Brookdale Silver Lake.

—: WA DSHS report: Inspections (11/2025)

This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: Brookdale Silver Lake Provider Type: Assisted Living Facility License/Cert.#: 1703 Compliance Determination #: 46344 Intake ID: 140984 Investigator: Wesler Dumecquias Region/Unit #: RCS Region 2 / Unit A Investigation Date(s): 08/28/2024 through 09/19/2024 Complainant Contact Date(s): Allegation(s): The Named Resident (NR) went missing from a secured Assisted Living Facility (ALF). Investigation Methods: Sample: Total residents: 47 Resident sample size: 3 Closed records sample size: 0 Observations: Identified resident Residents Activities Resident rooms Exit doors Interviews: Identified resident Nursing staff Residents Family members Record Reviews: Facility policies Incident investigation care plan Alarm Log Missing resident checklist Investigation Summary: The ALF investigated the incident and determined that the ALF's Furnace Room Exit door came off on 07/31/2024 at 10:12 AM. On 07/31/2024 at 11:50 AM, the ALF staff received a call from an Urgent Care about 0.9 miles away from the ALF that they had with them the NR. The ALF staff failed to follow their policy in accounting residents when the staff did not ensure that the NR was checked and included in their headcount. A failed practice was identified. A citation was issued for noncompliance with WAC 388-78A-2600 (2) (i)- Policies and Procedures. 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.

1/10/2024 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 3906-172nd St NE, Suite #100, Arlington, WA 98223 BROOKDALE SENIOR LIVING COMMUNITIES INC Brookdale Silver Lake 2015 LAKE HEIGHTS DR EVERETT, WA 982086034 RE: Brookdale Silver Lake License# 1703 Dear Administrator: This letter addresses Compliance Determination(s) 34358 (Completion Date 01/03/2024) and 29789 (Completion Date 10/03/2023). The Department completed a follow-up inspection of your Assisted Living Facility on 01/03/2024 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-2305-1, WAC 246-215-03306-1-d, WAC 388-78A-2466-1-a, WAC 388-78A- 2474-3, WAC 388-112A-0200-1, WAC 388-78A-2474-2-a, WAC 388-112A-0220-2, WAC 388- 112A-0220-2-a, WAC 388-112A-0220-1, WAC 388-78A-2474-2-c, WAC 388-78A-2480-1, WAC 388-78A-2160, WAC 388-78A-3090-1-a The Department staff who did the on-site verification: Jodi Condyles, ALF Licensor If you have any questions, please contact me at (360)651-6846. Sincerely, Kimberley Ripley, Field Manager Region 2, Unit A Residential Care Services This document was prepared by Residential Care Services for the Locator website. 10.17.2023 14:38:59 State of ~ashington STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALT H SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 3906-172nd St NE, Suite #100, Arlington, WA 98223 Statement of Deficiencies License #: 1703 Con1,pliance Determination# 29789 Plan of Correction Brookdale Silver Lake Completion Date Page 1 of 12 Licensee: BROOKDALE SENIOR LIVING 10/03/2023 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 09/19/2023, 09/20/2023 and 09/2112023 of: Brookdale Silver Lake 2015 LAKE HEIGHTS DR EVERETT, WA 982086034 The following sample was selected for review during the unannounced on-site visit: 7 of 42 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Christine Banta, Community Complaint investigator --Jodi Condyles, ALF Licensor - Qristina G911zalez, ALF Licensor From: DSHS, Aging and Long-Term Support Administration Residential Care Services. Region 2 , UI1it A 3906•172nd St NE, Suite #100 Arlington, WA 98223 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. -,,<t.ht,,~_ 10/17/2023 . . . . Residentl~Ca~ervicias . . 