Easthaven Villa.

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

Conclusion / Action: . Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . I&] □ □ STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 800 NE 136th Ave Ste 200, Vancouver, WA 98684 Statement of Deficiencies License #: 2144 Compliance Determination # 56956 Plan of Correction Easthaven Villa 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 03/26/2025 and 04/14/2025 of: Easthaven Villa 311 Cullens St NW Yelm, WA 98597 This document references the following complaint number(s): 169276, 170541, 171914 The following sample was selected for review during the unannounced on-site visit: 3 of 71 current residents and 1 former residents. The department staff that investigated the Assisted Living Facility: Pamela Horlick, NCI RN Complaint Investigator From: DSHS, Aging and Long-Term Support Administration 800 NE 136th Ave Ste 200 Vancouver, WA 98684 . Statement of Deficiencies License #: 2144 Compliance Determination # 56956 Plan of Correction Easthaven Villa Completion Date As a result of the on-site visit(s), the department found that you are not in compliance with the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. I understand that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. Administrator (or Representative) Date WAC 388-78A-2600 Policies and procedures. (1) The assisted living facility must develop and implement policies and procedures in support of services that are provided and are necessary to: (a) Maintain or enhance the quality of life for residents including resident decision-making rights; (b) Provide the necessary care and services for residents, including those with special needs; (c) Safely operate the assisted living facility; and (d) Operate in compliance with state and federal law, including, but not limited to, chapters 7.70 , 11.88, 11.92, 11.94, 69.41, 70.122, 70.129, and 74.34 RCW, and any rules promulgated under these statutes. (2) The assisted living facility must develop, implement and train staff persons on policies and procedures to address what staff persons must do: (a) Related to suspected abandonment, abuse, neglect, exploitation, or financial exploitation of any resident; (i) To supervise and monitor residents, including accounting for residents who leave the premises; This requirement was not met as evidenced by: Based on interview and record review the facility failed to implement policies and procedures to keep residents safe, address elopement behaviors, ensure appropriate supervision of residents, and report incidents to the complaint resolution unit (CRU) for 1 of 3 residents (Resident 1 [R1]) reviewed. These failures resulted in Resident 1 repeatedly eloping from the facility placing their health and safety at risk and placed all residents residing in the memory care unit at risk for elopement and injuries. . Statement of Deficiencies License #: 2144 Compliance Determination # 56956 Plan of Correction Easthaven Villa Completion Date Findings included… Record review of the facility policy, titled, “Elopement & Wandering,” dated 10/28/2024, showed, “The facility’s objective is to ensure resident safety, utilizing the least restrictive means available. It is the policy of the Facility to identify residents who walk or wheel about unrestricted and are a threat to leave the facility due to their confusion. Wandering is an acceptable activity within the secure confines of the Facility….All caregivers will be able to identify and recognize potential wanderers and will be able to intervene and redirect as necessary…The Facility will provide a safe area for wanderers by providing…Sufficient trained staff to monitor our residents.” Under the section titled, “Elopement”, showed, “showed when a resident is believed to be missing, an elopement is presumed and the following steps must be taken: a) if a temporary absence had been logged, the log entry will be used to determine appropriate contact numbers. These will be called in an attempt to locate the resident. b) An immediate search of the building and grounds will be initiated. All areas will be checked…If the building search is unsuccessful, surrounding streets and yards will be checked. c) If the resident is not located in the initial search (section b), local police, Administrator, Nurse, the respective state departments, and the family (section e) will be notified…f) Once the resident is located, he/she will be assessed for injuries. The reason for and method of elopement will be investigated. g) The Administrator and Nurse will discuss the facts relating to the elopement and a determination will be made as to the continued appropriateness of the Resident given the constraints of the Facility. h) In order to support the Resident safely, given his/her changing needs, appropriate changes will be made to the Service Plan… j) an investigation will be initiated and completed.” Record review of the facility policy, titled, “Abuse, Neglect and Exploitation,” undated, showed, “This Community will not tolerate verbal, physical, mental, or physical abuse, including involuntary seclusion of an