Brookdale Olympia West.

. . . . . . Statement of Deficiencies License #: 2497 Compliance Determination # 63850 Plan of Correction Brookdale Olympia West Completion Date becoming aware of an incident… The Executive Director or designee should maintain a written record of the investigation. A summary of interviews should be prepared by the Executive Director or designee, including the date, time, name of person being questioned and an impartial report of the facts.” <Resident 1> Review of Department Records showed the following two reports made by the memory care facility to the Department, that reported two injuries of unknown origin for R1 on 07/26/2025, and 08/04/2025. • 07/26/2025: “The resident [R1] was noted this morning at about 10 a.m. to have purple bruising to both of [their] wrists. No specific shape and it the bruising extends from about 1/3 of the way upper forearm from [their] wrist down, down to the wrist and a little bit onto the back of [their] hands.” • 08/04/2025: “Sometime after breakfast and before lunch today (8/4/25), [R1] suffered a skin tear to [their] right wrist in a crescent moon shape just smaller than a dime.” Review of R1’s face sheet showed that R1 was admitted to the memory care facility on /2022. Review of R1’s progress notes showed the following: • 07/26/2025 at 2:40PM: “Notified… of purple bruising to bilateral wrists. Unknown origin…” • 08/04/2025 which stated, “[R1] has a new skin tear of unknown origin on [their] right wrist. lt is a crescent moon shape, approx[imately] 1cm long x 0.5cm wide.” During an interview with Staff C, the Health and Wellness Coordinator, on 08/08/2025 at 10:11AM, Staff C was asked what steps were taken after the facility became aware of the injury of unknown origin for R1 on 07/26/2025. Staff C stated, “I interviewed the staff that were on and none of them knew what happened. [R1] got put on alert [charting] and put on a Temporary Service Plan.” Staff C was asked if they the outcome of the investigation, and if they knew how the bruising occurred. Staff C stated that the nursing management still do not know what happened, or how R1 sustained the bruises. Staff C was then asked to discuss the results of the investigation regarding the injury of unknown origin for R1 on 08/04/2025. Staff C stated that R1 spent a lot of time in their wheelchair and often did not navigate corners well. Staff C stated, “I am guessing [R1] bumped it.” Staff C was asked to provide the incident reports and respective investigations, including any resident/staff interviews for both incidents regarding R1’s reported injuries of unknown origin for review. The incident reports, investigations and . Statement of Deficiencies License #: 2497 Compliance Determination # 63850 Plan of Correction Brookdale Olympia West Completion Date interviews for both incidents were not provided. During an interview with Staff B, the Health and Wellness Director, on 08/08/2025 at 12:18PM, Staff B was asked if there were any incident reports completed for R1 and their 2 injuries of unknown origin, as they were not provided for review. Staff B stated that there were no incident reports or investigations completed for these incidents. Staff B stated, “There are definitely some things that we missed, and that we need to work on.” <Resident 2> Review of Department Records showed a report made to the Department by the memory care facility regarding an injury of unknown origin for R2 on 07/26/2025 which stated, “Resident had a small skin tear on left wrist with and abrasion and some discoloration that was blue in color. First aid was applied; hand was bandaged.” Review of R2’s face sheet showed that R2 was admitted to the memory care facility on /2023. Review of R2’s incident report for the injury of unknown origin, dated 07/26/2025, stated, “small skin tear noted by med-tech [Medication Technician] … after dinner in TV room, bruising also present to left wrist.” Under “Nature of Incident” it stated, “Incident of Unknown Origin.” Further review of incident report showed no additional investigation made by the facility. During an interview with Staff C, the Health and Wellness Coordinator, on 08/08/2025 at 10:11AM, Staff C was asked to explain the facility process of investigations, and if the investigation/summaries would normally be attached to the respective incident reports. Staff C stated, “Generally I just write a progress note with what I found at the time.” Staff C was asked if they normally completed a summary of the investigations. Staff C stated that they do not complete any written summaries of investigations. Staff C was asked if they, or Staff B ever conducted and documented any investigation for injuries of unknown origin to rule out any possibility of ongoing abuse or neglect. Staff C stated, “Not really.” During an interview with Staff A, the Executive Director, Staff B, Staff C, and Staff D, the Area Nurse Manager, all present on 08/08/2025 at 1:33PM, Staff B was asked if any residents or staff were interviewed regarding these 3 separate incidents. Staff B stated that they conducted a verbal interview with the residents. Staff B was asked if any of these interviews were documented. Staff B stated they were not. Staff A, Staff B, Staff C, and Staff D were asked if they can rule out the possibility of any abuse or neglect for the 3 injuries of unknown origin involving R1 and R2. Staff A, Staff B, Staff C, and Staff D all stated that they cannot, and expressed that they agreed that there were no investigations conducted by the facility. .