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. This document was prepared by Residential Care Services for the Locator website. -;~·38 1621lZ:l 10 11 10.17.2023 14:38:59 State of Washington 6, Statement of Deficiencies Lice11se #: 1703 · Compliance Determination# 29789 Plan of Correction Brookdale Silver Lake Completion Date Page2 of 12 Licensee: BROOKDALE SENIOR LIVING 10/03/2023 l o-oi~-~~ ·····•·•····• .................... . r or epres Date WAC 246-215-03306 Preventing food and ingredient contamination -- Packaged and unpackaged food -- Separation, packaging, and segregation (2009 FDA Food Code 3-302.11 ). (1) A FOOD must be protected from cross contamination by: (d) Except as specified under WAC 246-215-03520 (2)(b) and subsection (2) of this section, storing the FOOD in packages, covered containers, or wrappings; WAC 388•78A-2305 Food sanitation. The assisted living facility must: (1) Manage food, and maintain any on-site food service facilities in compliance with chapter 246-215 WAC, Food service; This requirement was not met as evidenced by: Based on observations and interview the Assisted Living Facility {ALF) failed to store food safely when the ALF had open food items that were uncovered. This failure resulted in possible cross contamination and placed residents at risk for foodbome illness. FindingsJncluded, .. During a tour of the kitchen on 09/20/2023 at 8:30 AM, the following food items were found uncovered: In the walk-in cooler; cooked elbow pasta in water, chocolate muffins, grated garlic, diced onions and three bean salad. At the end of the main kitchen preparation table, flour and sugar containers had unsecured, opened lids. On the top shelf of the preparation table, an box of Malt o Meal was opened and left unsealed. On the preparation table in a small plastic bin, Frenches Crispy French Onions were opened and left unsealed. On 09/20/2023 at 8:43 AM Staff H, Caregiver, stated that they were unaware food needed to remain covered on food trays and after opened or in the cooler. This document was prepared by Residential Care Services for the Locator website. ;··-··· 14 38 162on.10-_11_·~- '-:~: ___. _W_A_rt_c1_1 _ 10.17.2023 14:38:59 State of Uashington 7. Statementof Deficiencies · License #: 1703 Compliance Determination # 29789 Plan of Correction Brookdale Silver Lake Completion Date Page 3 of 12 Licensee: BROOKDALE SENIOR LIVING 10/03/2023 On 09/20/2023, Staff A, Executive Director, stated that they were aware food items should be covered and dated and will work with the kitchen staff to correct the issue. On 10/02i2023, Staff I, Dining Services Coordinator, stated that they were aware that food needs to be covered once opened and stored but was very busy and just didn't cover the food. 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, Brookdal:S ilver Lake is or will be in compliance with this law and/ or regulation on (Date) 1I • I~, 202,3. • · implement a system to monitor and ensure continued compliance with ··-·····lJ2~2~~?-026. ............,. . Date WAC 38S..78A-2466 Background checks Washington state name and date of birth background check Valid for two years National fingerprint background check Valid in_~t~fi!'lit~IY.~" 0 •.• ___ ...•..•..•. ( 1) A \IVcashii:,gte>n ~ti:!!~ ,,an,~ ~ng dctt~_9[ birth background .. check.is .. valid.f or. . two .. years.f rom.t he 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 requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure 1 of 6 staff (Staff F) had a background check every two years. This failure resulted in Staff F not having an updated background check and placed the safety of all residents at risk by allowing someone with a potentially disqualifying background access to them. Findings included ... Review of the ALF's employee files showed Staff F, Caregiver, was hired on 01/22/2020. The most recent baekground check in Staff F's file was dated 01/24/2020 with an expiration date of 01/24/2022. This document was prepared by Residential Care Services for the Locator website. 10.17.2023 14:38:59 State of ~ashington 8, Statement of Deficiencies License #: 1703 Compliance Determination # 29789 Plan of Correction Brookdale Silver Lake Completion Date Page4 of 12 Licensee: BROOKDALE SENIOR LIVING 10/03/2023 In an interview on 09/20/2023 at 9:52 PM, Staff G, Business Office Manager, stated that this was their most current background check for Staff F. Staff G stated that Staff F had yet to do the background check authorization form and that the form was currently in Staff F's ALF staff mailbox. In an interview on 09/20/2023 at 12:24 PM, Staff F stated that this was the first time they had heard about required updates for a background check, but that they had received a form this morning and would work on submitting it as soon as possible. 