Resident by any staff member, other Resident or visitor to the Community. An injury of unknown cause will be investigated as potential abuse.” Under “Procedures,” showed 1) “Mandatory reporting: (b) Any staff member who has a reasonable cause to believe that an incident of abuse, abandonment, neglect, or financial exploitation of a vulnerable adult has occurred will notify the following departments immediately: In Washington- Department of Social and Health Services (DSHS) Hotline: 1-800-562-6078 OR- Online (Washington only). Under 2) “Quality Assurance Investigation Report,” showed, a) “A Quality Assurance Investigation Report will be prepared for an abuse, neglect or exploitation to determine the circumstances of the event and to determine appropriate preventative measures to prevent similar future situations. The following information will be gathered: i) Resident information with relevant history ii) Location and date/time of incident management iii) Notification as appropriate (eg. Physician, family, Complaint Resolutions Unit) iv) Description of incident v) Contributing factors (if known) vi) Assessment of Resident vii) Signature of Person completing investigation viii) Review and signature of management b) Administrator will further investigate and implement measures to prevent re-occurrence. . Statement of Deficiencies License #: 2144 Compliance Determination # 56956 Plan of Correction Easthaven Villa Completion Date Under 4) “Documentation,” showed a) “The staff member will document the incident in the Resident health record and action of the staff related to the incident including preventative measures put in place to assure safety. Review of (Washington Administrative Code) WAC 388-78A-2670, showed : “Services by resident for assisted living facility. If a resident performs services for the assisted living facility, the assisted living facility must ensure: (1) The resident freely volunteers to perform the services without coercion or pressure from staff persons; (2) The resident performing services does not supervise, or is not placed in charge of, other residents; and (3) If the resident regularly performs voluntary services for the benefit of the assisted living facility, the volunteer activity is addressed in the resident's negotiated service agreement.” Record review of an email dated 03/27/2025 at 11:30AM, showed Staff A, Administrator, was asked if staff would follow the abuse, neglect, and exploitation policy when an elopement occurred, Staff A responded, yes. Review of Department Records showed that a report was made by the facility on 02/27/2025 at 1:05PM notifying the Department that on 02/26/2025 at 12:00PM Resident 1 (R1) had been escorted over to the assisted living unit to have lunch with their friend. Around 4:30PM the memory care unit medication aide on duty was walking near the front of the memory care building and saw R1 walking towards the front doors. Medication aide asked R1 what they were doing and R1 stated, “I got bored and went for a walk.” Report stated R1 did not appear to know how to find their way back. Medication Aide was able to get R1 back into the memory care unit. R1 denied leaving the parking lot but was unsupervised during her trip from assisted living to memory care. Resident 2 (R2), R1’s friend in assisted living, stated R1 told them they were going outside to look around. R2 became worried when R1 didn’t come back after 5 minutes. Prior to this incident, R2 was asked to pull the call light if R1 left the room unattended. R2 did not pull the call light.

Findings included… Record review of the facility policy titled “Universal Precautions”, dated 12/26/2024, stated that masks and goggles “should be worn when splashing of blood and other bodily fluids [was] likely.” The document also stated that hands should be washed before and after touching the resident. Record review of the Statement of Deficiencies for Compliance Determination 52410, showed that Staff A, Administrator, signed and attested that they reviewed the report and would take active measures to correct the deficiency by 02/17/2025. Staff A signed the document on 01/10/2025. In an interview on 03/03/2025 at 1:43 PM, Staff C, Lead Medication Aide, stated that the care staff did not normally use any personal protective equipment (PPE) beyond gloves. . Statement of Deficiencies License #: 2144 Compliance Determination # 55695 Plan of Correction Easthaven Villa Completion Date They stated if staff were worried about bodily fluids, they have goggles that they can use. Staff C was not able to show the Department where the goggles were located. In an interview on 03/03/2025 at 2:05 PM, Staff E, Caregiver, stated that staff only wear the goggles when there was an outbreak. Staff E stated that they did not know where the goggles were, Staff B, Resident Care Coordinator, was the one who knew. In an interview on 03/03/2025 at 2:23 PM, Staff B stated that extra PPE was in the shed outside they would be brought in the building during an outbreak. In an observation on 03/03/2025 at 2:25 PM, boxes with face shields were located in the shed outside, the side door