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written . N/A . Investigation Summary Report Provider/Facility: Brookdale Olympia West Provider Type: Assisted Living Facility License/Cert.#: 2497 Compliance Determination #: 42668 Intake ID: 133266 Investigator: Pamela Horlick Region/Unit #: RCS Region 3 / Unit E Investigation Date(s): 06/13/2024 through 06/26/2024 Complainant Contact Date(s): Allegation(s): 1. Quality of Care/Treatment: Report of water temperatures in shower rooms being too cold for residents to comfortably shower. 2. Misappropriation of property: Report of resident missing clothing and blankets. Investigation Methods: Sample: Total residents: 42 Resident sample size: 3 Closed records sample size: 0 Observations: Identified resident Residents Dining Staff to resident interactions Resident to resident interactions Interviews: Identified resident Nursing staff Residents Family members Laundry staff Record Reviews: State reporting log Facility policies Face Sheets Care Plan Investigation Summary: 1. Quality of Care/Treatment: Facility failed to ensure 2 of 4 showers had shower handles that functioned properly, adequate water pressure and had readily available hot water for showering. Failed practice identified. Facility provided water temperature policy that is not in compliance with state law. Failed practice identified. 2. Misappropriation of property: Facility actively looking for missing items. Several items have been found. Family was given opportunity to search lost and found to look for missing items. Unable to substantiate failed practice. . 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 800 NE 136th Ave Ste 200, Vancouver, WA 98684 Statement of Deficiencies License #: 2497 Compliance Determination # 42668 Plan of Correction Brookdale Olympia West 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 06/13/2024 and 06/27/2024 of: Brookdale Olympia West 420 YAUGER WAY SW OLYMPIA, WA 985028660 This document references the following complaint number(s): 133289, 133266 The following sample was selected for review during the unannounced on-site visit: 3 of 42 current residents and 0 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 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. . Statement of Deficiencies License #: 2497 Compliance Determination # 42668 Plan of Correction Brookdale Olympia West Completion Date Administrator (or Representative) Date WAC 388-78A-2950 Water supply. The assisted living facility must: (5) Provide hot and cold water under adequate pressure readily available throughout the assisted living facility; (6) Provide all sinks in resident rooms, toilet rooms and bathrooms, and bathing fixtures used by residents with hot water between 105 F and 120 F at all times; and This requirement was not met as evidenced by: Based on observation, interview, and record review the facility failed to ensure water temperatures met requirements and to provide hot water readily available under adequate pressure for 2 of 4 community showers. This failure placed 42 of 42 residents at risk for decreased quality of life. Findings included… Record review of the facility provided document titled, “Temperatures: Test and log water temperatures”, undated, showed, “Test temperature in shower areas.” In an interview via email on 6/13/2024 12:56PM, Staff A, Executive Director, stated the only water temperature policy they can locate is through the Temperatures: Test and log system. In an interview on 06/13/2024 at 11:20 AM, Staff B, Maintenance Director, was asked what the process was for checking water temperatures in the facility, they stated, we check temperatures every week, we check every water source. Staff B was asked if they check temperatures for the shower water, they stated no, only the kitchen and rooms. When Staff B was asked who checked the shower water temperatures they stated they should be checking the temperatures but don’t. Staff B was asked what the water temperatures should be between, they stated 110°-120° Fahrenheit. In an observation on 06/13/2024 at 11:27AM, of the shower on Clare side C court, the following water temperatures were obtained with weak water pressure: -At 11:28 AM, water turned on and knob pointing to blue line -At 11:33 AM, the water temperature was 79° Fahrenheit. Knob turned to red line. . Statement of Deficiencies License #: 2497 Compliance Determination # 42668 Plan of Correction Brookdale Olympia West Completion Date -At 11:34 AM, the water temperature was 67° Fahrenheit. -At 11:35 AM, the