Brookdale Vancouver Stonebridge.

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.

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 Vancouver Provider Type: Assisted Living Facility Stonebridge License/Cert.#: 2308 Intake ID: 143464 Compliance Determination #: 46833 Region/Unit #: RCS Region 3 / Unit I Investigator: Michael Burdick Investigation Date(s): 09/09/2024 through 09/12/2024 Complainant Contact Date(s): Allegation(s): 1. Quality of care/Treatment. Resident to resident altercation. Investigation Methods: Sample: Total residents: 68 Resident sample size: 4 Closed records sample size: 1 Observations: Identified resident Residents Staff to resident interactions Resident to resident interactions Medication administration Interviews: Nursing staff Family members Administrator Record Reviews: Medical records State reporting log Incident investigation Facility policies Investigation Summary: 1. Quality of care/Treatment. Facility investigated but failed to notify state of incident for 13 days. Failed practice. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . . . .

allegations and incidents identified in the intake. Based on interviews, observations, and records review, failed facility practice when resident was given a hot beverage that spilled causing a skin burn was substantiated during the investigation. 2. Resident/Patient/ Client Assessment: The on-site investigation was conducted in relation to all allegations and incidents identified in the intake. Based on interviews, . observations, and records review, failed facility practice in monitoring resident who was given a hot beverage that spilled causing a skin burn was substantiated during the investigation. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Statement of Deficiencies License #: 2308 Compliance Determination # 34053 Plan of Correction Brookdale Vancouver Stonebridge Completion Date Administrator (or Representative) Date WAC 388-78A-2170 Required assisted living facility services. (1) The assisted living facility must provide housing and assume general responsibility for the safety and well-being of each resident, as defined in this chapter, consistent with the resident's assessed needs and negotiated service agreement. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to provide for the safety and well-being for 1 of 4 sampled residents (Resident 1/R1) reviewed for injury related to hot beverage service. The failure to implement preventative measures as recorded in the resident’s negotiated services plan, resulted in a burn to R1. Findings included… Record review of a facility policy, titled “SAFETY OF HOT LIQUIDS”, dated 09/2020 showed “Appropriate interventions could be implemented to minimize the risk from burns. Such interventions may include but not limited to: Maintaining a hot liquid serving temperature of not more than 155 degrees Fahrenheit.” Record review of R1’s Personal Service Assessment and R1’s Personal Service plan both dated, 10/25/2023, documented that caregivers will provide direct staff attention to R1 while eating and will provide direct physical assistance to R1 while eating. Record review of R1’s Alert Charting Note dated 12/09/2023 documented R1 was given hot chocolate for dinner, the hot chocolate spilled on R1’s right inner thigh causing a large red mark. On 12/10/2023 R1’s Alert Charting note documented a large red mark on R1’s inner thigh had turned into a blister that had been broken open. Record review of R1’s Resident Log notes dated December 9; Staff C Caregiver documented R1 was given hot chocolate. The notes stated Staff C left R1 unattended to go serve other residents. When they returned to check on R1 they noted R1 had spilled their hot chocolate on their lap. In an interview on 12/19/2023 at 11:32AM, Staff B, Dining Service Manager, reported a hot water dispenser temperature of 164 degrees Fahrenheit as not safe to leave the kitchen and that the liquid needed to be cooled to between 140- and 135-degrees Fahrenheit to leave the kitchen for residents’ consumption. Staff B stated that caregivers were not trained to cool hot liquids prior to R1 getting their skin burned from spilled hot chocolate. Staff B admitted that Staff C did not cool the hot water resulting in a harm of R1 after they sustaining a skin burn from a hot chocolate. In an interview on 12/19/2023 at 2:45PM, Staff D, Caregiver, reported they worked the evening shift with Staff C who was assigned to dining room duties. They reported Staff C gave R1 hot chocolate and walked away to serve other residents. When they returned to R1 . Statement of Deficiencies License #: 2308 Compliance Determination # 34053 Plan of Correction Brookdale Vancouver Stonebridge Completion Date they noted R1 had spilled the hot chocolate on their lap. R1 was taken back to their apartment. The skin assessment showed redness to right inner thigh. In an interview on 01/16/2023 at 1:23 PM, Staff A, Executive Director, stated that Staff C took the hot water directly from the hot water dispenser and did not check the temperature. Staff A stated that Staff C should have checked the temperature of the hot water and placed a lid on the cup prior to giving the hot beverage to R1 for consumption. 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 Vancouver Stonebridge is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date .

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 August 28, 2023 ELECTRONIC-FACSIMILE Administrator Brookdale Vancouver Stonebridge 7900 NE Vancouver Mall Dr Vancouver, WA 98662 Assisted Living Facility License #2308 Licensee: Emeritus Corporation IMPOSITION OF CIVIL FINE Dear Administrator: On August 16, 2023, 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 a civil fine on the license for your assisted living facility, also known as Brookdale Vancouver Stonebridge, located at 7900 NE Vancouver Mall Dr, Vancouver, 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 August 16, 2023. Civil Fine WAC 388-78A-2320(1)(a)(b)(2)(a)(b) Intermittent nursing services systems. $300.00 The licensee failed to ensure a registered nurse (RN) had delegated nursing tasks as required when five medication technicians administered insulin injections to one resident prior to being delegated and were not supervised and evaluated at least weekly for the first four weeks for insulin administration. This failure placed residents at risk for harm and injury due to untrained and unsupervised care staff. This is an uncorrected deficiency previously cited on June 12, 2023. NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Administrator Brookdale Vancouver Stonebridge License #2308 August 28, 203 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: Michael Burdick, Field Manager Region 3, Unit I 800 NE 136th Ave Suite 220 Vancouver, WA 98684 Phone: (360) 450-1218/ Fax: (360) 992-7969 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. Send your written request to: Informal Dispute Resolution Program Manager Residential Care Services PO Box 45600 Olympia, Washington 98504-5600 Administrator Brookdale Vancouver Stonebridge License #2308 August 28, 203 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 $300.00 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, Washington 98507-9501 1-800-562-6114 (extension 45919) 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 Vancouver Stonebridge License #2308 August 28, 203 Page 4 If you have any questions, please contact Michael Burdick, Field Manager, at (360) 450-1218. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 3, Unit I 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