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, Brookdale Silver Lake is or will be in compliance with this law and/ or regulation on (Date) J, ... /-<2 • 2.02-3 . In addition, I will implement a system to monitor and ensure continued compliance with this requireme . 2Jo... lol,3'.. ...... ,. .. ...... ./ O·. Date WAC 388-78A-2474 Training and home care aide certification requirements. (3) The assisted living facility must ensure that all staff receive appropriate training and orientation to performtheir specific job duties and responsibilities: ·. . ·· ···· who WAC 388-112A-0200 Whafis orientation training, should complete it, and when should it be completed? There are two types of orientation training: Facility orientation training and long~term care worker orientation training. · (1) Facility orientation. Individuals who are exempt from certification as described in RCW 18.888.041 and volunteers are required to complete facility orientation training before having routine interaction with residents. This training provides basic introductory information appropriate to the residential care setting and population served. The department does not approve this specific orientation program, materials, or trainers. No test is required for this orientation. This requirement was not met as evidenced by: Based on record review and interview, the Assisted Living Facility (ALF) failed to ensure 1 of 6 staff (Staff B) completed facility orientation prior to providing care. This failure resulted in Staff B not receiving a timely orientation and placed residents at risk for compromised care and safety. Findings included,. . Review of the ALF's employee files showed the following: This document was prepared by Residential Care Services for the Locator website. 14 38 16 2023-10---17 ! "",j , WA TECII 10.17.2023 14:38:59 State of 14ashlnston 91 Statement of Deficiencies · License #: 1703 Compliance Determination # 29789 Plan of Correction Brookdale Silver Lake Completion Date Page 5 of 12 Licensee: BROOKDALE SENIOR LIVING 10/03/2023 Staff B, Caregiver, was hired on 04/04/2023. Staff B's orientation was completed on 09/18/2023. In an interview on 09/22/2023 at 12:01 AM, Staff B stated that it took them a while to come in to have a tour of the facility due to Staff B being night shift. Staff B stated that during this tour is when they were shown the locations of the ALF's emergency communications, fire alarms, fire extinguishers, and evacuation plans. In an interview on 09/20/2023 at 9:35 AM, Staff G, Business Office Manager, stated that new employees usually do their staff orientation including a tour of the facility on their first day, but they have up to seven days to complete it. Staff G stated Staff B's orientation should have been completed sooner than it was. 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, Brookdple ~Iver Lake is or will be in compliance with this law and I or regulation on (Date) lt/18 /2¢l.. 3 . In addition, I will1_!i!!Jm~· w:iie.nt a system to monitor and ensure continued compliance with this require .. ,,,·70,-,2;,i:,-..Z8,_... . ····-····· ----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; WAC 388-112A-0220 What is safety training, who must complete it, and when should it be completed? (1) Safety training is part of the long-term care worker requirements. It is a three hour training that must meet the requirements of WAC 388-112A-0230 and include basic safety precautions, emergency procedures. and infection control. (2) The following individuals must complete safety training: (a) All long-term care workers who are not exempt from certification as described in RCW 18.888.041 hired after January 7, 2012, must complete three hours of safety training. This safety training must be provided by qualified