Madrona Assisted Living, Llc.

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 06/30/2025 Madrona Assisted Living, LLC Madrona Assisted Living, LLC 8800 Madison Ave N Bainbridge Island, WA 98110 RE: Madrona Assisted Living, LLC # 2210 Dear Achainistrator: This letter addresses Compliance Determination 61472 (06/30/2025). The Department completed a full inspection of your Assisted Living Facility on 06/30/2025 and found no deficiencies. The Department staff who did the inspection: Shirley Grew, LTC Surveyor Cory Myers, NCI ALF Licensor If you have any questions, please contact me at (253)442-3013. Sincerely, Manfay Chan, Allied Health Field Manager Region 3, Unit D ‘BUSGAM 103907] BY} JO} SAd|AJaS ase jeljUapIsay Aq pasedaid sem uaWNIOp sIYL

Corrective Action Form”, dated 12/18/2023 “Unusual Incident/Injury Report”, dated 12/17/2023 “Assisted Living Incident Report Form”, dated 12/18/2023 “Physician’s Orders Fax Communication Sheet”, dated 12/17/2023 “Witness Statement Form”, dated 12/17/2023 “Abuse, Neglect, Fraud, and Wrongdoing” policy, dated 07/09/2021 AV’s Service Plan . AV’s Nursing Notes Investigation Summary: 1, 2, 3) Per interview and record review, the AV was injured while being transferred with the assistance of one caregiver. The AV required emergent medical attention and was sent to the hospital. Per interview and record review, an investigation was conducted, and a "Corrective Action Form" was written for the staff member. The investigation concluded that the AV’s injury was the result of transferring the AV with a one-person assist, instead of the required two person assist outlined in the AV’s service plan. The Corrective Action Form indicated that this type of incident can be considered negligence of a resident. Per interview, the incident was considered to be an internal matter, and management staff believed that a report to the Department was unnecessary. A record review of CRU intakes did not identify any facility reports related to an allegation of neglect. The facility failed to report an allegation of neglect as outlined in WAC 388.78A.2630 and RCW 74.34.035. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . . Statement of Deficiencies License #: 2210 Compliance Determination # 39323 Plan of Correction Madrona Assisted Living, LLC Completion Date Administrator (or Representative) Date WAC 388-78A-2630 Reporting abuse and neglect. (1) The assisted living facility must ensure that each staff person: (a) Makes a report to the department's Aging and Disability Services Administration Complaint Resolution Unit hotline consistent with chapter 74.34 RCW in all cases where the staff person has reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred; and This requirement was not met as evidenced by: Based on interviews and record reviews, the facility failed to report an allegation of neglect to the Department’s Aging and Disability Services Administration Complaint Resolution Unit hotline (CRU) for 1 of 1 sampled resident (Resident 1 [R1]). This failure to notify the Compliant Resolution Unit placed 48 of 48 residents at risk of unreported neglect and prevented the Department from evaluating facility systems in place to protect residents. Findings included… RCW 74.32.035 Reports-Mandated and permissive-Contents-Confidentiality. (1) When there is reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred, mandated reporters shall immediately report to the department. Record review of the Department of Social and Health Services book, “Assisted Living Guidebook”, dated February 2018, showed that individual mandated reporters must immediately report to the Department’s hotline when there is a reasonable cause to believe an incident is abuse, neglect, substantial injuries of unknown source, or personal and/or financial exploitation. Record review of the facility’s “Abuse, Neglect, Fraud, and Wrongdoing” policy, dated 07/09/2021, stated that (1) all staff will receive training on elder abuse incidence, signs and symptoms, and reporting requirements, (2) Residents, their responsible parties, personnel, health professionals and all relevant stakeholders are encouraged to report any suspected incidence of abuse, fraud, or other wrongdoing, (5) if the suspected abuse, fraud, or other wrongdoing is substantiated, a written report is made to the appropriate licensing/regulatory agency, and the responsible party. Record review of facility’s “Coaching and Corrective Action Form”, dated 12/18/2023, stated that Staff A, Caregiver, transferred R1 from their bed to a wheelchair without waiting . Statement of Deficiencies License #: 2210 Compliance Determination # 39323 Plan of Correction Madrona Assisted Living, LLC Completion Date for the required second person. R1 sustained an injury that required emergency room care. Record review of facility’s “Coaching and Corrective Action Form”, dated 12/18/2023, stated that after conducting a full investigation, Staff B, the Director of Nursing, planned to provide a formal “Coaching and a Corrective Action Form” to Staff A as a written warning, due to the severity of the incident and harm caused to R1. Record review of facility’s “Coaching and Corrective Action Form”, dated 12/18/2023, stated that Staff A was aware that a second person should have assisted with R1’s transfer, and that this type of incident can be considered negligence. Record review of the CRU intake dated 12/30/2023 indicated that Staff B conducted an internal investigation and confirmed in writing that R1’s injury was a result of the caregiver’s negligence and error. Record review of the CRU intake dated 12/30/2023 indicated that Staff B stated the incident was internal and did not need to be reported to the state. Record review of CRU intakes did not identify any facility reports related to an allegation of neglect. During an interview on 06/12/2023 at 11:15 a.m., Staff C, the Executive Director (ED) acknowledged that R1’s incident was considered to be an internal matter and believed that a report to the Department was unnecessary. 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, Madrona Assisted Living, LLC is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date .

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