water temperature was 79° Fahrenheit. -At 11:38 AM, the water temperature was 100° Fahrenheit while pointing to the blue line. -At 11:39 AM, the water temperature was 89° Fahrenheit. Knob turned to the red line. -At 11:40 AM, the water temperature was 79° Fahrenheit. -At 11:42 AM, the water temperature was 103° Fahrenheit. Knob pointing to blue line. In an observation and interview on 06/13/2024 at 11:27 AM, Staff B appeared confused on where the knob on the handle should be pointing. Staff B was asked if the water pressure was at its maximum, Staff B stated it should be higher than this. It was observed while the arrow was pointing to the right with the blue line indicating cold water, the temperature rose. Staff B was asked what was wrong with the knob. Staff B stated they will need to change the entire handle, it was not accurate. In an observation on 06/13/2024 at 11:52AM, of the shower on Bridge side F court, the following water temperatures were obtained: -At 11:52 AM, water turned on and pointing to red side of the handle. -At 11:54 AM, water temperature was 77° Fahrenheit. -At 12:03 PM, water temperature was 105° Fahrenheit. -At 12:04 PM, water temperature was 112° Fahrenheit. In an observation on 06/13/2024 from 11:52 AM to 12:03 PM showed that it took 11 minutes to reach the minimum of the required temperature range of 105°. In an observation and interview on 06/13/2024 at 12:02PM, the water handle of the bridge side F court shower appeared loose and floppy. Staff B was asked if the handle was supposed to be like that, they stated, no, its not. Staff B stated it was missing a screw. In an interview on 06/13/2024 at 12:42PM, Staff C, Medication Technician, was asked if there were any issues with the water temperature when showering residents, Staff C stated yes there was, especially if the washing machines were running. It was not good. Staff C stated, “its lukewarm and the water pressure is not good, its bad.” Staff C was asked if they had told anyone, Staff C stated they told Staff B. Staff C stated we complain all the time and nothing happens. In an interview on 06/13/2024 at 1:28PM, Staff D, Caregiver, was asked if there were any issues with the water temperature when showering residents, Staff D stated, its cold, court D shower water is ice cold and when you turn it, it will get warm and then immediately go cold. Staff D stated we have residents refusing showers because its cold. They stated care staff will use E court shower room because nobody wants to use D court. Staff D was asked if they told anyone their concerns about the water temperatures, they stated everyone knows. Staff D was asked if maintenance knows, they stated yes. . Statement of Deficiencies License #: 2497 Compliance Determination # 42668 Plan of Correction Brookdale Olympia West Completion Date In an interview on 06/13/2024 at 2:30PM, Staff A, Executive Director, was asked if they were aware of any issues with the water temperatures, they stated not until today when Staff B stated that the hot and cold were backwards. Staff A was asked how long it should take to get hot water running in the shower, they stated, if it’s the first shower of the day it will take a couple of minutes. Staff A stated after 2-3 showers it should be readily available.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: Brookdale Olympia West Provider Type: Assisted Living Facility License/Cert.#: 2497 Intake ID: 136782 Compliance Determination #: 44181 Region/Unit #: RCS Region 3 / Unit E Investigator: Paul Aube Investigation Date(s): 07/16/2024 through 07/18/2024 Complainant Contact Date(s): Allegation(s): Quality of Care/Treatment: Public report of low staffing in the community, which is affecting resident care. Investigation Methods: Sample: Total residents: 41 Resident sample size: 5 Closed records sample size: 0 Observations: Identified resident Residents Activities Dining Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Identified resident Family members Nursing staff Management Record Reviews: Facility policies Negotiated Service Plans Staff Schedules Shower Documentation Investigation Summary: Quality of Care/Treatment: Claims substantiated. Facility failed to provide resident showers, as per the negotiated service agreement, due to lack of staff. This was confirmed through multiple staff interviews, observation and document review. Failed practice identified. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written . Failed Provider Practice Not Identified / No Citation Written N/A . . . . .

