Brookdale Nine Mile.

Statement of Deficiencies License #: 1698 Compliance Determination # 56318 Plan of Correction Brookdale Nine Mile 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 the unannounced on-site full inspection on 03/10/2025, 03/11/2025, 03/12/2025 and 03/13/2025 of: Brookdale Nine Mile 5329 WEST RIFLE CLUB COURT SPOKANE, WA 99208 The following sample was selected for review during the unannounced on-site visit: 10 of 44 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Brian Zbylski, ALF Licensor Patricia Eddy, Community Licensor Carla Rose, NCI Community Licensor From: DSHS, Aging and Long-Term Support Administration 8517 E Trent Ave, Ste 102 Spokane Valley, WA 99212 . Statement of Deficiencies License #: 1698 Compliance Determination # 56318 Plan of Correction Brookdale Nine Mile Completion Date assistance with their medications. Review of Resident 4’s February 2025 and March 2025 medication administration records (MARs) showed a health care provider order for losartan (medication used to lower blood pressure) to be given daily and to hold (not give) the medication when the resident's SBP (systolic blood pressure, top number of blood pressure) was less than 110. Documentation showed the medication was administered when it should have been held on the following dates: -02/08/2025, SBP 109 -02/09/2025, SBP 107 -03/02/2025, SBP 108 <Resident 5> Review of Resident 5’s PSP, dated 02/12/2025, showed the resident was diagnosed with and , and required facility staff assistance with their medications. Review of Resident 5’s March 2025 MAR showed the resident had a health care provider order for amlodipine (used to treat high blood pressure) to be given daily with instructions to hold the medication when the resident's blood pressure was less than 120/50. Further review showed on 3/05/2025, Resident 5’s medication was not given and their blood pressure was not documented. In an interview on 3/11/2025 at 11:30 AM, Staff L, Licensed Practical Nurse, stated the resident’s blood pressure was not recorded. <Resident 8> Review of Resident 8’s PSP, dated 01/16/2025, showed the resident was diagnosed with and , and required facility staff assistance with their medications. Review of Resident 8’s January 2025 MAR showed the resident had a health care provider order for carvedilol (used to treat high blood pressure and can slow down heart rate) to be given twice daily. Further review showed that the medication was not to be given if the resident's SBP was less than 100/60 or the heart rate (HR) was less than 55. The MAR showed that the medication was not given on the following dates (when the SBP and HR were within parameters), with documentation stating vital signs were outside of parameters: -01/30/2025, 109/65- HR 59 . Statement of Deficiencies License #: 1698 Compliance Determination # 56318 Plan of Correction Brookdale Nine Mile Completion Date -02/10/2025, 102/65 - HR 57 Review of Resident 8’s February 2025 MAR showed the resident had a health care provider order for losartan/hydrochlorothiazide (used to treat high blood pressure and can slow heart rate) to be given once daily. Further review showed that the medication was not to be given if the resident's SBP was less than 100/60 or the HR was less than 55. The MAR showed that the medication was not given on the following date (when the SBP and HR were within parameters), with documentation stating vital signs were outside of parameters: -02/10/2025, 102/65 - HR 57 <Resident 9> Review of Resident 9’s PSP, dated 01/02/2025, showed the resident was diagnosed with and required facility staff assistance with their medications. Review of Resident 9’s January 2025 MAR showed the resident had a health care provider order for amlodipine to be given daily. Further review showed the medication was to be held when the heart rate (HR) was below 60. Documentation showed the medication was administered when it should have been held on the following date: -01/01/2025, HR 53 <Resident 10> Review of Resident 10’s PSP, dated 10/09/2024, showed they had a diagnosis of and that they required facility staff assistance with their medications. Review of Resident 10’s January 2025, February 2025, and March 2025 MARs showed the resident had a health care provider order for carvedilol to be given twice daily. Further review showed the medication was to be held when the SBP was less than 100 or the HR was less than 60. Documentation showed the medication was administered when it should have been held on the following dates: 01/06/2025, HR 59 01/12/2025, HR 51 01/14/2025, HR 58 02/26/2025, HR 58 02/27/2025, HR 54 03/10/2025, HR 55 . Statement of Deficiencies License #: 1698 Compliance Determination # 56318 Plan of Correction Brookdale Nine Mile Completion Date These failures resulted in Resident 1 not being monitored for further injury after multiple falls, Resident 4 not being evaluated for health complications from blood sugar levels outside of ordered parameters, and placed the residents at risk for health complications. Findings included... <Resident 1> Review of Resident 1’s Personal Service Plan (PSP, the facility’s titled combined