Cedar Creek Memory Care Community.

Residential Care Services Investigation Summary Report Provider/Facility: Cedar Creek Memory Care Provider Type: Assisted Living Facility Community License/Cert.#: 2453 Intake ID: 203909 Compliance Determination #: 70653 Region/Unit #: RCS Region 2 / Unit J Investigator: Hayley Pinkham Investigation Date(s): 12/29/2025 through 01/27/2026 Complainant Contact Date(s): 01/27/2026 Allegation(s): 1) The Named Resident’s (NRs) legal representative (LR) did not receive the NRs medical records as requested in a timely manner. 2) A nurse at the ALF “bent” a needle during insulin administration and the nurse continued to provide care to the NR after the incident. 3) The NR was experiencing extremes of fluctuating blood sugar checks. The ALF nurse was using the wrong insulin dosage at bedtime, resulting in low blood sugar checks in the morning. 4) The ALF withheld the NRs requested records and the close timing between the LR’s complaint regarding the incident with the nurse administering insulin with a “bent” needle raises concern for retaliation or unsafe continuation of care. 5) The ALF repeatedly provided meals that were inappropriate for the NR. Investigation Methods: Sample: Total residents: 57 Resident sample size: 5 Closed records sample size: 1 Observations: Residents Dining Resident care equipment Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Nursing staff Residents Record Reviews: Medical records Incident investigation Investigation Summary: 1) The NR no longer resides at the Assisted Living Facility (ALF). Observation and interview with sampled residents showed no voiced concerns for care and/or safety at the ALF. Interview and record review showed the ALF did not provide the requested records to the LR within two working days of the LR’s request for the This document was prepared by Residential Care Services for the Locator website. records. Findings of deficient practice, see Statement of Deficiencies dated 01/27/2026. 2) Interview and record review showed that the report of a bent needle used during insulin administration was investigated and ruled out as not occurring at the ALF. Record review of the investigation showed the ALF determined that the nurse did not provide insulin administration inaccurately. Unable to substantiate allegation. 3) Interview and record review showed the ALF received an order for sliding scale during waking hours and a bedtime insulin order and the order was transcribed inaccurately based on the need to clarify the order. Record review showed the NR did not experience several extremes of low morning blood sugars below normal range. The ALF investigated the medication error and corrected the medication error when it was discovered. Unable to substantiate allegation. 4) Interview and record review showed there was no correlation between the NR not receiving the requested medical records and the event of the allegation of a “bent” needle. The ALF investigated both allegations and ruled out abuse and/or neglect. The ALF took corrective action for the medication error. Unable to substantiate allegation regarding retaliation. 5) Record review showed the NR received a diabetic diet as ordered. Unable to substantiate allegation. 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. Residential Care Services Investigation Summary Report Provider/Facility: Cedar Creek Memory Care Provider Type: Assisted Living Facility Community License/Cert.#: 2453 Intake ID: 206810 Compliance Determination #: 70653 Region/Unit #: RCS Region 2 / Unit J Investigator: Hayley Pinkham Investigation Date(s): 12/29/2025 through 01/27/2026 Complainant Contact Date(s): 01/27/2026 Allegation(s): 1) The Named Resident (NR) has lost the ability to walk since being admitted to the Assisted Living Facility (ALF). The NR is having difficulty getting physical therapy (PT). 2) The NR fell at the ALF and sustained a black eye, and a cut above the eyebrow. Upon further inspection the NR was found with bruises on their abdomen. The bruises appeared old. Investigation Methods: Sample: Total residents: 57 Resident sample size: 5 Closed records sample size: 1 Observations: Identified resident Residents Dining Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Identified resident Nursing staff Residents Family members Record Reviews: Medical records Hospital records Incident investigation Facility policies Investigation Summary: 1) Interview and observation showed the NR needed physical assist to stand and the NR required a wheelchair for transport. The NR denied care concerns and reported staff treated them with respect. Interview and record review showed the NR was ambulatory prior to hospitalization and the NR returned from the hospital after an extended period in a weakened condition. The NR had orders for PT, but insurance This document was prepared by Residential Care Services for the Locator website. denied PT. The ALF is working with the insurance company to provide PT benefits to the NR. No findings of deficient practice. 2) Observation of the NR showed there was evidence of a few small pale-yellow discolorations on the abdomen. Interview showed that the NR denied any abuse and/or neglect at the ALF. Record review showed the NR was in the hospital for an extended period and the bruises were identified and investigated upon his return to the ALF. No findings of deficient practice. Interview and record review showed that the NR was hospitalized for unstable behaviors and inappropriate actions toward other residents. Findings for deficient practice. The ALF failed to notify the department and the local police department for resident to resident altercations. See Statement of Deficiency dated 01/27/2026 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. Residential Care Services Investigation Summary Report Provider/Facility: Cedar Creek Memory Care Provider Type: Assisted Living Facility Community License/Cert.