Aegis Lodge of Kirkland.

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Health and Community Living Administration PO Box 45600, Olympia, WA 98504-5600 June 26, 2025 ELECTRONIC-FACSIMILE Administrator Aegis Lodge of Kirkland 12629 116TH AVE NE KIRKLAND, WA 98034 Assisted Living Facility License # 2492 Licensee: 116 Ave Kirkland LLC IMPOSITION OF CIVIL FINES Dear Administrator: On June 12, 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 civil fines on the license for your assisted living facility, also known as Aegis Lodge of Kirkland, located at 12629 116TH AVE NE, KIRKLAND, 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 June 12, 2025. Civil Fines WAC 388-78A-2880 (1)(a)(b)(c)(d)(2)(3) Changing use of rooms. $400.00 The licensee failed to obtain approval from the Washington State Department of Health, Construction Review Services (CRS) when there were changes to 18 assisted living apartments. This failure placed eight residents who currently reside in some of these apartments, and potentially any future residents, at risk for harm when apartments were altered without CRS approval for use and occupancy. This is an uncorrected deficiency previously cited on April 30, 2025, for subsections (1)(a)(b)(c) and (2). Administrator Aegis Lodge of Kirkland License # 2492 June 26, 2025 Page 2 WAC 388-78A-2485 (1)(2)(3) Tuberculosis—Positive test result. $400.00 The licensee failed to ensure that two staff completed a chest X-ray within seven days, was evaluated for signs and symptoms of TB, and followed the health care provider’s recommendation, following a positive result to a Tuberculosis (TB) skin test. This failure placed all 61 residents at risk of exposure to tuberculosis, an infectious disease. This is an uncorrected deficiency previously cited on April 30, 2025, for subsections (1), (2), and (3). 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: 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). Administrator Aegis Lodge of Kirkland License # 2492 June 26, 2025 Page 3 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. Please email your request(s) and supporting documentation to: RCSIDR@dshs.wa.gov OR FAX to: 360-725-3225 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 $800.00 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 Administrator Aegis Lodge of Kirkland License # 2492 June 26, 2025 Page 4 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. NOTICE: State and federal law provide protections to defendants who are in military service, and to their dependents. Dependents of a service member are the service member’s spouse, the service member’s minor child, or and individual for whom the service member provided more than one-half of the individual’s support for one hundred eight days immediately preceding an application for relief. One protection provided is the protection against the entry of a default judgment in certain circumstances. This notice pertains only to a defendant who is a dependent of a member of the National Guard or a military reserve component under a call to active service, or a National Guard member under a call to service authorized by the governor of the state of Washington, for a period of more than thirty consecutive days. Other defendants in military service also have protections against default judgments not covered by this notice. If you are the dependent of a member of the national guard or a military reserve component under a call to active service, or a national guard member under a call to service authorized by the governor of the state of Washington, for a period of more than thirty consecutive days, you should notify the Department in writing of your status as such within twenty days of the receipt of this notice. If you fail to do so, then a court or an administrative tribunal may presume that you are not a dependent of an active duty member of the national guard or reserves, or a national guard member under a call to service authorized by the governor of the state of Washington, and proceed with the entry of an order of default and/or a default judgment without further proof of your status. Your response to the Department about your status does not constitute an appearance for jurisdictional purposes in any pending litigation nor a waiver of your rights. 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

Residential Care Services Investigation Summary Report Provider/Facility: Aegis Lodge of Kirkland Provider Type: Assisted Living Facility License/Cert.#: 2492 Intake ID: 147655 Compliance Determination #: 47620 Region/Unit #: RCS Region 2 / Unit D Investigator: Karri Hernandez Investigation Date(s): 09/24/2024 through 10/01/2024 Complainant Contact Date(s): 09/24/2024 Allegation(s): Facility failed to provide and administer ordered medications. Investigation Methods: Sample: Total residents: 64 Resident sample size: 2 Closed records sample size: Observations: Identified resident Residents Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Identified resident Identified staff Nursing staff Residents Family members Record Reviews: Medical records Hospital records Incident investigation Facility policies Investigation Summary: Reviewed intake. Interviewed facility staff, residents, collateral contact. Reviewed medical records, facility records, Washington State Administrative Code. Named Resident (NR) admitted to facility from hospital without all medications present from pharmacy on admit. NR re-admitted to hospital from facility three days later diagnosed with . Failed practice found; citation issued 10/08/2024 intake number 47620. 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 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.