Brookdale Alderwood.

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. 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.

Residential Care Services Investigation Summary Report Provider/Facility: Brookdale Alderwood Provider Type: Assisted Living Facility License/Cert.#: 1700 Compliance Determination #: 48911 Intake ID: 148250 Investigator: Michelle Mcglon Region/Unit #: RCS Region 2 / Unit J Investigation Date(s): 10/17/2024 through 11/12/2024 Complainant Contact Date(s): Allegation(s): 1. The Named Resident (NR) had a fracture of unknown origin at the Assisted Living Facility (ALF). Investigation Methods: Sample: Total residents: 36 Resident sample size: 2 Closed records sample size: Observations: Residents Staff to resident interactions Resident to resident interactions Resident rooms Interviews: Family members Nursing staff Record Reviews: State reporting log Incident investigation Facility policies Resident Records Investigation Summary: 1. Interview and record review showed the NR reported to the ALF staff, they had difficulty walking and had pain. Record review showed the ALF staff assisted the NR with transfers, but failed to follow their policy to have the resident evaluated by a physician until the following day. See Statement of Deficiency WAC 388-78A-2600 Conclusion / Action: 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.

—: WA DSHS report: Inspections (10/2024)

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 November 18, 2024 ELECTRONIC-FACSIMILE Administrator Brookdale Alderwood 18706 36th AVENUE WEST LYNNWOOD, WA 98037 Assisted Living Facility License # 1700 Licensee: BROOKDALE SENIOR LIVING COMMUNITIES INC IMPOSITION OF CIVIL FINE Dear Administrator: On November 12, 2024, 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 Brookdale Alderwood, located at 18706 36th AVENUE WEST, LYNNWOOD, 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 November 12, 2024. Civil Fine WAC 388-78A-2600 (1)(b) Policies and procedures. $700.00 The licensee failed implement their Change of Condition policy when one resident could no longer ambulate or transfer independently and was experiencing pain. This failure resulted in the resident experiencing pain and having a delay in medical evaluation after a broken hip. This is a recurring citation previously cited on January 9, 2023, and August 23, 2023. NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Administrator Brookdale Alderwood License # 1700 November 18, 2024 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: Jamie Singer, Field Manager Region 2, Unit J 20311 52nd Avenue West Suite 100 Lynnwood, WA 98036 Phone: (253) 312-1446 / Fax: (206) 971-6791 rcsregion2email@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 Brookdale Alderwood License # 1700 November 18, 2024 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 $700.00 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, WA 98507-9501 (360) 664-5919 / FAX: (360) 664-8401 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 Brookdale Alderwood License # 1700 November 18, 2024 Page 4 If you have any questions, please contact Jamie Singer, Field Manager, at (253) 312-1446. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 2, Unit J RCS Regional Administrator, Region 2 HCS Regional Administrator, Region 2 DDA Regional Administrator, Region 2 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW HP

Residential Care Services Investigation Summary Report Provider/Facility: Brookdale Alderwood Provider Type: Assisted Living Facility License/Cert.#: 1700 Compliance Determination #: 34739 Intake ID: 111280 Investigator: Hayley Pinkham Region/Unit #: RCS Region 2 / Unit J Investigation Date(s): 01/04/2024 through 03/20/2024 Complainant Contact Date(s): Allegation(s): 1) The Named Resident (NR) sustained a significant injury during care at the Assisted Living Facility (ALF). 2) The ALF nursing staff is unsure if the Staff Member (SM) assisting the NR for care was properly credentialed to provide care. Investigation Methods: Sample: Total residents: 30 Resident sample size: 2 Closed records sample size: Observations: Identified resident Residents Resident care equipment Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Identified resident Identified staff Nursing staff Residents Residents Family members Record Reviews: Medical records Incident investigation Personnel files Investigation Summary: 1) Interview with the NR showed the NR could not recall the incident. Observation and interview with sampled resident showed no concerns for care and/or safety issues. Record review showed the ALF investigated the injury, sought immediate medical attention, and notified the responsible party. Interview showed the family member was satisfied with the ALF's investigation and care of the NR. 2) Interview and record review showed the NR received assistance during care with subsequent injury from a SM not credentialed to provide care. Deficient practice This document was prepared by Residential Care Services for the Locator website. identified. Conclusion / Action: 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.