assessment and negotiated service agreement), dated 10/17/2024, showed that staff were to be alert for heightened risk of falling. In an interview on 03/11/2025 at 9:38 AM, Resident 1 stated they had fallen recently. Observation at that time showed Resident 1 pulled up their shirt sleeve revealing two long, narrow, reddish/purple bruises on the underside of their forearm. Review of Resident 1’s Temporary Service Plans (TSP), showed that the resident had fallen on 01/21/2025, 02/18/2025, 03/03/2025 and 03/04/2025, with instructions to check the resident’s vital signs (blood pressure, heart rate and temperature) daily for three days after each fall. Review of Resident 1’s Weights and Vitals Summary for January 2025 through March 2025 showed that vital signs were not recorded for the three days following the falls. In an interview on 03/12/2025 at 12:07 PM, Staff O, Health and Wellness Director/RN, confirmed that there was no documentation to show that vital signs had been taken for three days following Resident 1’s falls. <Resident 4> Review of Resident 4’s PSP, dated 12/17/2024, showed the resident had a diagnosis of and they required facility staff assistance with their medications. Review of Resident 4’s January 2025, February 2025, and March 2025 medication administration records (MARs), showed an order for blood sugars to be checked twice a day and for the PCP (Primary Care Provider) to be contacted if the blood sugar was below 80 or above 350. Further review showed the blood sugar was out of parameters on the following days/times: . Statement of Deficiencies License #: 1698 Compliance Determination # 56318 Plan of Correction Brookdale Nine Mile Completion Date class approved as specialty training. The specialty training applies to the type of residents served by the home as follows: (b) Dementia specialty training as described in WAC 388-112A-0440 ; and (c) Mental health specialty training as described in WAC 388-112A-0450 . 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 facility failed to ensure that mental health and dementia specialty training had been completed by 1 of 7 staff (Staff D). This failure resulted in residents receiving care from an individual who had not completed their mental health and dementia training and placed residents at risk for unmet care needs. Findings included... Review of the facility’s characteristic roster, dated 03/10/2025, showed that all residents residing in the facility were categorized as having dementia (age related cognitive impairment) and two residents received mental health services. Review of personnel records for Staff D, Caregiver, showed a hire date of 10/02/2024 and that they were certified as an NAC (Nursing Assistant Certified). Further review showed that Staff D’s records did not include documentation of specialized training for mental health or dementia. In an interview on 03/12/2025 at 1:50 PM, Staff N, Business Office Coordinator, stated they were not aware that specialty training was a separate required training outside of the NAC certification training.

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 PO Box 45600, Olympia, WA 98504-5600 May 23, 2024 ELECTRONIC-FACSIMILE Administrator Brookdale Nine Mile 5329 West Rifle Club Court Spokane, WA 99208 Assisted Living Facility License # 1698 Licensee: Brookdale Senior Living Communities Inc IMPOSITION OF CIVIL FINE Dear Administrator: On May 16, 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 Nine Mile, located at 5329 West Rifle Club Court, Spokane, 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 May 16, 2024. Civil Fine WAC 388-78A-2210(1)(a)(b)(2)(a) Medication services. $1,500.00 The licensee failed to ensure a safe delivery system was in place for medication administration and failed to provide medication as ordered for one resident. This failed practice resulted in the resident not receiving their end-of-life pain and comfort medications which caused distress and difficulty breathing for the resident during the dying process and placed residents at risk of unmet medication administration. This is a recurring deficiency previously cited on March 29, 2023, for subsections (2)(a) and September 1, 2022, for subsections (1)(b) and (2)(a). Administrator Brookdale Nine Mile License # 1698 May 23, 2024 Page 2 NOTE: This is the violation, which resulted in the fine; 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: Stephanie Jenks, Field Manager Region 1, Unit B 8517 E Trent Ave, Suite 102 Spokane Valley, WA 99212-2329 Phone: (509) 993-7821/ Fax: 509-921-2426 rcsregion1email@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 Nine Mile License # 1698 May 23, 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 $1,500.00 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 Nine Mile License # 1698 May 23, 2024 Page 4 If you have any questions, please contact Stephanie Jenks, Field Manager, at (509) 993-7821. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 1, Unit B RCS Regional Administrator, Region 1 HCS Regional Administrator, Region 1 DDA Regional Administrator, Region 1 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 .

