Memory Care at the Lodges.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . I&] □ □ . STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALT H SERVICES HOME AND COMMUNITY LIVING ADMINISTRATION 800 NE 136th Ave Ste 200, Vancouver, WA 98684 Statement of Deficiencies License #: 2600 Compliance Determination # 65676 Plan of Correction Memory Care At The Lodges 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 an unannounced on-site complaint investigation on 09/15/2025 and 01/20/2026 of: Memory Care At The Lodges 1530 Carpenter Rd SE Lacey, WA 98503 This document references the following complaint number(s): 190838, 190988, 191100, 208054 The following sample was selected for review during the unannounced on-site visit: 4 of 48 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Maria Salas, ALF Complaint Investigator From: DSHS, Home and Community Living Administration 800 NE 136th Ave Ste 200 Vancouver, WA 98684 . 02.05.2026 08:45:34 state of l,lashington 4/6 Statement uf Defici~ncie:s L~c~ms.e. #: 2600 Go mplia~ce Detern1matiim #85676 Pi an c-f C orre;:tion Memoq1 Care At l'he Lodge~ Cornp!stion 0.lh' Pags 2 013 {)2;'02/202:B As a result of tt1e on-site visH{sL the departrnent k,und that you ~re not in ,:a,mpl\;:mi::.e ,...yitt1 the \i,:;ensing Ja\NS and reguf.ahcns. i!lS ~tated in the, c.iterl defic.1enti'3:s in the c:ncfo~d re:port. 02/04/2026 Date i under~rnnd that tc:i rnarnt~in a:n .Assisted Uving Fac.mty tsc<":mse, tne fadhty rm.,st b~ h"l ~•:irnphan,:e with alt the l~c•::rrsing lav-.is and reg,.;le1tioris at all tim<!-s.. (b) M0k~s a-n trnrnediat~ re par~ to the appropriate law· entcr.cernent tige:r.cy and the department consistent ~~tt1 chapter 74.34 RC'vV of a}l 1nddtnffi l)f ~uspede-d sexual at-use-or physi,::3i abuse of a res;iaent. Thh, requir~mentwas not met as evfdeneed by: Based on iriter-11ew .~nct f,€:l}rd rev\\€>\', me facr:ity failed to report to law enkm::ement \·\1t1-en a re.i:.}dent af1e!Jt?.d st:>::Jal aSScHJlt for i of ·I res:;:if.nts {Resident 1}. This f3,lw·t rts:uited m tt1e faciHt'l faH;ng to notify lav.' enfrnaeernent regarding an at!egatkm of sexual assault betvveen Rt:sideri:t ·i (R~} and unk.r:<::iwn st"'f.f and placed all residents at ris~i for not having aif-egati,1ns rnpG,ted antifr,r responded ti:i by appropriate atJetv:;v~s Findings inr:loderl ... R:et:t1rd re1;1•ievv of Fac-e 8-heet shov,NHl R l admitted on 6!2024 'tl\~th a hl:&OI)' of d~rr'ientia (a k.\~S oh::ogrntive tund:1on thinking, rnmembering, and masoning;. R~<:.:ird revi'€\r\i of lnrn1er1t Repr)tt dared OW .17/202£, sh0v,.ies:l R·l h.;1ct vcHced im alleg<~tit:m Gf Sie)::ual assault tti StaH A, M edic~tf.on Techrnc:ian tMTL stating th flt the assault hnd happentd after n1~y had :~drn,tte(i ti:1 the facility. Ri repo1t-:.d the perp<:ltratur h~d been a male staff n~embei bd was unable to r~•:.aU hi.-s nam-e or give .~ descripbm, Document sho'l\1ed R·1· s Powef d Attom~y-, medical provider, Exec,.ttive Oirect<lr rn1d licensed nurs>:: ha.<l be~n notif1e<l ot the allegation. No do;;::urnentation \-Vas found that loc'31 ia\l'I enforcernent w:as notif1e<l . Statement of Deficiencies License #: 2600 Compliance Determination # 65676 Plan of Correction Memory Care At The Lodges Completion Date 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. 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-2630 Reporting abuse and neglect. (1) The assisted living facility must ensure that each staff person: (b) Makes an immediate report to the appropriate law enforcement agency and the department consistent with chapter 74.34 RCW of all incidents of suspected sexual abuse or physical abuse of a resident. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to report to law enforcement when a resident alleged sexual assault for 1 of 1 residents (Resident 1) . This failure resulted in the facility failing to notify law enforcement regarding an allegation of sexual assault between Resident 1 (R1) and unknown staff and placed all residents at risk for not having allegations reported and/or responded to by appropriate agencies. Findings included ... Record review of Face Sheet showed R1 admitted on /2024 with a history of dementia (a loss of cognitive function thinking, remembering, and reasoning). Record review of Incident Report dated 01/07/2026, showed R1 had voiced an allegation of sexual assault to Staff A, Medication Technician (MT), stating that the assault had happened after they had admitted to the facility. R1 reported the perpetrator had been a male staff member but was unable to recall his name or give a description. Document showed R1 's Power of Attorney, medical provider, Executive Director and licensed nurse had been notified of the allegation. No documentation was found that local law enforcement was notified. . 