of the facility. In an interview on 03/03/2025 at 2:47 PM, Staff B stated that the facility usually followed the Local Health Jurisdiction (LHJ) guidance on PPE, even though the facility’s policy stated to wear a mask with eye protection. Staff B stated that the facility has been using eye shields even though their policy says goggles. In an interview on 03/03/2025 at 2:43 PM, Staff D, Caregiver, stated that the staff normally used masks and gloves when they provided care to the residents. Staff D then stated the staff only used face shields during an outbreak. In an observation on 03/03/2025 at 3:17 PM, Staff C took a resident’s blood pressure and temperature in the dining room. Staff C was not wearing gloves and did not wash her hands after providing care. In an interview on 03/03/2025 at 3:10 PM, Staff A stated that they implemented the plan of corrections based on the facility’s Respiratory Protection Program documents and did not address the facility’s Universal Precautions policy. Staff A stated that they were not following the Universal Precautions policy because they did not wear masks and eye protection when conducting resident care at risk of bodily fluids such as the changing of resident briefs. This is an uncorrected deficiency previously cited on 01/03/2025. . Statement of Deficiencies License #: 2144 Compliance Determination # 55695 Plan of Correction Easthaven Villa Completion Date Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Easthaven Villa 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 . Investigation Summary Report Provider/Facility: Easthaven Villa Provider Type: Assisted Living Facility License/Cert.#: 2144 Compliance Determination #: 52410 Intake ID: 160140 Investigator: Emily Boniface Region/Unit #: RCS Region 3 / Unit E Investigation Date(s): 12/26/2024 through 01/03/2025 Complainant Contact Date(s): Allegation(s): Infection Control - reported outbreak Investigation Methods: Sample: Total residents: 68 Resident sample size: 5 Closed records sample size: 0 Observations: Identified resident Residents Staff to resident interactions Resident to resident interactions Interviews: Identified resident Identified staff Business office manager Staff development coordinator Record Reviews: Medical records Incident investigation Facility policies Personnel files Investigation Summary: Based on record review, observations and interview, the facility failed to have a policy that implements a system to prevent and reduce the spread of illness. Staff were not observed wearing goggles or wearing respirators while interacting with symptomatic residents. The facility failed to implement their universal precautions and respiratory prevention program policies. Failed practice identified. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written . N/A . . . .

Citation(s) Written [] Failed Provider Practice Not Identified / No Citation Written [L]) NA ‘BUSGAM 10} 907] BY} JO} SAd|AJaS ase jeljuapisay Aq pasedaid sem yuawNdOp sy, Investigation Summary Report Provider/Facility: Easthaven Villa Provider Type: Assisted Living Facility License/Cert.#: 2144 Compliance Determination #: 52236 Intake ID: 159781 Investigator: Emily Boniface Region/Unit #: RCS Region 3 / Unit E Investigation Date(s): 12/26/2024 through 01/03/2025 Complainant Contact Date(s): Allegation(s): Received complaint for resident-to-resident sexual contact in memory care unit. Investigation Methods: Sample: Total residents: 68 Resident sample size: 5 Closed records sample size: 0 Observations: Identified resident Residents Staff to resident interactions Interviews: Identified staff Identified resident Administrator Care Staff Resident Care Coordinator Record Reviews: State reporting log Incident investigation Facility policies Negotiated Service Agreements department case manager assessments Investigation Summary: After observation, interview, and record review the facility failed to incorporate the department's assessment into the resident service agreement which led to the resident-to-resident interaction. Failed practice identified. Conclusion / Action: x} | Failed Provider Practice Identified / Citation(s) Written [] Failed Provider Practice Not Identified / No Citation Written [L]) NA ‘BUSGAM 10} 907] BY} JO} SAd|AJaS ase jeljuapisay Aq pasedaid sem yuawNdOp sy, 6 STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 800 NE 136th Ave Ste 200, Vancouver, WA 98684 atement of Deficiencies cense # ompliance Determination Plan of Correction Easthaven Villa Completion Date Pagel of3 Licensee: Caring Places Management, LLC 01/03/2025 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 an unannounced on-site complaint investigation on 12/26/2024, 12/26/2024 and 12/26/2024 of. Easthaven Villa 311 Cullens St NW Yelm, WA 98597 This document references the following complaint number(s): 157558, 159781 The following sample was selected for review during the unannounced on-site visit 5 of 68 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Emily Boniface, Community Program Nurse Licensor Megan Zerby, Community ALF/AFH Licensor From: DSHS, Aging and Long-Term Suppart Administration 800 NE 136th Ave Ste 200 Vancouver, WA 98684 As a result of the on-site visit(s), the department found that you are not in campliance with the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. 