Statement of Deficiencies License #: 2497 Compliance Determination # 43731 Plan of Correction Brookdale Olympia West 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 follow-up on 07/08/2024 and 07/08/2024 of: Brookdale Olympia West 420 YAUGER WAY SW OLYMPIA, WA 985028660 This document references the following SOD dated: 07/11/2024 The following sample was selected for review during the unannounced on-site visit: 42 of 42 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Anissa Bearden, Licensor Celeste Vashey, ALF LTC Licensor From: DSHS, Aging and Long-Term Support 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 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. . 07.24.2024 12:01;34 State of Mashington ~'taternent of Oefid~ncies Ucense # 2497 Complianc.e Determination# 43731 Plan of Ccmectrnn Sroo!<.d«le 01yrnpia v'V'est Cnmp!stmn D.ite Pags 2 cf 7 D1/1 3/2024 (1) The a!;s1~ted living fa,::1hty rnust c-mnply t~th all ott,er appli<.::able federal, state, cuunty and rnunic1pa! statuti:s, ni!es, codt::s and ordinances., 1ndud'tng. w~thout Hrnifat:1 :ins thG'ie triat prohibit d1~•:mnination This require-ment was not m-et as evidenced by: Based on obsNv<lt1,:}n, 1r1t~!'v!i::W. and re<:•Jrd rev;ew the fadily tailed to "?.ns.ur~ that alt fae 1;:xtingwishers lwd servk:;,;- tags that sliovved when tttev were serviced and cJ·i•~c.J<i;,d and failed to ~nsurB th.Jt a!! fire ::,'tinguishu5 ½iere serv.iced yi:;arly for ·1 of 1 fad~;t; revi~.wed These fa~tures pla..::,;d all 42 0f 42 resraents. ~t;:iff, and 'l··i'S-ltors at. risi, of htlffn dunng a fire Find,ngs included .. C Stat~ Fire Ml!lmhall regulutmn :::ode If(: 905 2 2'015,20:rn '·P{;rtaulc: fhe 1,n<t~n'.Jurshers shall tH: sBieo:;ti::d. lnstail~d. and mamtained in aGC()rdanc<:! i.'\~tb thrn sect~on. and t'-lfPA '10. Exc~iinorisi. l The d~stai1ce of trnvi;;I to r~.ich an rfttH,guisher st1aii nat apply the travel distanc~ ti:, rea('!l ai1 }€ :ti1iguisller shall rmt apply to the spectator seating portir.ms Qf Grnup A.5 (1ccup~ncies. 2. Thti'ty-da~'.· inspections sna!i noHle requir-et1, and rnaintenar~ce shall be t1flc\.ve!J to be 011,::e every triree yea ts for dty-chenical· or hal·o9e1:ated agent portable fo·c extinguishers tnat are supervisecl by Zi irsted and approved ~le dronic t)i<.:mitoring ct~vice. provided t':at al~ d the foilo~••Mlg crJ1,ditmt1~ are rnet 2 .i. Eli:ctroni,c.ml)nltorlng shall confrrm thiJt ~xtingu~shers are propt'!r~y p(1sitmn€d, prop€rly cnar9ed an·d un'obstrwcted. 2.:f Lns.s·ot pc,wer or circuit contimiity to thi::, electron[( mo·rnrnr;ng device shall [nit1ate a troub~e Silft~}al. 2 3 Tn-: ·e)<tingu1sM~rs shall be insiailed ins\a·€ of a bui!rling cir cabinet in a n(mcorromv~ erivin:inment 2 .4. Electronit _ri-idqitohn9 a:evi.:es and s.uperv;sol)' ::ircwits shal! be tested every 3 years 11-4i'~en eA~nguis.t1e(malnt~naoci:: is perfor.med: 2.5 · A written log of required ~rydrastatk. test dates for extingwshen, shall be nut1nta1ned by th~ mt~ner to verify ti1at hydrofilatit~-tests ar":'! cnnducted at th€ fi'equenr..y required tiy NFP.A 10. 3. ln.Gi'oup 1-3, p::ntat,1e fire- €x hngu~~·he~~ shat! be pennitted to be foc.ated at staH l•J•:.atwns' Rei:t:ird revie~v of .the "Deintrtment af Sodol And Health s~rvic1;.s" document, Cornpletli}f! date L 05/0Bl2024, sho\.-i.•ed ''.As ·a res.ult or Hie on-site visit{$} t~ie depmtment found th;:it . Statement of Deficiencies License #: 2497 Compliance Determination # 43731 Plan of Correction Brookdale Olympia West Completion Date Administrator (or Representative) Date WAC 388-78A-2040 Other requirements. (1) The assisted living facility must comply with all other applicable federal, state, county and municipal statutes, rules, codes and ordinances, including without limitations those that prohibit discrimination. This requirement was not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that all fire extinguishers had service tags that showed when they were serviced and checked and failed to ensure that all fire extinguishers were serviced yearly for 1 of 1 facility reviewed. These failures placed all 42 of 42 residents, staff, and visitors at risk of harm during a fire. Findings included… State Fire Marshall regulation code IFC 906.2 2015,2018 “Portable fire extinguishers shall be selected, installed, and maintained in accordance with this section and NFPA 10. Exceptions: 1. The distance of travel to reach an extinguisher shall not apply the travel distance to reach an extinguisher shall not apply to the spectator seating portions of Group A-5 occupancies. 