This document was prepared by Residential Care Services for the Locator website. STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALT H SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20311 52nd Ave W, Suite 100, Lynnwood, WA 98036 BROOKDALE SENIOR LIVING COMMUNITIES INC Brookdale Alderwood 18706 36th AVENUE WEST LYNNWOOD, WA 98037 RE: Brookdale Alderwood License # 1700 Dear Administrator: This letter addresses Compliance Determination(s) 33234 (Completion Date 12/22/2023) and 30051 (Completion Date 10/04/2023). The Department completed a follow-up inspection of your Assisted Living Facility on 12/22/2023 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-2690-5, WAC 388-78A-2690-6-c, WAC 388-78A-2690-7-b, WAC 388-78A-2690- 7-a, WAC 388-78A-2690-7 The Department staff who did the on-site verification: Lisa Hauk, Complaint Investigator If you have any questions, please contact me at (425)670-6070. Sincerely, . s · Jamie Singer, Field M~ Region 2, Unit J Residential Care Services This document was prepared by Residential Care Services for the Locator website. 11;18;22 2023--10..09 4 I WA TECH 10.09.2023 09:18:48 State of l,lashington STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20311 52nd Ave W, Suite 100, Lynnwood, WA 98036 Statement oft>e'ficiendes·•···--· ·····.·.··. ·····-· ..... U. cen·se #: ·1. 100, ·· ·· --co·n,pliiince t>eteiminat,on # 3c>'os1 Plan of Correction Brookdale Alderwood Completion Date Page 1 of 4 Licensee: BROOKDALE SENIOR LIVING COMMUNITIES INC 10/04/2023 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 an unannounced on-site complaint investigation on 09/27/2023 and 09/27/2023 of: Brookdale Alderwood 18706 36th AVENUE WEST LYNNWOOD, WA 98037 This document references the following complaint number(s): 98275, 98935, 99873, 100054 The following sample was selected for review during the unannounced on-site visit: 3 of 34 current residents and 1 former residents. The department staff that investigated the Assisted Living Facility: Lisa Hauk. Complaint Investigator From: DSHS, Aging and Long-Term Support Administration Residential Care Services, Region 2 , Unit J 20311 52nd Ave W, Suite 100 Lynnwood, WA 98036 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. 10/9/2023 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. 11;18:22 2023-10-09 s I WA TECH 10.09.2023 09:18:48 State of Washington s Statement of Deficiencies , • ·••h License#: 1700 ..... ··· Compliance Determination# 30051 Plan of Correction Brookdale Alderwood Completion Date Page 2 of 4 Licensee: BROOKDALE SENIOR LIVING COMMUNITIES INC 10/04/2023 • ..• ••• .. ••••••• . ..,. · \ •' •---•-•._..,,..: ou.• • ~-;; •••~•u•• · • u• · oou' ' .......... WAC 388-78A-2690 Electronic monitoring equipment Resident requested use. (5) The release of audio or video monitoring recordings by the facility is prohibited. Each person or organization with access to the electronic monitoring must be identified in the resident's negotiated service agreement. (6) If the resident requests the assisted living facility to conduct audio or video monitoring of his or her apartment or sleeping area, before any electronic monitoring occurs, the assisted living facility must ensure: (c) The resident and the assisted living facility have agreed upon a specific duration for the electronic monitoring and the agreement is documented in writing. (7) The assisted living facility must: (a) Reevaluate the need for the electronic monitoring with the resident at least quarterly; and (b) Have each reevaluation in writing, signed and dated by the resident. This requirement was not met as evidenced by: Based on interview. observation and record review, the Assisted Living Facility (ALF) failed to conduct, document and get resident or representatives signatures for quarterly evaluations and time duration of electronic monitoring for 2 of 3 residents (Resident 1 and Resident 2). T~is failure placed Resident 1 and 2 at risk of having their privacy and rights violated. Findings included ... Record review of a policy titled, "SafelyYou Fall Detection System Policy" dated 