Brookdale Puyallup South.

Statement of Deficiencies License #: 1702 Compliance Determination #60521. Plan of Correction Brookdale Puyallup South Completion Date Paget of3 Licensee: BROOKDALE SENIOR LIVING COMMUNITIES INC 06/10/2025 You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility ficense. The department completed data collection for the unannounced on-site full inspection on 06/03/2025 and 06/09/2025 of: Brookdale Puyallup South 8811 176TH ST EAST PUYALLUP, WA 98375 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: Cathleen Davis, ALF Licensor Melisa Moran, Assisted Living Facility Nursing Consultant Institutional From: DSHS, Aging and Long-Term Support Administration Lakewood, WA 98496 ‘BUSGAaM JOJEIO] BY} JO} SAdIAJaS aseD jelWUapIsay Aq pasedaid sem yUaWINIOp sSIYyL wv Wo.12, L005 15:96:02 State Or Washington Statement of Deficiencies License #1702 = Compliance Determination # 60521 Plan of Correction Brookdale Puyallup South Completion Date Page2 of3 Licensee; BROOKDALE SENIOR LIVING COMMUNITIES INC 06/10/2025 As aresult 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. | understand that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. Administrator (or Representative) WAC 388-78A-2466 Background checks Washington state name and date of birth background check Valid fortwo years National fingerprint background check Valid indefinitely. (1) A Washington state name and date of birth background check is valid for two years from the 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 ({b) There is a valid Washington state name and date of birth background check for all administrators, caregivers, staff persons, volunteers and students. This requirement was not met as evidenced by: Based on record reviews and interview the Assisted Living Facility (ALF) failed to ensure a Washington state name and date of birth background check (BGC) was completed every two years for 1 of 6 sampled staff (Staff F). This failure placed 42 of 42 residents at risk of having care and services provided by staff with a potential disqualifying crime. Findings included... Review of personnel records revealed Staff F, Care Partner, Home Care Aide (HCA), was hired on 08/08/2017. A Washington state name and date of birth background check (BGC) was completed on 02/22/2023 and found in the personnel file. There was no record of the Washington state name and date of birth background check (BGC) required every two years and due 02/22/2025 in the personnel file. On 06/05/2025 at 10:15 am during an interview, Staff A, Executive Director, stated that Staff F had a national fingerprint background check completed on 07/27/2023 and she ‘BUSGAaM JOJEIO] BY} JO} SAdIAJaS aseD jelWUapIsay Aq pasedaid sem yUaWINIOp sSIYyL b/ 6.12.4020 1S4f BL State OF WaSNINYTON Statement of Deficiencies License #. 1702 Compliance Determination # 60521 Plan of Correction Brookdale Puyallup South Completion Date Page3 of3 Licensee: BROOKDALE SENIOR LIVING COMMUNITIES INC 06/10/2025 believed that the Washington state name and date of birth background check (BGC) that was completed on 02/22/2023 was not due until 07/27/2025. Pian/Attestation Statement i hereby certify that | have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Brookdale Puyallup South is or will be in compliance with this law and / or regulation on (Date) \ Q- | q : an . In addition, | will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representatives Yn thi Vygere Date (e 1G OS ‘BUSGAaM JOJEIO] BY} JO} SAdIAJaS aseD jelWUapIsay Aq pasedaid sem yUaWINIOp sSIYyL tt

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