2. Thirty-day inspections shall not be required, and maintenance shall be allowed to be once every three years for dry-chemical or halogenated agent portable fire extinguishers that are supervised by a listed and approved electronic monitoring device, provided that all of the following conditions are met: 2.1. Electronic monitoring shall confirm that extinguishers are properly positioned, properly charged and unobstructed. 2.2. Loss of power or circuit continuity to the electronic monitoring device shall initiate a trouble signal. 2.3. The extinguishers shall be installed inside of a building or cabinet in a noncorrosive environment. 2.4. Electronic monitoring devices and supervisory circuits shall be tested every 3 years when extinguisher maintenance is performed. 2.5. A written log of required hydrostatic test dates for extinguishers shall be maintained by the owner to verify that hydrostatic tests are conducted at the frequency required by NFPA10. 3. In Group 1-3, portable fire extinguishers shall be permitted to be located at staff locations." Record review of the “Department of Social And Health Services” document, Completion date 05/09/2024, showed “As a result of the on-site visit(s) the department found that . Statement of Deficiencies License #: 2497 Compliance Determination # 43731 Plan of Correction Brookdale Olympia West Completion Date you are not in compliance with the licensing laws and regulations [including WAC 388-78A-2040] 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.” The administrator section showed Staff A, Executive Director, signed the document on 05/22/2024. Staff A signed the “Plan/Attestation Statement” for all citations cited that read “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, [the facility] is or will be in compliance with this law and/or regulation on 06/21/2024.” In an observation on 07/08/2024 at 9:59 AM, the fire extinguisher on the wall by the Clare country kitchen dining room noted the tag showed it was last serviced in May 2024. There was no monthly check completed for June 2024 documented for review. In an observation on 07/08/2024 at 10:00 AM, the fire extinguisher on the wall by “E” court by the shower room door, the tag showed the fire extinguisher was last serviced in May 2024. There was no monthly check completed for June 2024 documented for review. In an observation on 07/08/2024 at 10:03 AM, the fire extinguisher on the wall by the “F” court by the shower room door, the tag showed it was last serviced in May 2024. There was no monthly check completed for June 2024 documented for review. In an observation on 07/08/2024 at 10:04 AM, the fire extinguisher on the wall by the “D” court by the laundry room door, the tag showed it was last serviced in May 2024. There was no monthly check completed for June 2024 documented. In an observation on 07/08/2024 at 10:12 AM, the fire extinguisher on the wall by the Townsquare public bathroom, the tag showed it was last serviced in May 2024. There was no monthly check completed for June 2024 documented for review. In an observation on 07/08/2024 at 10:14 AM, the fire extinguisher on the wall by the “A” court, there were two metal rings but no tags that hung from the fire extinguisher. There were no tags observed to verify when the fire extinguisher was last services and if monthly checks were completed for review. In an observation on 07/08/2024 at 10:16 AM, the fire extinguisher on the wall by the “B” court, the tag showed it was last serviced in May 2024. There was no monthly check completed for June 2024 documented for review.