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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 whally funded by the department or the health care authority: This requirement was not met as evidenced by: Based on interview and record review, the facility failed to incorporate information fram the department case manager's assessment into the facility's service plan (facility's negotiated service agreement [NSA]) for 1 of 1sampled residents (Resident 4 [R4]). This failure placed R4 at risk for not receiving necessary services resulting in unmet care needs. Record review of R4’s “Resident Info Sheet," shawed R4 was admitted ta the memory care unit within the facility on = and hada — ; a | Record review of the department's CARE assessment, dated 07/16/2024 and completed by the department's case manager, showed that staff instructions under sections labeled "safety," and "lacomation outside of room," was to keep client within line-of- sight. The record showed the facility was the paid provider for those tasks and that the support needs were unmet in those categories. Under the cognitive section of the assessment, it nated “the client made impulsive decisions related to ADLs and was unaware of the consequences. The client required reminders, cues, and supervision in planning, organizing and correcting daily routines.

Statement of Deficiencies License #: 2144 Compliance Determination# 49160 Plan of Correction Easthaven Villa Completion Date Page2 of 12 Licensee: Caring Places Managemer1t, LLC 10/28/2024 ~fhlV-a Administrator (or Representative) WAC 388-78A-2610 Infection control. (1) The assisted living facility must institute appropriate infection control practices in the assisted living facility to prevent and limit the spread of infections. (2) The assisted livihg facility must: (c) Provide $taff persons with the necessary supplies, equipment and protective clothing for preventing and controlling the spread of infections; This requirement was not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide necessary handwashing supplies in 2 of 3 ·sampled assisted living residents (Resident 3 [R3) and Resident 4 [R4]) rooms. This failure resulted in staff not having access to hand hygiene supplies, and placed all 37 of 37 assisted living residents, staff, and visitors at risk for spread of infectious disease. Findings included ... Record review of the Centers of Disease Control (CDC) document titled, "about hanctwashing", dated 02/16/2024, showed many diseases and conditions were spread by not washing hands with soap and clean, running water. Handwashing with soap was one of the best ways to stay healthy. Handwashing could keep a person healthy and prevent the spread of respiratory and diarrheal lnfections. Germs could spread from person to person or from surface to people when a person touches their eyes, nose, or mouth with unwashed hands, if a person touches surfaces or· objects that have germ~ on them, blow their nose, cough, or sneeze rnto th err hcU")ds and then touch other person's hands or common objects. Hands were to be washed often. Record_r eview of the CDC's docL1ment titled, "clinical safety: hand hygiene for t,ealthcare workers", dated 02/27/2024, showed hand hygiene protects both healthcare personnel and patients. Hand hygiene means cleaning your hands with handwashing with water and soap or antiseptic hand rub. VVhen a heal~hcare worker cleans their hands it reduces the potential spread of deadly germs to patients. spread of germs that include ones that were resistance to antibiotics, and reduces the risk of healthcare personnel from being infected from germs received from the patient. Healthcare workers were to clean their t1ands before touching a patient, before moving from work from soiled to clean, after touching a patient or patient's surrounding, after contact with blood, body fluids, or contaminated surfaces, and immediately after glove removal. Healthcare works were. to wash their hands with soap and water when their hands were visibly soiled. Record review of ihe facility provided policy titled, "hand washing", dated 09/17 i2024, showed hand washing was the single most important measure for preventing the . 