#: 2453 Intake ID: 200764 Compliance Determination #: 68811 Region/Unit #: RCS Region 2 / Unit J Investigator: Hayley Pinkham Investigation Date(s): 11/17/2025 through 12/01/2025 Complainant Contact Date(s): Allegation(s): 1) The facility failed their second fire and life safety inspection and have been issued a State Fire Marshal’s Office Letter of Noncompliance. Investigation Methods: Sample: Total residents: 55 Resident sample size: 2 Closed records sample size: 1 Observations: Residents Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Nursing staff Fire Marshal Record Reviews: Fire Marshal Report Facility Records Investigation Summary: 1) Interview and observation showed documented violations identified in report were not corrected in a timely manner. The facility failed to pass the required Fire Marshal safety inspection. See statement of deficiencies dated 12/01/2025. 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. Statement of Deficiencies License #: 2453 Compliance Determination # 68811 Plan of Correction Cedar Creek Memory Care Community Completion Date Page 2 of 3 Licensee: Edmonds Memory Care, LLC 12/01/2025 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. 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. 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. (2) The assisted living facility must have its building approved by the Washington state fire marshal in order to be licensed. This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure compliance with the Washington State Fire Marshal Office (OSFM) when the ALF failed their second follow-up Fire and Life Safety Inspection (LSI). This placed 55 assisted living residents, staff, and visitors’ safety at risk. Findings included… Review of the Department’s Secure Tracking and Reporting System, on 11/17/2025, showed the ALF was licensed for 80 beds. Review of a Resident Characteristic Roster showed the ALF was providing care and services for 55 residents. Review of records from the OSFM, showed the ALF failed their initial LSI on 06/26/2025 and their first follow-up visit on 08/07/2025. The second follow-up visit on 10/29/2025 showed the ALF failed to comply with following International Fire Codes (IFC): • Facility was unable to provide documentation for the monthly single or multi station smoke alarm testing. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2453 Compliance Determination # 68811 Plan of Correction Cedar Creek Memory Care Community Completion Date Page 3 of 3 Licensee: Edmonds Memory Care, LLC 12/01/2025 • Facility was unable to provide documentation for the monthly carbon monoxide detector testing. National Fire Protection Association (NFPA) 720 8.7.1 Single and multiple-station carbon monoxide alarms and all connected appliances shall be inspected and tested in accordance with the manufacturer's published instructions at least monthly. • Facility was unable to provide documentation for the annual service of the emergency generator. Facility failed to provide documentation indicating a monthly generator battery test was being conducted in accord with NFPA 110 2021 edition section 8.3.6.1 • Facility was unable to provide annual fuel testing results per NFPA 110 83.7 • Facility could not provide documentation for the completion of unannounced fire drills, one drill per shift, per quarter, in the previous 12 months. In an interview, on 11/17/2025 at 12:40 PM, Staff A (Executive Director) stated that she was aware of the violations, and the documentation for testing was not available at the time of the OSFM visit. 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, Cedar Creek Memory Care Community 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 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. 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.

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 January 9, 2024 ELECTRONIC-FACSIMILE Administrator Cedar Creek Memory Care Community 21006 72nd Ave W Edmonds, WA 98026 Assisted Living Facility License #2453 Licensee: Edmonds Memory Care, LLC IMPOSITION OF CIVIL FINES Dear Administrator: On January 2, 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 Cedar Creek Memory Care Community, located at 21006 72nd Ave W, Edmonds, 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 January 2, 2024. Civil Fines WAC 388-78A-2140(1)(a)(iii)(2)(a)(3) Negotiated service agreement contents. $400.00 The licensee failed to develop and document a Negotiated Service Agreement (NSA) that supported the care needs of one resident. This placed the resident at risk of health complications related to use of anticoagulant medication (medication that thins the blood to prevent clots). This is an uncorrected deficiency previously cited on November 6, 2023, and a recurring deficiency previously cited on January 25, 2022, and October 8, 2021. Administrator Cedar Creek Memory Care Community License #2453 January 9, 2024 Page 2 WAC 388-78A-2480(1) Tuberculosis—Testing—Required. $200.00 The licensee failed to ensure one staff member had tuberculin (TB) screening within three days of employment. This placed all 49 residents at risk of exposure to a communicable disease. This is an uncorrected deficiency previously cited on November 6, 2023. 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: Jamie Singer, Field Manager Region 2, Unit J 20311 52nd Avenue West Suite 100 Lynnwood, WA 98036 Phone: (253) 312-1446 / Fax: (206) 971-6971 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. Administrator Cedar Creek Memory Care Community License #2453 January 9, 2024 Page 3 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 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 $600.00 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 Administrator Cedar Creek Memory Care Community License #2453 January 9, 2024 Page 4 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. If you have any questions, please contact Jamie Singer, Field Manager, at (253) 312-1446. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 2, Unit J 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