02.05.2026 08:45:34 state of Washington 5/6 Statt!ment of Defici~nctes Uceils.e. #: 2600 Compliaf!ce Detern1Jn~ti1)n #65676 Plan M Corrnctio~"f M11mo1-,, C;m~ Atlht:1 Li:H~g,as Ci:•mp1etiotl O.. ite Psg8 3 of 3 02,fJ2!.202B Re~:ord reviet~· of prn9r.ess r1,1tes dated 01 i'Q N202F5 thn.1u9h D 1H0t'2026 show~d ~t-atf entiv of an alleged se;<ua! assault V')iced by RI. f\J !} documentatrnn that itF.::a! lt1w t::nfartement was-rn:;tified of th~ aHegat\1Jn. In an inti~M€V<it.n 02102nn26 21t i t55 Atv1.. Staft C, Executve Direct<H {ED), stated the r~spcmsibil:ity tiJ cr.mtai::t !Deal !aw enfon:~ment when Med ad for an incident was eitnerth~irs or Staff B's respon$ibili!y StJif C stated tho::y· di:! not have a -sy~t~m i11 ptace to ensure aH re-quired p-arts af ~n 1nddent itWt'!stigBticn are cornptet~d sw:h as contacting ioca! iaw ~r1forcernent. PlanJAttesbtion Statement [ h~reby >.::ertify that I have reviewed thrs H:pott ilMd hav<:: tahen Gt wig t;)i,,.,e adive rneas.LiH,s to c::orrn:et this detklancv. Bv ta~dng. tnis at.tkm, Memorv Car1:1 At '"IL,--~11:: Lod•~~s is _'lO~_k_ . Of.W11~ be (fl CJJrnpimn:i:J ~'1.1\th U1is law ind .i Ot~ regulation ,:1ri (Oat-ei~b.11 J:n additlo:i, l \-\'ill implement a system to n1Gr1it0r and ':'!nsurt i:on~nued wmpfian,:e \Nltti thls requ~r£:{nent. Date . Statement of Deficiencies License #: 2600 Compliance Determination # 65676 Plan of Correction Memory Care At The Lodges Completion Date Record review of progress notes dated 01/07/2026 through 01/10/2026 showed staff entry of an alleged sexual assault voiced by R1. No documentation that local law enforcement was notified of the allegation. Record review of email dated 01/23/2026, from Staff B, Residential Care Coordinator (RCC), showed Staff B had been asked if local law enforcement had been notified of allegation of sexual assault of R1. Staff B had replied that local law enforcement had not been contacted. In an interview on 02/02/2026 at 11 :55 AM, Staff C, Executive Director (ED), stated the responsibility to contact local law enforcement when needed for an incident was either theirs or Staff B's responsibility. Staff C stated they do not have a system in place to ensure all required parts of an incident investigation are completed such as contacting local law enforcement. This is a recurring deficiency previously cited on 08/05/2024 and 05/14/2025. 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, Memory Care At The Lodges 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

Findings included… Record review of the facility policy, titled, “Resident Service Plans (See Negotiated Service Agreement”), revised on 02/15/2024, showed that based on the initial Statement of Deficiencies License #: 2600 Compliance Determination # 62995 Plan of Correction Memory Care At The Lodges Completion Date evaluation conducted prior to admission, an initial Service Plan will be developed. The initial Service Plan will be reviewed according to state regulations which are 14 days, 30 days and then annually or at change of condition. Record review of facility document, “Plan of Correction”, had a compliance date of 06/18/2025. This document showed that the Health Services Director (Staff C) and Clinical Support Specialist (Staff A) were assigned to each lodge. DO (Director of Operations) was to ensure that Staff C was following policy with new admits and Staff A was to track in YARDI (computer program used for tracking care plans) for compliance. Staff C was to tend to the task with DO oversight for each move in. Record review of facility document in-service sign in sheet titled, “Service Planning,” dated 05/29/2025, was signed by Staff A and Staff C that they received training on updating the service plan on day of move in and as needed and that they were to follow the facility’s policy and procedures. Review of R1’s face sheet, dated 07/23/2025, showed that R1 was