instructors that meet the requirements in WAC 388-112A-1260 This document was prepared by Residential Care Services for the Locator website. ;_,_a_: _ _ 14 3s 102on-10-1, ___ ····-_·;N_·A_rfr__H _~ 10.17.2023 14:38:59 State of Washington 10, Statement of Deficiencies · License #: 1703 · Compliance Determination # 29789 Plan of Correction Brookdale Silver Lake Completion Date Page6 of 12 Licensee: BROOKDALE SENIOR LIVING 10/03/2023 This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure 1 of 6 staff {Staff C) completed orientation and safety training. This failure placed residents at risk of not having their care needs met due to unqualified staff. Findings included ... Review of the ALF's employee files showed Staff C, Caregiver, was hired on 12/19/2022 and showed no evidence of orientation and safety training. On 09/21/2023 at 12:14 PM, Staff G, Business Office Manager, stated that they did not have a copy of Staff C's orientation and safety training certificate. On 09/21/2023 at 3:12 PM, Staff C stated that they were shown around the facility for orientation and safety training. Staff C does not recall any other type of orientation and safety class. 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, Brookdjlle syver Lake is or will be in compliance with this law and I or regulation on (Date) // l1 3..1 UJ2-3 . .. -~ •····•"••·-..., .,, ......... •.·•. . ··~ .,I'.?-----,---···. " ........ . In addition, I will implement a system to monitor and ensure continued compliance with this requir Io-U - 2...,;'? o•••••••n•-• .. • •"•••••u ...... , ••, .,_,_,.••••• -~. ....... u ........ _ 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: (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 Assisted Living Facility (ALF) failed to ensure 2 of 6 staff (Staff C and E) completed the required specialized dementia and mental health trainings. This failure placed the residents with a diagnosis of or This document was prepared by Residential Care Services for the Locator website. _ _ i4_.:i_i!"_i6_20-2')-_•··1_0···_11_ '---11-_! __._N A_f_Wl __ j 10.17.2023 14:38:59 State of Uashington Statement of Deficiencies · · License #: 1703 Compliance Determination # 29789 Plan of Correction Brookdale Silver Lake Completion Date Page 7 of 12 Licensee: BROOKDALE SENIOR LIVING 10/03/2023 at risk of not receiving proper care. Findings included ... Record review of Resident 7 assessment dated 06/19/2023 showed Resident 7 was admitted on /2023 to the ALF with a diagnosis of ) and . Review of the ALF's employee files showed: Staff C, Caregiver, was hired on 10/19/2022 with no documentation of specialized dementia training. Staff E, Caregiver, was hired on 10/05/2020 with no documentation of mental health training. On 09/20/2023 at 9:45 AM. Staff G, Business Office Manager, stated that Staff C became sick during the specialized dementia training and couldn't complete the training. Staff Chas been signed up for the dementia class in October. On 09/20/2023 at 9:48 AM. Staff G stated that they had no documentation of mental health training fqr §t~ff E:_f:lndwas unsure iJ the (:le>cument is missing .or the training.was not.completed. On 09/21/2023 at 3: 11 PM, Staff C stated that they had become sick during the dementia training and were unable to complete the final exam and was rescheduled for the next class in October. On 09/22/2023 at 12:01 PM, Staff Estated that they were going to do the mental health training, but due to Covid, the class was cancelled and Staff E didn't follow up. Staff Estated that the ALF has them on the class list now. 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, Brookd~e SiJver Lake is or will be in compliance with this law and/ or regulation on (Date) // L I d'/2AJ ?::3. 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. , ,_14.36 16i02H 0~1i NA IICII 10.17.2023 14:38:59 State of Uashington 12/ Statement of Deficiencies License #: 1703 · Compliance Determination # 29789 Plan of Correction Brookdale Silver Lake Completion Date Page 8 of 12 Licensee: BROOKDALE SENIOR LIVING 10/03/2023 3 / {) - 2-(; . 2.