8-Nou-2024 21:50 13607253258 WA TECH p.5 11.08.2024 13:37:46 State of Washington 5/17 ·statement or Deficiencies License #: 2144 Compliance Determination# 49160 Plan of Correction Easthaven Villa Completion Date Page3 of12 Licensee: Caring Pl.aces M,magement, LLC 10/28/2024 spread of infection and disease. All staff would be responsible for carrying out the hand washing policy. St;3.ff woulcl wash their hands after personal body function, before and after helping resident with personal care tasks of daily living, whenever staff changed from doing a "dirty" task to a "clean" task, and whenever hands were obviously soiled. The use of .gloves did not replace hand washing. Under the section titled, ''procedure", showed staff were to wet hands with running water, apply soap, lather hands by rubbing them together with the soap and scrub for 20 seconds. Staff were to rinse hands well under running water and then dry their hands using a clean towel or air dry them. Record review of the facility's "Plan of Correction", dated 08/05/2024, showed under the deficiency section WAC 388 78A 2610 (1)(2)(c). The actions section showed handwashing supplies would be available in the resident's rooms. The person responsible section showed it was the housekeeping staff; the Resident Care Coordinator, and the administrations responsibility. The due date showed 09/19/2024 and it showed the task had been completed on 08112/2024. R3 In an interview and observation on 10/22/2024 at 1 :46 PM, R3's bathroom showed a container of bacterial hand soap. R3 said the facility did not supply them hand soap and that they purchased and suppiied the soap on their own. R4 In an observation and ·interview on 10/22/2024 at 1 :52 PM, inside R4's bathroom, there was no facility provided soap available for staff to use. R4 stated the soap t_hat was in the bathroom was their personal soap. R4 stated the staff washed their hands all the time in the bathroom after they helped them to the bathroom anc:l taking their gloves -off. In an interview on 10/22/2024 at 2:57 PM, Staff A, Administrator, said the facility put new soap atid paper towel dispensers up and had them filled with -supplies in the resident rooms. Staff A declined to come with the Department to visually see the resident rooms that lacked soap. This is an uncorrected and recurring deficiency previously cited on 08/05/2024 for subsections (1)(2)(c) and 02/07/2023 for subsection (1) 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, Ea1t_haven Villa is or will be in compliance with this law and I or regulation on (Date) \ 'L / tl I 2.'-\ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. . 8-Nou-2024 21:51 13607253258 WA TECH p.6 11.08.2024 13:37:46 State of Washington 6/17 Statement of Deficiencies License#: 2144 Compliance Determination# 49160 Plan of Correction Easthaven Villa C.ompletion Date Page4 of 12 Licensee: Caring Places Managemertt, LLC 10/28/2024 1 J\/11 2c{ --- 1-oate WAC 388-78A~2040 Other requirements, (1) The assistecl living facility must cornply with all other applicable federal, state, county and municipal statutes, rules, codes and ordinances. including without limitations those that prohibit discrimination, (2) The assisted living facility must have its building approved by the Washington state fire marshal in order to be licensed. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to have their respiratory protection program updated for 2 of 2 facility .buildings (Assisted Living building and Memory care building). This failure placed all. 71 of 71 residents and staff safety at risk in the event of an infectious disease outbreak. Findings included ... Record review of the dear provider letter number 2023-014, dated 03/30/2023,. showed that the Secretary of Health announced the order that required weadng a fac.e covering in long term care facilities had ended on 04/03i2023. Despite that the order had ended the individuals in long-term care facilities, including residents, staff, and visitors, were required to continue to follow the Department of Health (DOH) and Centers of Disease Control and Prevention {CDC) guidance. Facilities were asked to revise their policies to re.fleet the updated guidance by 05/01/2023. Facilities may create th.eir own policies that require staff ano ask residents and visitors to wear a face covering, as long as they were at least as stringent as DOH and CDC guidance. Respiratory Protection Program (RPP) requirements were not changed by the ending of the Secretary of Health's order, nor would they change when the federal public health emergency ended on 05i11 /2023, Staff would still. be required to wear N95 respirators around individuals witt1 suspected or confirmed COVID-19, and an RPP was required anytime a respirator was used in a long-term care faciHty. An RPP must include medical cl.earance, fi.t testing, training, wri.tten poHci~s. ~nd documentation. Record review of the dear provider letter number 2022-040, dated 11/Q.9/2022, showed that on 09/08/2022 the Washington state's Governor announced that the state of emergency due to the COVID-19 pandemicwould end on ·10/31/2022. All long-term care COVID response plans would no longer be effective beginning 10/27/2022. Facilities m.ust continue to meet national stanqards for infection prevention. "WAC 296-842-12005 Develop ar,d maintain a written program. Exemption: This section does NOT apply to respirator use that is voluntary. See WAC .296-842-11 oos·f or voluntary use program requirements. (1) Develop a complete worksite-specific written respiratory protection program that includes the applicable elements listed in Table 3. The program must cover each employee requited by this section to use a respirator. Note: Pay for respirators, medical evaluations, fit testing, training, maintenance, travel . 8-Nou-2024 21:52 13607253258 IJA TECH p.7 11.08.