admitted to the facility on /2024. In a records request for R1’s initial NSA, one was not provided. Review of R2’s face sheet, dated 07/23/2025, showed that R2 was admitted to the facility on /2024. In a records request for R2’s initial NSA, one was not provided. In an interview on 07/23/2025 at 11:13AM, Staff A, Clinical Support Specialist, stated initial service plans were not completed for R1 or R2. Staff A stated it wasn’t triggered in the system to do an initial service plan. Staff A stated they would have done the initial service plan the day the residents moved into the facility. Staff A stated R1’s should have been completed on 06/23/2025 and R2’s should have been completed on 06/24/2025. Staff A was asked who was responsible for completing the NSA’s, they stated they were and the Health Services Director (HSD). In a joint interview on 07/23/2025 at 12:54PM, Staff B, Business Office Manager and Staff A stated nothing was triggered in the system to complete the NSA. R1’s NSA should have been completed by 07/07/2025 and R2’s NSA should have been completed by 07/08/2025. Staff A stated we missed it. In an interview on 07/23/2025 at 1:28PM, Staff C, Health Services Director, stated the initial NSA should be completed within 14 days of the resident being admitted to the facility. Staff C stated they typically do it the day the resident admits to the facility. Staff C stated they and the Executive Director were responsible for ensuring the care Statement of Deficiencies License #: 2600 Compliance Determination # 62995 Plan of Correction Memory Care At The Lodges Completion Date plan was done on time. This is an uncorrected deficiency previously cited on 05/21/2025. 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, Memory Care At The Lodges 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 WAC 388-78A-2090 Full assessment topics. The assisted living facility must obtain sufficient information to be able to assess the capabilities, needs, and preferences for each resident, and must complete a full assessment addressing the following, within fourteen days of the resident's move-in date, unless extended by the department for good cause: (1) Individual's recent medical history, including, but not limited to: (a) A licensed medical or health professional's diagnosis, unless the resident objects for religious reasons; (b) Chronic, current, and potential skin conditions; or (c) Known allergies to foods or medications, or other considerations for providing care or services. (2) Currently necessary and contraindicated medications and treatments for the individual, including: (a) Any prescribed medications, and over-the-counter medications commonly taken by the individual, that the individual is able to independently self-administer, or safely and accurately direct others to administer to him/her; (b) Any prescribed medications, and over-the-counter medications commonly taken by the individual, that the individual is able to self-administer when he/she has the assistance of a caregiver; and (c) Any prescribed medications, and over-the-counter medications commonly taken by the individual, that the individual is not able to self-administer, and needs to have administered to him or her. (3) The individual's nursing needs when the individual requires the services of a nurse on the assisted living facility premises. (4) Individual's sensory abilities, including: Statement of Deficiencies License #: 2600 Compliance Determination # 62995 Plan of Correction Memory Care At The Lodges Completion Date (a) Vision; and (b) Hearing. (5) Individual's communication abilities, including: (a) Modes of expression; (b) Ability to make self understood; and (c) Ability to understand others. (6) Significant known behaviors or symptoms of the individual causing concern or requiring special care, including: (a) History of substance abuse; (b) History of harming self, others, or property; or (c) Other conditions that may require behavioral intervention strategies; (d) Individual's ability to leave the assisted living facility unsupervised; and (e) Other safety considerations that may pose a danger to the individual or others, such as use of medical devices or the individual's ability to smoke unsupervised, if smoking is permitted in the assisted living facility. (7) Individual's special needs, by