-()'2,.., A Date WAC 388-78A-2480 Tuberculosis Testing Required. (1) The assisted living facility must develop and implement a system to ensure each staff person is screened for tuberculosis within three days of employment This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure 2 of 6 staff (Staff A and C) were screened for tuberculosis (TB) (a bacterial infection that usually attack the lungs, but TB bacteria can attack any part of the body such as the kidney, spine, and brain) within three days of hire. This failure placed all residents as risk for possible exposure to a communicable disease. Findings included ... Review of the A LF's employee files showed: Staff A, Executive Director, was hired on 02/27/2020, a first step TB test was given on 03/03/2020, Staff C, Caregiver, was hired on 10/19/2022, a first step TB test was given on 02/15/2023. On 09/21/2023 at 3:10 PM, Staff C stated that when they were hired, they did the TB test but weren't sure of the date it was done. 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, Brookd le Si er Lake is or will be in compliance with this law and / or regulation on (Date)-4~..:./-=:J>~=~~ In addition. I will implement a system to monitor and ensure continued compliance with this requireme . This document was prepared by Residential Care Services for the Locator website. ._I _ 1_4 3_8_16_;;.:_,•?3_:;_o·~_;·,_··· _···· ·~:_,_)'-I __ ·,_v A_TE_Ct_l _____ ) 10.17.2023 )q:38:59 State of Uashington 13. Statement of Deficiencies - - License #: 1703 - Compliance Determination # 29789 Plan of Correction Brookdale Silver Lake Completion Date Page 9 of 12 Licensee: BROOKDALE SENIOR LIVING 10/03/2023 WAC 388-78A-2160 Implementation of negotiated service agreement. The assisted living fa,cility must provide the care and services as agreed upon in the negotiated service m ag u r t e u e a m lly e n a t g t r o e e e d a c u h p r o e n s i b d e e t n w t e u e n n l e th s e s a a s d s e is v t i e a d ti o li n v i f n ro g m fa t c h il e it y n e a g n o d t i t a h t e ed r e s s e id rv e i n c t e o a r g t r h e e e m re e s n id t e is n t's representative at the time the care or services are scheduled. This requirement was not met as evidenced by: Based on observations, Interviews, and record review, the Assisted Living Facility (ALF) failed to provide services as negotiated for 1 of 7 residents (Resident 3) who required treatment and t n m h o e o t n A h it a L o v F r i i n n a g g n d t a h s p e s l i a i r s c w ta e e n d i c g R e h e t b s m y id o t e h n n e it t o A 3 r L e a F d t . a r T i s s h k p is r f o e f r s a c i m lu ri e r b e d e i d c re a b s l y u c l o t t h e m e d p ir i l n i p c r a R im t e io s a n i r d s y e . c n a t r 3 e n p o h t y r s e ic c i e a iv n i n a g n d th n e e ir g o o x ti y a g te e d n b a y n d Findings included ... Resident 3 was admitted to the ALF on /2021 th multiple medical diagnoses including ( ) and ). o R x e y v g i e e n w ( o u f s R e e o s f i d o e x n y t g 3 e ' n s a p s h y m s e ic d ia ic n a l o t r r d e e a r t m da e t n e t d i n 0 4 w / h 2 e 0 r /2 e 0 o 2 x 3 y g s e h n o w is e d d e R liv e e s r id e e d n t t o 3 a r e p q e u rs ir o e n d t s h u ro p u p g le h m ental medical equipment such as a nasal cannula) running at a prescribed rate continuously. a a R t s e t s e v i n s ie t t i a w o n n o c a e f n a w d n i t p e h h g m y o s t e i i a c d t a i e c l d a a t s s io e s n i r s s v t . i a c T n e h c a e e g w N re i S t e h A m m s e h o n o n t w i ( t N o e r S d in A M g ) e a d d n a d t T e e u d c s 0 h e 5 s o / 3 ( f M 1 o / T x 2 y s 0 ) g 2 e w 3 n e s r e h e q o u r w e ip e s m d p o e R n n e s t. s i b id le e n to t 3 p r r o e v q id u e i · r ed p R R e e e r v s c i i e d e n e w t n a o t g f 3 e a ' s o p p r r o o n w g o r t e e b r s e o s i f n n a g o t t t t o u e r r n d n e a e y t d e d d o i n s 0 . c 9 u /1 ss 4 e /2 d 0 c 2 o 3 n s c h e o rn w s e w d i t t h h a f t i n d d u in ri g n g R a e s c i a d r e e n c t o 3 n 's f e o r x e y n g c e e n w d it e h v i A c L e F a t s t a a f l f o , w w o O x h n y e g 0 e e 9 lc n /2 h d 1 a e / ir 2 v . 