as having various diagnoses including . Record review showed an initial NSA dated 11/24/2023. Resident 18 (R18) On 01/05/2024 at 1:35 PM, R18’s records showed that R18 admitted to the facility on /2023. R18 was documented to have various diagnoses including . Record review showed an initial NSA dated /2023 and signed on /2023 and a 30-day NSA /2023 and signed on /2023. In an exit interview on 01/08/2024 at 1:30 PM, Staff A, Executive Director, acknowledged that the initial NSAs for R10, R14, R15, R16, R18 were not completed upon admission to the facility and that the 30-day NSAs for R4, R9, R18 were not completed and signed within 30 days of admission. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. .12.2024 11: 57:25 State of Uashington 23, SMtiini~nt {r! Diifli:.:l~t~des; u,~tlns~ <ft 2640 G(m1pliiii'H~~ Detett'tc1in~H$t1 #34671 Pfat.1 ;..,f C 0n-e.ction CQg~t ~t thB-Ot.1<"my c·orr~p~e.tk1·n D~t~· Page of 1:9 Plan/Attesfation Statement In ~dciiti{ff:, I -~\Im irnptcrs•.::nt a svstc:rnto rn::,nitorand emit.~re conHnued compl!Mce-with th1s requirnme ·tt. Statement of Deficiencies License #: 2640 Compliance Determination # 34671 Plan of Correction Cogir at the Quarry Completion Date Page of 19 Licensee: Cogir Management USA Inc 01/08/2024 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, Cogir at the Quarry 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. Residential Care Services Investigation Summary Report Provider/Facility: Cogir at the Quarry Provider Type: Assisted Living Facility License/Cert.#: 2640 Compliance Determination #: 39129 Intake ID: 125632 Investigator: Jason Rose Region/Unit #: RCS Region 3 / Unit I Investigation Date(s): 04/01/2024 through 04/26/2024 Complainant Contact Date(s): Allegation(s): 1. Quality of Care/ treatment. Facility failed to provide resident records to surviving famly within two working days. Investigation Methods: Sample: Total residents: 166 Resident sample size: 3 Closed records sample size: 1 Observations: Identified resident Residents Activities Dining Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Identified resident Nursing staff Residents Family members Administration Record Reviews: Service plans. Intermittent Service Plans (ISP's) Alert charting. Email communications. Facility rental agreements and disclosure of services. Investigation Summary: 1. Quality of Care/ treatment. Facility failed to provide resident records to surviving famly within two working days. Facility took 15 days to fully release records. Failed practice. Conclusion / Action: This document was prepared by Residential Care Services for the Locator website. 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. Residential Care Services Investigation Summary Report Provider/Facility: Cogir at the Quarry Provider Type: Assisted Living Facility License/Cert.#: 2640 Compliance Determination #: 39129 Intake ID: 118447 Investigator: Jason Rose Region/Unit #: RCS Region 3 / Unit I Investigation Date(s): 04/01/2024 through 04/26/2024 Complainant Contact Date(s): Allegation(s): 1. Resident Patient/Client/ Rights. Facility changed a service plan for a resident without the resident’s involvement or consent. Investigation Methods: Sample: Total residents: 166 Resident sample size: 3 Closed records sample size: 1 Observations: Identified resident Residents Activities Dining Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Identified resident Nursing staff Residents Family members Administration Record Reviews: Service plans. Intermittent Service Plans (ISP's) Alert charting. Facility rental agreements and disclosure of services. Investigation Summary: 1. Resident Patient/Client/ Rights. Facility changed a service plan for a resident without the resident’s involvement or consent. Failed practice. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written This document was prepared by Residential Care Services for the Locator website. 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. 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 800 NE 136th Ave Ste 200, Vancouver, WA 98684 Cogir Management USA Inc Cogir at the Quarry 415 SE 177th Ave Vancouver, WA 98683 RE: Cogir at the Quarry # 2640 Dear Administrator: This document references Compliance Determination 29380 (10/02/2023), which included complaint number(s) 97443. The Department completed a complaint investigation of your Assisted Living Facility on 10/02/2023 and found that your facility does not meet the Assisted Living Facility requirements. The department staff who did the inspection and provided consultation: Jason Rose Consultation: WAC 388-78A-3000 Ventilation. The assisted living facility must meet the ventilation requirements of the mechanical code as adopted and amended by the Washington state building council; and (3) Provide intact sixteen mesh screens on operable windows and openings used for ventilation; and Residents screen was off of the bed room window that resident fell out of. Family and facility uncertain who removed the screen. Facility did full audit to make certain all windows have required screens. This document was prepared by Residential Care Services for the Locator website. Cogir at the Quarry # 2640 10/02/2023 Page 2 of 2 You Must: • Begin the process of correcting the deficiency or deficiencies immediately; and • Complete correction as soon as possible. You Are Not: • Required to submit a plan-of-correction for the deficiency or deficiencies found. The Department May: • Inspect the facility to determine if you have corrected all deficiencies. 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 (360)450-1218. Sincerely, Michael Burdick, Field Manager Region 3, Unit I Residential Care Services This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: Cogir at the Quarry Provider Type: Assisted Living Facility License/Cert.#: 2640 Compliance Determination #: 29380 Intake ID: 97443 Investigator: Jason Rose Region/Unit #: RCS Region 3 / Unit I Investigation Date(s): 09/12/2023 through 10/02/2023 Complainant Contact Date(s): Allegation(s): 1. Death - General: Facility had an unexpected death. Investigation Methods: Sample: Total residents: 175 Resident sample size: 4 Closed records sample size: 1 Observations: Residents Activities Dining Resident rooms Resident care equipment Staff to resident interactions Resident to resident interactions Medication administration Interviews: Residents Nursing staff Identified staff Medical Examiner. identified resident family. Record Reviews: Alert Charting. Service Plan. Medication administration records (MARs). Facility reports. Incident investigation report. Investigation Summary: 1. Death - General: Facility had an unexpected death. Death was accidental and unexpected however not likely to have been anticipated. Consultation for screen out of window. Conclusion / Action: This document was prepared by Residential Care Services for the Locator website. 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.