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

Findings included… Record review of the “Department of Social And Health Services” document, Completion date 12/14/2023, showed “As a result of the on-site visit(s) the department found that you are not in compliance with the licensing laws and regulations [including WAC 388-78A-2320] 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.” The administrator section showed Staff A, Executive Director, signed the document on 12/21/2023. Staff A signed the “Plan/Attestation Statement” for all citations cited that read “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, [the facility] is or will be in compliance with this law and/or regulation on 01/28/2024.” Record review of the Washington State (WA) Department of Social and Health Services document titled, “Community Nurse Delegation Orientation 2024”, undated, showed it was mandatory for delegation to a long term care worker that the Registered Nurse (RN) must ensure the long term care worker was currently a registered or certified as a nursing assistant or home care aide in WA state without restrictions, they completed the nurse . Statement of Deficiencies License #: 2497 Compliance Determination # 36297 Plan of Correction Brookdale Olympia West Completion Date delegation for caregiver’s core training, and if they were to administer insulin, the special focus on diabetes training was completed. The RN’s evaluations of all residents that required RN delegated tasks were on-going and must be completed at least every 90 days. The residents would have an updated assessment. The resident’s goals and outcomes were reviewed if met or not. The delegated long term care workers were supervised and evaluated for each assigned nurse delegated task for each resident. The RN delegator would document the assessment, evaluation, and the competency on the nursing visit form for each resident. For a resident to have medication assistance in place, the resident must functionally be able to get the medication where it needs to go and be cognitively aware they received mediations that does not include the name of the medications or intended side effects. Record review of the facility policy, titled, “Nurse Delegation Policy”, dated 01/2023, showed “Before performing any delegated task, the RN must: a. Verify that the nursing assistant or home care aid is currently registered in Washington state without restriction; b. Verify that the nursing assistant or home care aide has completed both basic caregiver training and core delegation training before performing any delegated task; c. Verify that the nursing assistant or home care aid has evidence as required by the department of social and health services of successful completion of nurse delegation core training; and nurse delegation special focus on diabetes training when providing insulin injections to a diabetic client… Delegation may only be done through written instructions to the nursing assistant or home care aide with a copy maintained in the resident record… Nursing assistants or home care aids: a. must show the certificate of completion of both the basic caregiver training and core delegation training (this can be obtained from any approved trainer) to the registered nurse delegator. b. Who may be completing insulin injections, must give a certificate of completion of diabetic training from the department of social and health services to the registered nurse delegator.” Delegation may only be done through written instructions to the nursing assistance or home care aide with a copy maintained in the resident’s record that included the nursing task (s), rationale for the nursing task, nature of the condition requiring the treatment and the purpose of the delegated nursing task, clear description of the procedure or steps to follow to perform the task, predictable outcomes of the nursing tasks, risks of the treatment, interactions of prescribed medications, and how, what, and when to report possible side effects. The RN delegator must evaluation the resident’s responses to the delegated nursing care, supervises and evaluates the performance of the delegated medication technicians, and with any insulin injection supervision shall occur at least every 90 days. Review of the documentation of the delegation process has to be completed at least every 90 days or with a change of condition. Staff Credentials Record review on 02/02/2024 of the RN Delegation binder showed there were no credential and training verification, Washington state Department of Health (DOH) credentials, nurse delegation certificate, or diabetes specialty delegation certificate for Staff A, Executive Director; Staff F, Medication Technician; Staff G, Medication Technician; and Staff H, Medication Technician for review. In the binder for Staff E, Medication Technician, there was a credential and training verification form that had only Staff E’s name and no other information documented for review. Staff E’s WA DOH credential verification, dated 12/04/2023, showed Staff E had a Nursing Assistance Registration credential that expired on 03/26/2019. 