Citation(s) Written L] Failed Provider Practice Not Identified / No Citation Written LJ) NA “BUSQAM 1032907 BU} JOJ SAdIAUaS ase>D jeENUAaPIsay Aq pasedaid sem UaWNIOp sIYL 10.20.2023 11:33:40 State oF Washington a/t 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 #::2144 = Compliance Determination # 26882 Plan of Correction Easthaven Villa Completion Date You are required to be in compl ance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed date collection for an unannounced on-site complaint investigation on 07/19/2023 and 07/25/2023 of: Easthaven Villa 311 Cullens St NW Yelm, WA 98597 This document references the following complaint number(s}: 90002 The following sample was selected for review during the unannounced on-site visit: 3 of 77 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Maria Salas, ALF Complaint Investigator From: DSHS, Aging and Long-Term Support Administration 800 NE 136th Ave Ste 200 Vancouver, WA 98684 “BHSGIM 4JOJEIO7] BY} JO} SBDIAIBS Jie jelUSpIsoy Aq pasedaid SEM JUSWINIOP SIYL 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. Mo Qucet” Jody Just Region 3 Field Serices Administrator 10/25/2023 ' ~ Residential Care Services Date | understand that fo maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. 10.25.2023 11:33:40 State oF Washington 4/i Statement of Deficiencies License #: 2144 Comptiance Determination # 26882 Plan of Correction Easthaven Villa Completion Date Gl Bea LIS —. \g/es. Pei aicr (or Répresentative) Date WAC 388-78A-2160 Implementation of negotiated service agreement. The assisted living facility must provide the care and services as agreed upon in the negotiated service agreement to each resident unless a deviation from the negotiated service agreement is mutually agreed upon between the assisted living facility and the resident or the resident's representative at the time the care or services are scheduled. This requirement was not met as evidenced by: Based on record review and interview, the facility failed to implement the Negotiated Service Plan for 1 of 3 reviewed residents (Resident 1 [R1]). This failure resulted in harm when R1 choked and died. Findings included... Record review of R1's Face Sheet, undated, showed R1 admitted on Jj2022, with a history of Alzheimer’s disease (a loss of cognitive function thinking, remembering, and reasoning). Record review of R1’s Negotiated Service Plan, dated 05/01/2023, showed R1's diet was regular textured foods cut up and thin liquids (thin liquids are most often used if you do not have a swallowing problem with liquids. Water, milk, tea, coffee, and juice are all examples of the thin liquids.). R1 was able to feed himself. R1 was known to eat too fast and pocket food in his cheeks. Staff interventions showed for every meal staff were to observe R11 for pocketing of foods. Staff were to cue R1 to swallow and drink fluids as needed. Staff were to cue R11 to eat slowly. Staff were to cue R1 to take sips of fluids between every three to four bites of food. Record review of an Incident Report, dated j2023, showed that R1’s table was one of the first tables served at dinner, As the staff were serving meal plates, Staff A, Caregiver, noticed R1 eating quickly and encouraged him to slow down and take a drink of water. Staff A then continued to walk around and help serve dinner plates. While staff were serving plates to the other side of the dining room, Staff B, Caregiver, heard residents yelling out for help, Staff B went aver toa where R1 was seated and observed him to be in distress and what appeared to be him choking. Abdominal thrusts were attempted without success. R1 then became pale in color arid Staff E, Assistant Administrator, instructed for CPR (Cardiopulmonary Resuscitation) to be started when no pulse was felt for R1. R1 was declared deceased at the local Emergency Department. In an interview on 07/19/2023 at 12:15om, Staff C, Caregiver, stated that a copy of the “9UISGAM 10}2907 9Y} JOJ SadIAUaS aseD jeNUapIsay Aq paiedaid sem yuaWNIOp SIU 10.25.2023 11:33:40 State of Washington Statement of Deficiencies License #: 2144 Compliance Determination # 26882 Plan of Correction Easthaven Villa Completion