evaluating available information, or if available information does not indicate the presence of special needs, selecting and using an appropriate tool, to determine the presence of symptoms consistent with, and implications for care and services of: (a) Mental illness, or needs for psychological or mental health services, except where protected by confidentiality laws; (b) Developmental disability; (c) Dementia. While screening a resident for dementia, the assisted living facility must: (i) Base any determination that the resident has short-term memory loss upon objective evidence; and (ii) Document the evidence in the resident's record. (d) Other conditions affecting cognition, such as traumatic brain injury. (8) Individual's level of personal care needs, including: (a) Ability to perform activities of daily living; (b) Medication management ability, including: (i) The individual's ability to obtain and appropriately use over-the-counter medications; and (ii) How the individual will obtain prescribed medications for use in the assisted living facility. Statement of Deficiencies License #: 2600 Compliance Determination # 62995 Plan of Correction Memory Care At The Lodges Completion Date (9) Individual's activities, typical daily routines, habits and service preferences. (10) Individual's personal identity and lifestyle, to the extent the individual is willing to share the information, and the manner in which they are expressed, including preferences regarding food, community contacts, hobbies, spiritual preferences, or other sources of pleasure and comfort. (11) Who has decision-making authority for the individual, including: (a) The presence of any advance directive, or other legal document that will establish a substitute decision maker in the future; (b) The presence of any legal document that establishes a current substitute decision maker; and (c) The scope of decision-making authority of any substitute decision maker. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to complete an initial assessment within 14 days after a resident moved to the community for 1 of 2 residents (Resident 1[R1]). This failure placed R1 at risk for unmet care needs and a decreased quality of life. Findings included… Record review of the facility policy, titled, “Accepting and Retaining Residents,” dated 02/15/2024, showed, “To ensure residents seeking move in are evaluated in a manner that is consistent with WAC 388-78A-2050 through WAC 388-78A-2090 and that prior to moving in, the community has determined that it has the ability to meet the identified needs and potential additional needs based on the residents risk factors identified during the initial move in evaluation.” Record review of facility document, “Plan of Correction”, had a compliance date of 06/18/2025. This document showed that the Health Services Director (HSD) (Staff C) and Clinical Support Specialist (Staff A) were assigned to each lodge.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . I&] □ □ Investigation Summary Report Provider/Facility: Memory Care At The LodgesProvider Type: Assisted Living Facility License/Cert.#: 2600 Intake ID: 152269 Compliance Determination #: 50167 Region/Unit #: RCS Region 3 / Unit E Investigator: Pamela Horlick Investigation Date(s): 11/13/2024 through 12/19/2024 Complainant Contact Date(s): Allegation(s): Quality of Care/Treatment: Report of a resident sustaining an injury after a fall and taken to the hospital. Investigation Methods: Sample: Total residents: 51 Resident sample size: 3 Closed records sample size: 0 Observations: Identified resident Residents Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Identified resident Nursing staff Residents Record Reviews: State reporting log Incident investigation Facility policies Care plan progress notes Investigation Summary: Quality of Care/Treatment: Facility failed to complete an assessment and update the care plan after a resident had a change in condition. Failed practice identified. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . I&] □ □ . STA1"E OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 800 NE 136th.Ave Ste 200, Vancouver~ WA 98684 Statement of Deficiencies License #: 2600 Compliance .Determination# 58169 Plan of Correction Memory Care At The Lodges Completion Date Page 1 of4 Licensee: Greenlake Management Lacey, LLC 05/14/2025 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 follow-up on 04/16/2025 of: Memory Care At The Lodges 1530 Carpenter Rd SE Lacey, WA 98503 This document references the following SOD dated: 05/14/2025 The following sample was selected for review during the unannounced on-site visit: 3 of 42 current residents and O former residents. The department staff that inspected the Assisted Living Facility: Pamela Horlick, NCI RN Complaint Investigator Cory Cisneros, Field Manager From: DSHS, Aging and Long-Term Support Administration 800 NE 136th Ave Ste 200 Vancouver, WA 98684 . 05.21.2025 13:31:31 state of Washington Statement of Deficiencies License#: 2600 Compliance Determination# 58169 Plan of Correction Memory Care At The Lodges Completion Date Page 2 of4 Licensee: Greenlake Management Lacey, LLC 05/14/2025 As a result of the on-site vlsit(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. ~ ~4,, 05/21/2025 Resfckntial Care Services Date 1 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. ~ Patricia $antOS-lOVe Administrator (or Representative) WAC 388-78A-2100 Ongoing assessments. (2) The assisted living facility must (a) Complete a full assessment addressing the elements set forth in WAC 388-78A-2090 for each resident at least annually; (b) Complete an as.sessment specifically focused on a resident's identified problems and related issues: (f) Consistent with the resident's change of condition as specified in WAC 388-78A-2120; (ii) IM"len the resident's negotiated service agreement no longer addresses the resident's current needs and preferences; This requirement was not met as evidenced by: Based on interview and record review the facility failed to update the resident assessment and negotiated service agreement (NSA) after a change in condition for 1 of 3 residents (Resident 2 [R2]). This failure placed R2 at risk of unmet care needs and decreased quality of life. Findings included. .. Record review of the "Department of Social And Health Services" document, Completion date 12/19/2024, showed "As a result of the on-site visit(s) the department found that you are not in compliance with the licensing laws and regulations [including WAC (Washington Adrni'nistrative Code) 388-78A-2630] as stated in the cited deficiencies in the enclosed report. 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." The administrator section showed Staff A, Administrator, signed the document on 05/21/2025 . Statement of Deficiencies License #: 2600 Compliance Determination# 58169 Plan of Correction Memory Care At The Lodges Completion Date 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. ~ ~4, Resl'ntial 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-2100 Ongoing assessments. (2) The assisted living facility must: (a) Complete a full assessment addressing the elements set forth in WAC 388-78A-2090 for each resident at least annually; (b) Complete an assessment specifically focused on a resident's identified problems and related issues: (i) Consistent with the resident's change of condition as specified in WAC 388-78A-2120 ; (ii) When the resident's negotiated service agreement no longer addresses the resident's current needs and preferences; This requirement was not met as evidenced by: Based on interview and record review the facility failed to update the resident assessment and negotiated service agreement (NSA) after a change in condition for 1 of 3 residents (Resident 2 [R2]). This failure placed R2 at risk of unmet care needs and decreased quality of life. Findings included ... Record review of the "Department of Social And Health Services" document, Completion date 12/19/2024, showed "As a result of the on-site visit(s) the department found that you are not in compliance with the licensing laws and regulations [including WAC (Washington Administrative Code) 388-78A-2630] as stated in the cited deficiencies in the enclosed report. 