4 of 6 staff (Staff H, Staff F, Staff G, and Staff E) listed medication technicians on the facility provided employee list were unqualified and did not have all the required credentials, verifications, and training, and required . Statement of Deficiencies License #: 2497 Compliance Determination # 36297 Plan of Correction Brookdale Olympia West Completion Date certifications. Record review of facility provided documents on 02/05/2024 at 1:00 PM, showed Staff D’s credentials and training verification was completed on 02/03/2024. Staff D did not have a certification for their WA home care aide core basic training for review. Review of Staff F’s credentials and training verification form showed it was completed on 02/02/2024. Staff F’s WA DOH credential verification and certificates for nurse delegation core and diabetes were not provided for review. Record review on 02/22/2024 of the DOH healthcare provider credential website, showed Staff H’s Nursing Assistant Registration verification, had expired on 03/08/2022. Record review of the facility’s safety plan sent to the department on 02/02/2024 at 5:50 PM, titled, “Safety Plan – Brookdale Olympia West 02/02/2024 RE: Safety plan re: med tech coverage,” dated 02/02/2024, showed “The community execs to maintain safe and appropriate medication distribution by using Med Tech’s and Licensed Nurse.” Record review of the facility’s safety plan sent to the Department on 02/16/2024 at 5:23 PM, titled, “Clinical Schedule”, dated 02/16/2024 through 02/23/2024, showed the facility was coordinating with staffing agency to have caregivers and licensed nurses (in lieu of medication technicians) staff to fill the shifts they did not have staff to work. There were 38 shifts that were either filled by agency staff and were needing to be filled by agency staff on the schedule for day, evening, and night shift. Resident Records R1 Record review of R1’s Admission Record, dated 09/13/2023, showed R1 moved into the facility on /2021 with multiple diagnoses that included ( ). Record review of R1’s Personal Service Plan (facility’s version of negotiated service agreement and nursing assessment together), dated 11/21/2023, showed R1 required a licensed nurse or delegated medication technician was to check R1’s blood sugar and administer R1’s insulin injection once in the morning and once in the evening. R1 was not always aware of current time. Record review of R8’s Nurse Delegation: Nursing Visit form, dated 10/30/2024, showed R1 required nurse delegation for medication administration, insulin administration and blood sugar checks related to R1’s dementia. Review of the section titled, “long-term care worker (LTCW) Training/Competency”, showed Staff A, Staff D, Staff E, Staff F, Staff G, and Staff H were not listed to have been reviewed, trained, and observed and approved to administer R1’s RN delegated tasks. There were no other nursing visit forms in the RN delegation binder for review that R1 was evaluated at 90 days. Review of R1’s Nurse Delegation: Instructions for Nursing Task form, dated 10/30/2023, showed R1 was delegated for all oral (in the mouth) medication administrations. Record review of R1’s Medication Administration Record (MAR), dated 01/01/2024 through 01/31/2024, showed Staff F had administered R1’s oral medications 1 of 4 days from the attestation date of 01/28/2024. Staff E checked R1’s blood sugar and administered R1’s . Statement of Deficiencies License #: 2497 Compliance Determination # 36297 Plan of Correction Brookdale Olympia West Completion Date insulin injection and oral medications 1 of four days. --- STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEAL TH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 800 NE 136th Ave Ste 200, Vancouver, WA 98684 BKD Clare Bridge of Olympia LLC Brookdale Olympia West 420 YAUGER WAY SW OLYMPIA, WA 985028660 RE: Brookdale Olympia West License# 2497 Dear Administrator: This letter addresses Compliance Determination(s) 41428 (Completion Date 05/17/2024) and 37855 (Completion Date 03/26/2024). The Department completed a follow-up inspection of your Assisted Living Facility on 05/17/2024 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-2160, WAC 388-78A-2371, WAC 388-78A-2371-1, WAC 388-78A-2371-3, WAC 388-78A-2371-4 The Department staff who did the on-site verification: Anissa Bearden, Licensor If you have any questions, please contact me at (253)254-3190. Sincerely, Cory Cisneros, Field Manager Region 3, Unit E . . . . . . .

