The Gardens at Town Square.

This document was prepared by Residential Care Services for the Locator website. STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALT H SERVICES HOME AND COMMUNITY LIVING ADMINISTRATION 20425 72nd Avenue S, Suite 400, Kent, WA 98032 BELLEVUE GARDENS MANAGER LLC THEGARDENSATTOWNSQUARE 933 111th Ave NE Bellevue, WA 98004 RE: THE GARDENS AT TOWN SQUARE License# 1604 Dear Administrator: This letter addresses Compliance Determination(s) 75364 (Completion Date 04/03/2026) and 71226 (Completion Date 02/03/2026). The Department completed a follow-up inspection of your Assisted Living Facility on 04/03/2026 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-2240 The Department staff who did the on-site verification: Deborah Carlis, Complaint Investigator If you have any questions, please contact me at (206)305-3489. Sincerely, James Sherman, Field Manager Region 2, Unit D Residential Care Services Residential Care Services Investigation Summary Report Provider/Facility: THE GARDENS AT TOWN Provider Type: Assisted Living Facility SQUARE License/Cert.#: 1604 Intake ID: 206804 Compliance Determination #: 71226 Region/Unit #: RCS Region 2 / Unit D Investigator: Deborah Corlis Investigation Date(s): 01/09/2026 through 02/03/2026 Complainant Contact Date(s): 02/03/2026 Allegation(s): Delayed medication orders and administration of eye drops for named resident. Investigation Methods: Sample: Total residents: 43 Resident sample size: 3 Closed records sample size: 0 Observations: Facility environment, common areas, residents engaged in playing cards, resident and staff interactions, residents conversing with each other in the lobby area. Interviews: Reporter, Executive Director, Health Services Director, Resident Assistant, Licensed Practical Nurse, Named Resident (NR), sample resident, family contact/Power of Attorney. Record Reviews: Characteristic Roster, face sheets, individual service plans, electronic medication administration records, progress notes, physician communication/faxes, Abuse and Neglect Policy, Medication Policy and Procedures, Medication Not Available Policy. Investigation Summary: Facility failed practice identified. The Assisted Living Facility failed to obtain prescription medication in a timely manner, causing delayed eye drop administration for the named resident. 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 Uashington 02.05.2026 09:14:39 STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEAL TH SERVICES HOME AND COMMUNITY LIVING ADMINISTRATION 20425 72nd Avenue S, Suite 400, Kent, WA 98032 Statement of Deficiencies License#: 1604 Compliance Determination# 71226 Plan of Correction THE GARDENS AT TOWN SQUARE Completion Date Page 1 of 3 Licensee: BELLEVUE GARDENS MANAGER LLC 02/03/2026 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 01/09/2026 of: THE GARDENS AT TOWN SQUARE 933111TH AVE NE BELLEVUE, WA 98004 This document references the following complaint number(s): 206804 The following sample was selected for review during the unannounced on-site visit: 3 of 43 current residents and O former residents. The department staff that investigated the Assisted Living Facility: Deborah Carlis, Complaint Investigator From: DSHS, Home and Community Living Administration Residential Care Services, Region 2 , Unit D 20425 72nd Avenue S, Suite 400 Kent, WA 98032 This document was prepared by Residential Care Services for the Locator website. State of l-lashington 6/10 02.05.2026 09:14:39 Statement of Deficiencies License#: 1604 Compliance Determination# 71226 Plan of Correction THE GARDENS AT TOWN SQUARE Completion Date Page 2 of 3 Licensee: BELLEVUE GARDENS MANAGER LLC 02/03/2026 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. 