Date Page 3 of3 Licensee: Caring Places Management, LLC 10/12/2023 care plans for each resident living in the Memory Care Unit were kept in the breakroom. Staff were required to review and sign care plans when initial care plans were started or any updates with. changes to the care plan had happened. Staff C stated that there was always at least one staff persen in the dining room during moale. Staff C stated that etaff walk around circling ketween each area of the dining room, so they could monitor residents for safety. In an interview on 08/29/2023 at 12:35pm, Staff A stated that R1 had a modified diet. Staff A stated they had noticed R1 eating unusually fast that day and shoveling food inte his mouth. Staff A stated she had cued R11 to slow down and had observed him take food out of his mouth and putin on the plate. Then she had returned to the kitchen to grab more plates to pass out to other residents. Staff A stated that she was the only staff person monitoring the side of the dining room R1 was sitting in. Staff A stated that R1 did not require a staff person to be with him at ail times while eating meals. Staff A stated that she was unable to recall what R1’s care planned interventions were related to eating. Staff A stated she was aware that R1 needed close observation. When asked how she would know when R71 took every three to four bites of food so he could be cued to fake a drink of fluids, Staff A stated that a staff person was always in the dining room observing the residents. In an interview on 07/19/2023, Staff E, Assistant Administrator, stated that they did not do one to one observation for R1 during meals. When asked how the staff were to know many bifes R1 had taken to implement interventions stated in Service Plan, Staff E stated that there was always at least one person in the dining room. Plan/Attestation Statement | hereby certify that I have reviewed this report and have taken or will fake active measures to correct this deficiency. By taking this action, Gasthaven Villa is or will be in compliance with this law and / or regulation on (Date) N/dS/>93 . In addition, i wil implement a system to monitor and ensure continued campliance with comb La] OR... inistrator (or Representative) ate 9/7 “BHSGIM 4JOJEIO7] BY} JO} SBDIAIBS Jie jelUSpIsoy Aq pasedaid SEM JUSWINIOP SIYL Easthaven Villa Plan of Correction Statement of Deficiencies Report Dated 10/12/23 Deficiency Actions Responsible Person(s) Completed Date Binder made for kitchen to show in , Nurse, RCC, Admin 11-25-23 writing specialized diets, likes and dislikes, choking history and interventions to prevent choking. and interventions for swallowing. Staff will be able to state which Residents have specialized diets, which Nurse, RCC, Admin, 11-25-23 require supervision from a far, and Caregivers interventions for each Resident. I | | Staff educated by reading and initialing NSA on all resident dietary information Nurse, RCC, Admin 11-25-23 | | I *a}LISGaM 1032907 BY} 410} SadIANaS aue> jeNUapIsay Aq pasedaid sem juawNdOp SUL Easthaven Villa Weekly Checks with caregivers to check for knowledge of specialized diets and those Residents that need supervision, cues or reminders while eating. RCC, Nurse, Admin, Caregiver 11-25-23 Daily checks on diets served by staff ,to check for appropriate textures served. Alert dietary staff if changes need to be made. Caregiver, RCC, Nurse, Admin 11-25-23 *@UISGAM 40}L907 BY} JO} SadIAUaS aie jeNUapIsay Aq pasedaid sem JUaWNIOp SIYL Easthaven Villa Re-educate importance of supervising Resident, not to leave resident if observe issues with chewing or swallowing. Random spot checks on knowledge and appropriate diets served to Resident. Nurse, RCC, Admin RCC, Nurse, Admin 11-25-23 11-25-23 “BUSQAM 1032907 BU} JOJ SAdIAUaS ase>D jeENUAaPIsay Aq pasedaid sem UaWNIOp sIYL

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