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 September 5, 2024 ELECTRONIC-FACSIMILE Administrator Brookdale Olympia West 420 Yauger Way SW Olympia, WA 98502-8660 Assisted Living Facility License # 2497 Licensee: BKD Clare Bridge of Olympia LLC IMPOSITION OF CIVIL FINES Dear Administrator: On August 23, 2024, the Department of Social and Health Services (DSHS), Residential Care Services completed a follow-up visit at your facility. This letter constitutes formal notice of civil fines on the license for your assisted living facility, also known as Brookdale Olympia West, located at 420 Yauger Way SW, Olympia, 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 fines on the license are based on the following violation of the RCW and/or WAC as described in the attached Statement of Deficiencies (SOD) report dated August 23, 2024. Civil Fines WAC 388-78A-2950(5)(6) Water supply. $200.00 The licensee failed to ensure water temperatures met requirements for one facility reviewed. This failure placed 40 residents at risk for decreased quality of life. This is an uncorrected deficiency previously cited on June 26, 2024. WAC 388-78A-2600(1)(d) Policies and procedures. $200.00 The licensee facility failed to ensure their water temperature policy was in compliance with State law for one facility reviewed. This failure placed 40 residents at risk of exposure to unsafe or uncomfortable water temperatures Administrator Brookdale Olympia West License # 2497 September 5, 2024 Page 2 and decreased quality of life. This is an uncorrected deficiency previously cited on June 26, 2024. NOTE: These are the violations, which resulted in the fines; see the attached Statement of Deficiencies for any additional violations. 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. Administrator Brookdale Olympia West License # 2497 September 5, 2024 Page 3 Send your written request to: Informal Dispute Resolution Program Manager Residential Care Services PO Box 45600 Olympia, Washington 98504-5600 Formal Administrative Hearing You may contest the civil fines by requesting a formal administrative hearing to challenge the deficiency, which resulted in the civil fines. 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 fines are due to the Office of Financial Recovery twenty-eight (28) calendar days after receipt of this letter. Mail a check for $400.00 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 Olympia West License # 2497 September 5, 2024 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

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written . N/A . Investigation Summary Report Provider/Facility: Brookdale Olympia West Provider Type: Assisted Living Facility License/Cert.#: 2497 Compliance Determination #: 28044 Intake ID: 92694 Investigator: Paul Aube Region/Unit #: RCS Region 3 / Unit E Investigation Date(s): 08/14/2023 through 08/14/2023 Complainant Contact Date(s): Allegation(s): Quality of Care/Treatment: Facility report of a resident fall with injury in the community. Investigation Methods: Sample: Total residents: 56 Resident sample size: 4 Closed records sample size: 0 Observations: Residents Activities Dining Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Nursing staff Family members Management Record Reviews: Hospital records Incident investigation Facility policies Progress Notes Care Plans Investigation Summary: Quality of Care/Treatment: Facility failed to complete an incident report at the time of the incident as per policy. This resulted in family not being notified timely, and delay of resident care. Failed practice identified. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written . N/A . Investigation Summary Report Provider/Facility: Brookdale Olympia West Provider Type: Assisted Living Facility License/Cert.#: 2497 Compliance Determination #: 28044 Intake ID: 92657 Investigator: Paul Aube Region/Unit #: RCS Region 3 / Unit E Investigation Date(s): 08/14/2023 through 08/14/2023 Complainant Contact Date(s): Allegation(s): Quality of Care/Treatment: Facility report of a resident-to-resident altercation in the community. Investigation Methods: Sample: Total residents: 56 Resident sample size: 4 Closed records sample size: 0 Observations: Residents Activities Dining Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Nursing staff Family members Management Record Reviews: Hospital records Incident investigation Facility policies Progress Notes Care Plans Investigation Summary: Quality of Care/Treatment: Facility failed to notify the Complaint Resolution Unit timely, after an incident occurred as per their policy. This issue was investigated. Please see Statement Of Deficiency dated 08/14/2023. 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 . . . . . . . .