02-05-2026 Residential Care Services 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. Mz_ WAC 388-78A-2240 Nonavailability of medications. When the assisted living facility has assumed responsibility for obtaining a resident's prescribed medications 1 the assisted living facility must obtain them in a correct and timely manner. This requirement was not met as evidenced by: This requirement was not met evidenced by: Based on interviews and record reviews, the Assisted Living Facility (ALF) failed to obtain prescribed medication in a timely manner for 1 of 3 sample residents (Resident 1). This failure resulted in Resident 1 not receiving timely prescribed eye drops and placed them at risk for medical complications. Findings included ... Review of ALF's policy titled "If Medications Are Not Available" dated 04/02/2013 showed staff will contact preferred providers and the pharmacy to ensure availability of all prescribed medications when the ALF has assumed responsibility for medication management. Review of Resident 1' s Face Sheet showed the resident was admitted on /2025 with a . diagnosis of Review of Resident 1' s service plan dated 11/10/2025 showed the ALF staff assisted with ordering medications and provided assistance with eye drop administration. This document was prepared by Residential Care Services for the Locator website. State of Washington f/lH 02.05.2026 09:14:39 Statement of Deficiencies License#: 1604 Compliance Determination# 71226 Plan of Correction THE GARDENS AT TOWN SQUARE Completion Date Page 3 of 3 Licensee: BELLEVUE GARDENS MANAGER LLC 02/03/2026 Review of Resident 1' s Medication Administration Record (MAR) showed staff administered two separate eye drops, prescribed by the resident's Primary Care Physician after admission .on 11/15/2025. In interview on 01/13/2026 at 3:25 PM collateral contact 1 stated the facility staff removed the [compound] eye drop medication from Resident 1's apartment around 12/15/2025. The compound eye drop medication was prescribed by resident's eye doctor. Review of a fax dated 12/19/2025 showed that the facility faxed the eye doctor (specialist) for eye drop compound orders and clarification of orders. The facility received discontinuation orders for the two eye drops and received new orders for the compound eye drops via fax on 12/30/2025. Review of Resident 1' s MAR dated January 2026 showed Resident 1 received the eye drop compound, two times daily, beginning 01/05/2026. On 01/09/2026 at 10:05 AM, Staff A Health Services Director stated that they were aware of the conflicting eye drop orders and had sent faxes to the prescriber for clarification. 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, THE GARDENS AT TOWN SQUAR~ is f.r5 w i}I / be in compliance with this law and/ or regulation on a J,.oa..i, (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 March 11, 2025 ELECTRONIC-FACSIMILE Administrator THE GARDENS AT TOWN SQUARE 933 111th Ave NE Bellevue, WA 98004 Assisted Living Facility License # 1604 Licensee: BELLEVUE GARDENS MANAGER LLC IMPOSITION OF CIVIL FINE Dear Administrator: On February 26, 2025, 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 THE GARDENS AT TOWN SQUARE, located at 933 111th Ave NE, Bellevue, 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 February 26, 2025. Civil Fine WAC 246-980-030 (2) Working while obtaining certification as a $300.00 home care aide. WAC 388-112A-0090 (4) Which long-term care workers are exempt from the 70-hour long-term care worker basic training requirement? WAC 388-78A-2450 (2)(e)(3)(d)(i)(A)(B) Staff. The licensee failed to ensure that one staff was qualified to work with vulnerable adult residents. This failure placed all 38 residents at risk for receiving care from an unqualified staff. This is an uncorrected deficiency previously cited on January 16, 2025, for WAC 388- 78A-2450 subsections (2)(e)(3)(d)(i)(A)(B). Administrator THE GARDENS AT TOWN SQUARE License # 1604 March 11, 2025 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: Laurie Anderson, Field Manager Region 2, Unit D 20425 72nd Ave S suite 400 Kent, WA 98032-2388 Phone: (253)234-6020 / Fax: (253) 395-5071 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 THE GARDENS AT TOWN SQUARE License # 1604 March 11, 2025 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, 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 THE GARDENS AT TOWN SQUARE License # 1604 March 11, 2025 Page 4 If you have any questions, please contact Laurie Anderson, Field Manager, at (253) 234-6020. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 2, Unit D 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

—: WA DSHS report: Inspections (01/2025)