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 Nine Mile Provider Type: Assisted Living Facility License/Cert.#: 1698 Compliance Determination #: 32183 Intake ID: 103778 Investigator: Sylvia Shauvin Region/Unit #: RCS Region 1 / Unit B Investigation Date(s): 11/06/2023 through 11/29/2023 Complainant Contact Date(s): Allegation(s): 1 - A resident required cardiopulmonary resuscitation (CPR), and hospitalization Investigation Methods: Sample: Total residents: 43 Resident sample size: 5 Closed records sample size: 0 Observations: Residents' well-being Any signs of unmet residents' needs Access to staff and means to summon staff's assistance Staff's response to residents' needs/concerns Interviews: Three residents including named resident/alleged victim Resident Care Coordinator Business Office Manager Two facility caregivers Agency licensed nurse Hospice nurse Human Resources staff Administrator Record Reviews: Sample residents' Face Sheets, assessments, and care plans Sample three staff's personnel records Facility's investigation documents Policy and procedures - cardiac & pulmonary resuscitation Investigation Summary: 1 - Named resident was observed alert, and actively engaged in activities. Staff interview and review of documentation pertinent to named resident showed staff performed cardiopulmonary resuscitation (CPR) on resident, summoned emergency personnel, and had resident transported to the hospital. While hospitalized, named resident was treated was able to return to the facility. Review of sample staff's personnel files showed a caregiver did not have CPR and first aid training. Failed facility practice was found and documented in a Statement of Deficiencies under Washington Administrative Code (WAC) 388-78a-2450(2)(e)(h)(i-vii), (3)(d)(i)(A)(C)(D) . Staff. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . . . . . .

findings did not support failed facility practices related to allegation. 2 - This allegation was investigated in May 2023 at which time no failed facility practices were found. 3 - Observations of medication passes showed medication aides provided medications to current residents, as ordered. Department investigator was unable to observe medication services to named resident, as they no longer resided in the facility. Interview with named resident's representative showed they were responsible for obtaining resident's medication from the pharmacy, and they asked an acquaintance to pick up a refill. The representative stated the facility didn't immediately notify them of the need for a refill, and the representative's and acquaintance's inability to go to the pharmacy right away created an additional delay of several days. The resident, who had existing health issues, was hospitalized for treatment, and investigation findings did not show their hospitalization was the result of the medication delay. Investigation findings did not support failed facility practice/warrant citation. 4 - Per named residents' representative, the residents were missing money while in the facility. The representative stated they reported the missing money to facility Administrator and receptionist. Administrator stated facility did not make reports to the Department hot line or investigate the allegations of residents' missing money. Failed facility practices were found and documented in Statement of Deficiencies under Washington Administrative Code (WAC) 388- 78a-2630 Reporting abuse and neglect and WAC 388-78a-2371 Investigations. 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 Nine Mile Provider Type: Assisted Living Facility License/Cert.#: 1698 Compliance Determination #: 25428 Intake ID: 88859 Investigator: Sylvia Shauvin Region/Unit #: RCS Region 1 / Unit B Investigation Date(s): 06/14/2023 through 08/21/2023 Complainant Contact Date(s): Allegation(s): 1 - Resident injury 2 - Resident to resident altercation 3 - Resident aggression toward staff 4 - Facility didn't allow resident to return Investigation Methods: Sample: Total residents: 36 Resident sample size: 14 Closed records sample size: 4 Observations: Residents' safety and well-being Any injuries, signs of distress Accessibility of staff, staff's response to residents' needs Staff's response to residents' problem behaviors e.g. anxiety, agitation, aggression Interviews: Seven residents Eight resident representatives Two facility medication aides Two caregivers Health and Wellness Director Receptionist Business Office Coordinator Police detective Administrator Record Reviews: Sample residents' Face Sheets, assessments, care plans, Progress Notes, and medication administration records (MARS) Facility injury/incident investigation documents Staff schedule - June 2023 Policy and procedures - Abuse/neglect and Mandatory Reporting Disclosure of Services Residency Agreement Police Field Case Report . Investigation Summary: 1 - Staff interviews and facility investigation documents showed staff found named resident with facial injuries i.e. bruising and swelling to the eyes, bruising of the neck, and bloodied face. Per these sources, named resident's roommate told staff they hit the named resident, and the roommate assaulted a staff person the day before. Named resident was observed in the hospital with bruising to the face and neck, but was unable to say how the injuries happened. Staff and representatives of named resident stated they were concerned facility allowed roommate to share apartment with named resident, given the roommate's prior assault of staff member. Failed facility practice was found and documented in Statement of Deficiencies under Washington Administrative Code (WAC) 388-78a-2660 Resident rights; with reference to Revised Code of Washington (RCW) 70.129.130 Abuse, punishment, seclusion-Background checks. 