0 ic R 2 e e 3 w s a i a d t e s 4 n : o 1 t b 8 3 s ' P e s r M b v r e , e d R a e t t o h s i i n b d g e e n t b u t e r 3 c n a e w m d a e s o f o i f n . b c S s r e t e a r a f v s f e i D n d , g s l C y e a l s f r - h e p a g r l o i l v o p e w e r l , l a i w 'n n g a d s t r h a n e p o m i t d i s f . i e e R r d v e e a s s n id d t e o c n t o t h n 3 e n ' i s r e r p c o t o o e r m d ta b in le t heir Resident 3 to an in-room oxygen device. This document was prepared by Residential Care Services for the Locator website. 14 38 16 2on .. 10 .. , ! _14~!~_ WA. I ECH ...•... __ I 10.17.2023 14:38:59 State of I-lash in gton Statement of Deficiencies · License #: 1703 · Compliance Determination # 29789 Plan of Correction Brookdale Silver Lake Completion Date Page of 12 Licensee: BROOKDALE SENIOR LIVING 10/03/2023 In an interview on 09/21/2023 at 4:35 PM, Staff D stated that the MTs and the nurses are supposed to make sure oxygen devices are being tumed on to the set amount and placed on the residents. In an interview on 09/21/2023 at 4:22 PM, Resident 3 stated that they have had issues with their oxygen device not being turned on. Resident 3 stated that staff are supposed to turn on their oxygen machine and that they are depend on staff to do this as they are unable to remember to ask staff to turn it on as they only realize they need their oxygen when they begin to struggle to breathe. In an interview on 09/21/2023 at 4:36 PM, Staff J, Health and Wellness Director, stated that Resident 3's oxygen should have been running at a rate given by their physician and that ALF staff were responsible for placing the oxygen equipment and setting it to the prescribed rate. Staff J stated that they would work on this issue. Weight monitoring Review of an NSA dated 05/31/2023 showed Resident 3 required weights to be taken weekly and that ALF staff ware to physically assist Resident 3 with this task. Review of an electronic medication administrations record (EMAR) dated 09/20/2023 showed Resident 3 was to have their weight taken weekly. An EMAR dated August 2023 showed Resident 3 did not-have-their weight taken·for 3 oMheA-weeks: An·EMAR dated September 2023 showed REtsiderit ~gid nQt.have their weight.taken for 2 of the 3 weeks. In an interview on 09/21/2023 at 1 :52 PM, Staff J stated that they were unable to find records of weights for Resident 3 in their computer records nor their paper records. Staff J stated that if it is not documented in the records then it didn't happen. 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, Brookd le ·rver Lake is or will be in compliance with this law and I or regulation on (Date) / 2J ___ /a-26- ZCJZt_3 Date This document was prepared by Residential Care Services for the Locator website. WA r[CH 10.17,2023 14:38:59 State of ~ashington Statement of Deficiencies License #: .1703 · · Compliance Determination # 29789 Plan of Correction Brookdale Silver Lake Completion Date Page of 12 Licensee: BROOKDALE SENIOR LIVING 10/03/2023 WAC 388-78A-3090 Maintenance and housekeeping. (1) The assisted living facility must: (a) Provide a safe, sanitary and well-maintained environment for residents; This requirement was not met as evidenced by: Based on observations and interviews the Assisted Living Facility (ALF) failed to provide a safe, sanitary, well-maintained environment for residents living at the ALF. This failure resulted in residents living in an Lmsafe and unsanitary environment and placed residents at risk for injury and a decreased quality of life. Findings included ... The facility has two separate wings, the Bridge Household and Clare Household. Each household has resident sleeping quarters, shower rooms, laundry facilities, dining room, kitchen, library and a common outdoor gardening area. On 09/19/2023. the following was observed: At 11 :37 AM, water pooled on the floor next to the toilet and sink forming a puddle inside the Spa ~oom in Bridge Household. Completely saturate~ i:,ap_er to~els were next_to the Q§rb~ge can. In an interview on 09/19/2023 at 11:38 AM, Staff A. Executive Director. stated that it looks like the toilet had flooded. Staff A stated they would be notifying maintenance immediately to fix this issue. At 11 :39 AM, in the Laundry Room of Bridge Household, the vent on the dryer was covered in dust and lint. At 11 :38 AM, the base of the fire sprinkler was protruding from the ceiling by the Spa Room. There was a hole where the sprinkler should have been flush against the ceiling. On 09/19/2023 at 11: 39 AM, Staff A stated that they would get the sprinkler fixed and that it was in working order. At 12:15 PM, the vents in the Dining Room of Bridge Household ceiling were layered in dust. This document was prepared by Residential Care Services for the Locator website. 14.38162023_\0_ll__ ---1'-6'--~!- - WA · l · ( ·· C ··· t - l - ·~-~---··· , .. 10.17.2023 14:38:59 State of Washington 16, Statement of Deficiencies · - License #: 1703 · -Compliance Determination # 29789 Plan of Correction Brookdale Silver Lake Completion Date Page of12 Licensee: BROOKDALE SENIOR LIVING 10/03/2023 In an interview on 09/19/2023 at 12: 16 PM, Staff A stated that they saw the dust and will be working on fixing this right away. At 12:21 PM, in the kitchen, a large vent in the ceiling above a kitchen preparation and storage table, had layers of dllst. Strings of this dust hung off the vent. At 12:29 PM, in the staff handwashing sink, between the kitchen and dining room in the Bridge Household, there were dark and light brown stains inside the lower cabinet. At 12:37 PM, in the resident kitchenette of Clare Household, a container of Clorox wipes was in an unlocked cabinet on top of the fridge. The label on the container read "Precautionary statements: hazards to humans". At 12:55 PM, the ceiling vent in the Quiet Room of Clare Household had a dust coating on the grilles. In an interview on 09/19/2023 at 12:16 PM, Staff A stated they would work on correcting all issues presented as soon as possible. ·---- Plan/Attestation Statement· I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency._E 3y taking this action, Bmokd e Sil uer ~Lak e i-sor--- -- will or on (batef · " Y -btfin cornptiancif witfitnis·Iaw and I regulation lement a system to monitor and ensure continued compliance with Date

This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: Brookdale Silver Lake Provider Type: Assisted Living Facility License/Cert.#: 1703 Compliance Determination #: 20123 Intake ID: 68357 Investigator: Christine Banta Region/Unit #: RCS Region 2 / Unit A Investigation Date(s): 02/27/2023 through 04/06/2023 Complainant Contact Date(s): Allegation(s): It was alleged... The Named Resident (NR) had an injury fall in the Assisted Living Facility (ALF). Investigation Methods: Sample: Total residents: 42 Resident sample size: 3 Closed records sample size: 2 Observations: Environment Residents Staff-resident interactions Interviews: Executive Director Residents Others not associated with the ALF. Record Reviews: Resident records ALF records Medical records Investigation Summary: It was determined... The NR was sitting on the edge of the bed, leaned to the left, and fell to the floor with the blanket and rolled to the right side. The med tech was alerted by the Safely You alert system and watched the Safely You video of the NR’s fall. The med tech assumed the NR had a controlled fall. The NR was sleeping on the floor of their room which set off the Safely You alarm. The NR was moved into another room so they could continue to sleep on the floor. At 10:00 AM the NR was found on the floor in pain. The Director of Nursing called 911 to have the NR taken to the emergency department. The ALF failed to follow their policy for falls. Citation for WAC 388-78A-2600 Policies and Procedures. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written This document was prepared by Residential Care Services for the Locator website. Failed Provider Practice Not Identified / No Citation Written 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.