05/2021, showed the ALF would update the consenting resident's Personal Service Plan {PSP-equivalent to a Negotiated Service Agreement) to indicate the use of the SafelyYou Fall Detection System. In interview, on 10/02/?023 at 2: 15 PM, Staff A (Executive Director) stated tha~ the SafelyYou system consisted of an Al (artificial intelligence) camera that scanned resident apartments on a 30- minute loop. If the resident did not fall during the 30-minute loop, the system deleted the acquired video footage. If a resident ,had a fall and remained on the ground for a minute or two, the camera would select five or ten minutes of video before the fall and SafelyYou would send that video'to the ALF. Record review of an undated Admission Record showed the ALF admitted Resident 1 on This document was prepared by Residential Care Services for the Locator website. I 11; 18;22 2023-10..,09 6 WA TECH 10.09.2023 09:18:48 State of Mash I ngton 6 Statement of Deficiencies ··-····~--• .. -········-"-cicei,se ·1rTfoo . Compliance 0-efe'rmination # 30051 . Plan of Correction Brookdale Alderwood Completion Date Page 3 or 4 Licensee: BROOKDALE SENIOR LIVING COMMUNITIES INC 10/04/2023 /2020 with and diagnoses. A PSP, dated 09/18/2023, showed Resident 1 required medication assistance and 1 to 2-person full assistance with all Activities of Daily Living (AOL - a term used in healthcare to refer to people's daily self-care activities such as bathing, grooming, ambulation, etc.). Observation of Resident 1's apartment, on 09/27/2023 at 11: 15 AM; showed a video camera installed above the window across from the bed. The camera was pointed at Resident 1' s bed. Record review of the PSP for Resident 1 did not mention the SafelyYou Fall Detection System, the duration of its use, or who had access to the video. There was no quarterly evaluation of Resident 1' s need for electronic monitoring with Resident 1 or their legal representative's signature. Record review on an undated Admission Record showed the ALF admitted Resident 2 on /2023 with and diagnoses. A PSP, dated 09/11/2023, showed Resident 2 required medication assistance, dressing and bathing. Observation of Resident 2's apartment, on 09/27/2023 at 11:40 AM, showed a video camera installed above the window across from the bed. The camera was pointed at Resident 2's bed. Record review of the PSP for Resident 2 did not mention the SatelyYou Fall Detection System, the duration of its use, or who had access to the video. There was no quarterly evaluation of Resident 2's need for electronic monitoring with Resident 2 or their legal representative's signature. In interview, on 10/04/2023 at ·10:51 AM, Staff A (Administrator) stated that the ALF had not ipentified individuals who had access to the Safe!yYou electronic monitoring system, or the duration of its use documented in Resident 1 and Resident 2's PSP. Staff A stated that the ALF did not have quarterly evaluations for resident's need of the electronic monitoring system and would need to start documenting evaluations this month for residents who utilized the SafelyYou system. Pl ap/A ttestati on Statement This document was prepared by Residential Care Services for the Locator website. f 11; 1s:22 2023-10-09 , I WA TECH 10.09.2023 09:18:48 State of lolashington ·····-········-····-·····-~L-i-ce-n-se #: 1700 Statement of Deficiencies · Compliance Determination # 30051 Plan of Correction Brookdale Alderwood Completion Date Page4 of 4 Licensee'. BROOKDALE SENIOR LIVING COMMUNITIES INC 10/04/2023 ···············································-········-··--·-··- ······-···•·~----···-····-·······························-··························································· , 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, Brookdalf Al~erwood is or will be in compliance with this law and I or regulation .on (Date) ... JI f,9 J / @c@Q 3 .1 1 / 18/2 0 3 SB confirmed POC date with provider 10/17/2023 plement a system to monitor and ensure continued compliance with 1oj1b fu;':)_3 ··-----------··••a.------------- ----------!-~---------------- Date