Fieldstone Memory Care.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written . N/A . STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEAL TH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 1200 Alder Street, Union Gap, WA 98903 Statement of Deficiencies License #: 2646 Compliance Determination # 59639 Plan of Correction Fieldstone Memory Care Completion Date You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for an unannounced on-site complaint investigation on 05/15/2025 of: Fieldstone Memory Care 4120 Englewood Ave Yakima, WA 98908 This document references the following complaint number(s): 177862 The following sample was selected for review during the unannounced on-site visit: 2 of 57 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Anna Cairns, ALF Long Term Care Surveyor From: DSHS, Aging and Long-Term Support Administration 1200 Alder Street Union Gap, WA 98903 . 05.22.2025 12:21:07 State of Washington 6/9 Statement of Deficiencies license #: 2646 Compliance Determination# 59639 Plan of Correction Fieldstone Memory Care Completion Date As a result of the on-site visit(s), the department found that you are not in cornpliance with the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. LawuL W~D~ 05/22/2025 I understand that to maintain an Assisted Living Facility license, the facility must be in co.mpliance with all the licensing laws and regulations at all times. RCW 70.129.140 Quality of life - Rights. (1} The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in f1JII recognition of his or her individuality. WAC 388-78A-2660 Resident rights. The assisted living facility must: (1) Comply witl1 chapter 70.129 RCW, Long-term care resident rights; This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility failed to ensure care for residents was done in a manner that maintained each resident's dignity for 1 of 2 residents (Resident 1). This failure resulted in a resident being cared for in an L1ndignified manner, that caused llnnecessary pain. Findings included .. Review of Resident 1's demographic sheet, dated 05i15/2025, showed that the resident was admitted to the facility on /2025. Review of Resident 1's full facility assessment. dated /2025, showed that the resident had diagnoses of and tl1at required a wheelchair. Resident 1's assessment showed that the resident was incontinent of bowel and required two-person assistance for all transfers with a hayer lift {device to assist caregivers in transferring residents witl"I limited mobility) and for assistance. . Statement of Deficiencies License #: 2646 Compliance Determination # 59639 Plan of Correction Fieldstone Memory Care Completion Date Review of Resident 1' s April 2025, Medication Administration Record (MAR), showed that the resident had a routine medication, docusate sodium, that they were given twice a day for constipation that had been given since /2025, when they had been admitted to the facility. Additionally, Resident 1's MAR also showed that they had two additional medications, gentle laxative suppository and milk of magnesia for constipation to be given "as needed" that the resident had not been given since /2025. As of 05/16/2025, Review of Resident 1' s progress notes did not include any documentation of the resident having constipation. Review of the facility investigation, dated 05/02/2025, showed that two staff had been present in an incident, 24 hours after the resident had moved in, where the previous nurse at the facility had physically transferred Resident 1 from their bed to the toilet without a hoyer lift and performed digital disimpaction (procedures to remove stool from the rectum using a gloved finger) on the resident three separate times. The facility investigation showed that the previous facility nurse had staff lift Resident 1 up to a standing position three times while performing the digital disimpaction procedure. In an interview on 05/15/2025 at 10:28 AM, Staff A, Administrator, stated that after they had completed their investigation for the incident that had occurred with Resident 1, they saw that the resident had other interventions for constipation, and that they had two medications that were not utilized before they had performed the digital disimpaction procedure. In an interview on 05/15/2025 at 11: 10 AM, Collateral Contact 1 (CC1), Resident Representative, stated that Resident 1 was at a higher cognitive level than the other residents in the memory care unit. CC1 stated that they were notified of the incident with staff assisting Resident 1 with a bowel movement and that it, "hurt him." Additionally, CC1 stated that Resident 1 does not complain often, that the "whole process was alarming," and that a digital disimpaction would be done occasionally at long term care facilities, "but it was never the first call to do that first." . 05.22.2025 12:21:07 state of ~ashin9ton 8/9 Statement of Deficiencies License#: 2646 Compliance Determination# 59639 Plan of Correction Fieldstone Memory Care Completion Date Pian/Attestation Statement I hereby certify that I have reviewed th.is report and have taken or w!ill take active My1J.10~ measures to correct this deficiency. By taking this action, Fieldston Care is or will be in compliance with this law and I or regulation on (Date) (p 1 f ~zo1,.r.; In addition. I will implement a system to monitor and ensure continued compliance with this requirement. .

. STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 1200 Alder Street, Union Gap, WA 98903 AMENDED 06/18/2024 CSL Yakima WA Tenant LLC Fieldstone Memory Care 4120 Englewood Ave Yakima, WA 98908 RE: Fieldstone Memory Care # 2646 Dear Administrator: The Department completed a full inspection of your Assisted Living Facility on 03/27/2024 and found that your facility does not meet the Assisted Living Facility requirements. You requested an Informal Dispute Resolution (IDR) review. The IDR review resulted in the enclosed amended Statement of Deficiencies. The Department: • Wrote the enclosed report; and • May take licensing enforcement action based on many deficiency listed on the enclosed report; and • May inspect your program to determine if you have corrected all deficiencies; and • Expects all deficiencies to be corrected within the timeframe accepted by the department. You Must: • Begin the process of correcting the deficiency or deficiencies immediately; • Contact the Field Manager for clarifications related to the Statement of Deficiencies (SOD); • Within 10 calendar days after you receive this letter, complete and return the enclosed 'Plan/Attestation Statement'; o Sign and date the enclosed report; o For each deficiency, indicate the date you have or will correct each deficiency; o Mail the Plan/Attestation Statement and report with original signatures to: Michelle Closner, Field Manager . Fieldstone Memory Care # 2646 03/27/2024 Region 1, Unit G 1200 Alder Street Union Gap, WA 98903 • Complete correction(s) within 45 days, or sooner if directed by the Department, after review of your proposed correction dates. • Have your plan approved by the Department. Consultation(s): In addition, the Department provided consultation on the following deficiency or deficiencies not listed on the enclosed report. 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: (6) Significant known behaviors or symptoms of the individual causing concern or requiring special care, including: (d) Individual's ability to leave the assisted living facility unsupervised; and The Assisted Living Facility (ALF) failed to assess a residents’ ability to leave the ALF unsupervised. WAC 388-78A-2310 Intermittent nursing services. (2) The assisted living facility may choose to provide any of the following intermittent nursing services through appropriately licensed and credentialed staff; however, the facility may or may not need to provide additional intermittent nursing services to comply with the reasonable accommodation requirements in federal or state law: (f) Nurse delegation consistent with chapter 18.79 RCW. Based on interview and record review, the assisted living facility (ALF) failed to follow the required elements for nurse delegation. You Are Not: • Required to submit a plan of correction for the consultation deficiency or deficiencies stated in this letter and not listed on the enclosed report. You May: • Contact me for clarification of the deficiency or deficiencies found. If You Have Any Questions: • Please contact me at (509)572-7394. . Fieldstone Memory Care # 2646 03/27/2024 Sincerely, Michelle Closner, Field Manager Region 1, Unit G Enclosure .