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 October 25, 2023 ELECTRONIC-FACSIMILE Administrator Easthaven Villa 311 Cullens St NW Yelm, WA 98597 Assisted Living Facility License #2144 Licensee: Caring Places Management, LLC IMPOSITION OF CIVIL FINE Dear Administrator: On October 12, 2023, the Department of Social and Health Services (DSHS), Residential Care Services completed a Complaint Investigation at your facility. This letter constitutes formal notice of a civil fine on the license for your assisted living facility, also known as Easthaven Villa, located at 311 Cullens St NW, Yelm, by the State of Washington, Department of Social and Health Services. These actions are taken under the authority granted pursuant to Laws of 1998, Chapter 272 and RCW 18.20.190. The civil fine on the license is based on the following violation of the RCW and/or WAC as described in the attached Statement of Deficiencies (SOD) report dated October 12, 2023. Civil Fine WAC 388-78A-2160 Implementation of negotiated service agreement. $2,000.00 The licensee failed to implement the Negotiated Service Plan for one resident. This failure resulted in harm when the resident choked and died. NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Administrator Easthaven Villa License #2144 October 25, 2023 Page 2 Attestation (Plan of Correction): Return the enclosed SOD within 10 calendar days with the following: • The date you have or will have each deficiency corrected; • A signature and date attesting that you are taking actions to correct and maintain correction for each cited deficiency. Return the signed and dated SOD to: Cory Cisneros, Field Manager Region 3, Unit E 6639 Capitol Blvd SW Point Plaza West Tumwater, WA 98501 Phone: (253) 254-3190 / Fax: (360) 664-8451 rcsregion3email@dshs.wa.gov Appeal Rights: You have two appeal rights: Informal Dispute Resolution (IDR) and an Administrative Hearing. Each has a different request timeline. Informal Dispute Resolution [RCW 18.20.195] You have an opportunity to challenge the deficiencies and/or enforcement actions through the state's IDR process. All IDR requests must be in writing and include: • The deficiencies you are disputing; and • The method of review you prefer (face-to-face, telephone conference or documentation review). The written request must be received by the 10th working day from receipt of this letter. During the IDR process, you will have the opportunity to present written and/or oral evidence to dispute the deficiencies. Send your written request to: Informal Dispute Resolution Program Manager Residential Care Services PO Box 45600 Olympia, Washington 98504-5600 Administrator Easthaven Villa License #2144 October 25, 2023 Page 3 Formal Administrative Hearing You may contest the civil fine by requesting a formal administrative hearing to challenge the deficiency, which resulted in the civil fine. All hearing requests must be in writing and include: • A copy of this letter; and • A copy of the Statement of Deficiencies. The written request must be received within twenty-eight (28) calendar days of receipt of this letter. Send your written request to: Office of Administrative Hearings PO Box 42489 Olympia, Washington 98504-2489 Payment: If you do not request a formal administrative hearing, the civil fine is due to the Office of Financial Recovery twenty-eight (28) calendar days after receipt of this letter. Mail a check for $2,000.00 payable to the ‘Department of Social and Health Services’, and if you have or have had a Medicaid resident(s), please include your ProviderOne ID Number # on the check, to: DSHS Office of Financial Recovery PO Box 9501 Olympia, Washington 98507-9501 1-800-562-6114 (extension 45919) OFRMMISVendor@dshs.wa.gov If the Office of Financial Recovery has not received your payment within twenty-eight (28) days after receipt of this letter, interest will begin to accrue immediately on the balance, at the rate of one percent per month. If you do not submit a hearing request or make payment within twenty-eight (28) days, the balance due will be recovered. Administrator Easthaven Villa License #2144 October 25, 2023 Page 4 If you have any questions, please contact Cory Cisneros, Field Manager, at (253) 254-3190. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 3, Unit E RCS Regional Administrator, Region 3 HCS Regional Administrator, Region 3 DDA Regional Administrator, Region 3 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW HP