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." The administrator section showed Staff A, Administrator, signed the document on . Statement of Deficiencies License #: 2600 Compliance Determination # 58169 Plan of Correction Memory Care At The Lodges Completion Date Page 3 of4 Licensee: G.reenlake Management Lacey, LLC 05/14/2025 01/06/2025. Staff A signed the "Plan/Attestation Statement" for all citations c.ited that read "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 facility] is orwiH be in compliance with this I.aw and/or regulation on 02/02/2025." Record review of R2's face sheet, dated 04/16/2025, showed R2 admitted to the facility on /2024 with a diagnosis of ( ) and ( ). Record review of the Communication and Alert Charting log binder, dated 04/01/2025--04/15/2025, showed R2 had the following notes; - 04/02/2025: Resident showing severe behaviors, not eating or drinking. - 04/03/2025: Behaviors for R2 are increasing, not eating or drinking. - 04/07/2025: Resident not eating or drinking. - 04/08120.25: Resident not eating or drinking. - 04/09/2025: Resident not eating or drinking. - 04/10/2025: Resident not eating or drinking. - 04/11/2025: Resident not eating or drinking. - 04/14/2025: Resident not eating or drinking. - 04/15/2025: Resident in room all day, did not eat. Record review of R2's NSA, dated 04/08/2025, showed R2 was independent with meal consumption and the goaJ was for R2 to maintain or maximize their current level of functioning with meal consumptton. R2's recent decline in eating and drinking was not addressed on the NSA Record review of R2's Quarterly Assessment. dated 04/08/2025, showed R2 had a fair appetite and ate at least 50% or more of their meals. The assessment showed R2 was insulin (medication to manage blood sugar levels) dependent. The assessment did not address R2's recent decline in eating and drinking. In an interview on 04/16/2025 at 11 :45 AM, Staff B, Licensed Nurse, stated when they complete new assessments they review old assessments, talk to staff, observe the resident, review records, and look back over information from the quarter. Staff B confirmed they completed R2's quarterly assessment on 04/08/2025. Staff B was informed of the notes from 04/01/2025-04/15/2025 showing R2 was not eating or drinking and did not reflect accurately on the recently completed assessment. In an interview on 04/16/2025 at 3:41 PM, Staff A, Staff C, Director of Operations, and Staff B confirmed that the assessment and NSA did not accurately capture or address the change in R2's eating and drinking intake. This is an uncorrected deficiency previously cited on 1.2/19/2024. . sn 05.21.

findings for any alleged or suspected abuse, neglect, or financial exploitation; or accident or: incident jeopar:dizing or affecting a r:esident health or life; (2) Determine the circumstances of the event; (3) When necessary, institute and document appropr:iate measures to pr:event similar future situations if the alleged incident is substantiated; and (4) Protect residents during the course of the investigation. . The Department staff who did the On Site verification: Pamela Horlick, NCI RN Complaint Investigator If you have any questions, please contact me at (360)450-1218. Sincerely, ~n,r~- Clinton Fridley, Adult Family Home efse Field Manager Region 3, Unit E STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 800 NE 136th Ave Ste 200, Vancouver, WA 98684 Statement of Deficiencies License #: 2600 Compliance Determination # 58171 Plan of Correction Memory Care At The Lodges 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 an unannounced on-site follow-up on 04/16/2025 of: Memory Care At The Lodges 1530 Carpenter Rd SE Lacey, WA 98503 This document references the following SOD dated: 05/14/2025 The following sample was selected for review during the unannounced on-site visit: 3 of 42 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Pamela Horlick, NCI RN Complaint Investigator Cory Cisneros, Field Manager From: DSHS, Aging and Long-Term Support Administration 800 NE 136th Ave Ste 200 Vancouver, WA 98684 . . 05.22.2025 09:06:20 state of l,lashington 4/13 Statement of Defidendes lk:ense. #' 2600 Compliance D~t~m11nation #&31Ti Plan M Co!'!e~:tion M~mc,ry C:arn At. ll1~ Lndg~s Cu-mp!etio11 tJ.;3te om Pagt12 Ucil!~s-ee: Greenlake Managinnent Lacey. LLC 05h 4/202£ .1-\s a re suit eif th~ on-s.ite visitt~) th € department found that you are not m cornpllance 'with the !tGtnsing laws and regt,f·atkins a,s stated 111 ~,e i::itea defid1mc1es m the ern:::t-os.ed ,epcrt 05/21/2025 Date l ,Jn,:jerstand that to maintain an .Assisted Living Fad§ity ~i~:ense. the facility musti:,e JO an campHanci:: ~th the lk--=nsir:g laws a:nd reguiatkil1S: at ail times. WAC 388-78A-26l0 Repo-rtin9 abuse and neglect. (a} Mal<.