2 - Refer to summary under Issue 1, above. Failed facility practice was found, and and documented in Statement of Deficiencies under Washington Administrative Code (WAC) 388- 78a-2660 Resident rights; with reference to Revised Code of Washington (RCW) 70.129.130 Abuse, punishment, seclusion-Background checks. 3 - Refer to summary under Issue 1, above. Failed facility practice was found, and and documented in Statement of Deficiencies under Washington Administrative Code (WAC) 388- 78a-2660 Resident rights; with reference to Revised Code of Washington (RCW) 70.129.130 Abuse, punishment, seclusion-Background checks. 4 - Per staff interviews and review of named resident's Progress Notes, the facility sent resident to the hospital for evaluation of assaultive behavior, and did not allow the resident to return because of concern for the safety of residents. Assisted living requirements allow facilities to discharge residents for this reason. No failed facility practices were found. 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 Nine Mile Provider Type: Assisted Living Facility License/Cert.#: 1698 Compliance Determination #: 25428 Intake ID: 92403 Investigator: Sylvia Shauvin Region/Unit #: RCS Region 1 / Unit B Investigation Date(s): 06/14/2023 through 08/21/2023 Complainant Contact Date(s): Allegation(s): 1 - Staff drinks and uses drugs while on duty 2 - Facility is understaffed 3 - Facility doesn't make required reports 4 - Resident hit another resident Investigation Methods: Sample: Total residents: 36 Resident sample size: 14 Closed records sample size: 4 Observations: Residents' safety and well-being Any signs of lack of care Staff's care of residents and response to residents' concerns Staff's response to residents' behavior problems, such as agitation/aggression Interviews: Seven residents Eight resident representatives Two facility medication aides Two caregivers Health and Wellness Director Receptionist Business Office Coordinator Police detective Administrator Record Reviews: Sample residents' Face Sheets, assessments, care plans, and Progress Notes Facility injury/incident investigation documents Police narrative Staff schedule - June, July, August 2023 Policy and procedures - Management of Aggression Sample staff's credentials Investigation Summary: . 1 - No observations were made of staff under the influence of drugs or alcohol while on duty. Residents and representatives interviewed had no concerns about staff being under the influence of drugs or alcohol while on duty. Reviews of sample staff's credentials showed the facility did not have records of two staff's personnel records in the facility, as required. Failed facility practice was found. The deficiency was documented in a Statement of Deficiencies (SOD) under Washington Administrative Code (WAC) 388-78a-2450 Staff. 2 - Facility was observed conducting caregiving applicant interviews. Staff was observed responding to residents' needs in a prompt manner. No signs of lack of care were observed. Although several representatives stated the facility was under-staffed, they did not identify specific adverse outcomes related to it. The investigation findings did not support failed facility practices and warrant citations. 3 - Representative and staff interviews, and review of facility's investigations and department reporting data base showed facility failed to report and investigate allegations of two sample residents' missing money. Failed facility practices were found. The deficiencies were documented in the SOD under WAC 388-78a-2371(1-4) Investigations, and WAC 388-78a- 2630(1)(a) Reporting abuse and neglect. 4 - Staff interviews and facility investigation documents showed staff found named resident with facial injuries i.e. bruising and swelling to the eyes, bruising of the neck, and bloodied face. Per these sources, named resident's roommate told staff they hit the named resident, and the roommate assaulted a staff person the day before. Named resident was observed in the hospital with bruising to the face and neck, but was unable to say how the injuries happened. Staff and representatives of named resident stated they were concerned facility allowed roommate to share apartment with named resident, given the roommate's prior assault of staff member. Failed facility practice was found and documented in Statement of Deficiencies under Washington Administrative Code (WAC) 388-78a-2660 (1)(4) Resident rights; with reference to Revised Code of Washington (RCW) 70.129.130 Abuse, punishment, seclusion-Background checks. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A .