~s a-report to the department's A.gmg and D.isatulity Servica-s Admirnstration Con1pf:aint Re:s:olutwn Unit rwtlin1t conslstent witl1 d1aµter 14 .34 RGVV in all cases 'Nhere the staff persoit has reasa:nat<le caw;;-e tc beHeve that abandonment, abt,se, hnanc1.a~ expio1ta~on, tJr negl-.:,:t of a vu!n,erablt adult. has ac{.:urred; and (bi Ma!-:e-s an imrned:tste report to t11~ appropriate law tmfon:ement agent::,,· and the dep.mtment consistent -."4~th ..::t1apter 74 34 RC'W of all indtients of -suspi::cted :se}(ual abuse or physical abuse of a reskient This requirt'.ment was nr>t me-t as evidenced by: Sst;ed ;Jn 111t~Niew and reccrd review_ the facmty failed to 1:mmedi:ately' repJri an ~{t}pemi:nt and an incident of pote:n!ml $exua! abuse to the tiepartrr1enfs Comp!aint Re-svtuticn Unn (CR-U} for 2 of -4. inddents re,vre\Ned. This fo;lt.He pfactd 42 af 42 residan.ts at risk for i.mrep,:irt<:!d t~.arm atid unmet care ne~ds. "RC\tV 74 .34.0% Report~Mandated and Pern1issiv~-Contents.-Confid-ent~altW-( 1) V\i'hen theH! 1s rf::as:3-nat,Je -.:ausa t11 beHev!';; 'that abar.ckmrntri:t, abt..me, hnancfa] e.xti!Grt:3~Gn. or neglect i:if a vulnerable adult has occurred, mamfatecl reporters s11a-li jmrne<liatefy report to ti1e depattm-ent" Rt:sopj review of Assrn.tetj Uving Facility Guide·brJo~;, dated Fttln.rnry 20!8, sh01Ned to rep mt t{.l the deparrrnent 1p.,hen there wc1s reasartablt ,::ause bd:eve vio.fabons nad occ.ur.rect invo!v111g ahusf!. tl) neglect, abandonrrent. signirfc,mt inJune~ of tmknovvn S{lwn::i::, · · Statement of Deficiencies License #: 2600 Compliance Determination # 58171 Plan of Correction Memory Care At The Lodges Completion Date 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. 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-2630 Reporting abuse and neglect. (1) The assisted living facility must ensure that each staff person: (a) Makes a report to the department's Aging and Disability Services Administration Complaint Resolution Unit hotline consistent with chapter 74.34 RCW in all cases where the staff person has reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred; and (b) Makes an immediate report to the appropriate law enforcement agency and the department consistent with chapter 74.34 RCW of all incidents of suspected sexual abuse or physical abuse of a resident. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to immediately report an elopement and an incident of potential sexual abuse to the department’s Complaint Resolution Unit (CRU) for 2 of 4 incidents reviewed. This failure placed 42 of 42 residents at risk for unreported harm and unmet care needs. Findings included… “RCW 74.34.035 Reports—Mandated and Permissive—Contents—Confidentiality. (1) When there is reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred, mandated reporters shall immediately report to the department." Record review of Assisted Living Facility Guidebook, dated February 2018, showed to report to the department when there was reasonable cause to believe violations had occurred involving abuse, neglect, abandonment, significant injuries of unknown source, . Statement of Deficiencies License #: 2600 Compliance Determination # 58171 Plan of Correction Memory Care At The Lodges Completion Date or personal and/or financial exploitation. The guidebook showed for missing residents it should be reported to the department CRU hotline depending on the circumstances of each individual event/incident, the facility may be required to report any alleged, suspected or actual neglect of a resident. Record review of facility policy, titled, “Abuse and Neglect-Resident,” dated 02/15/2024, stated, “This Community will make every reasonable effort to ensure the safety and wellbeing of our residents and staff and promote a healthy atmosphere free of abuse, neglect, or exploitation. The community will not hire or continue to employ persons with a history of or propensity for abuse in accordance with Guidelines found in the DSHS Assisted Living Guidebook: Partners in Protection. Based on RCW 70.129 Resident Rights, WAC 388-78A-2660, WAC 388-78A-2630…All staff members and residents will be educated about abuse and neglect in the assisted living setting, including definitions, prevention, awareness, investigation and reporting…All allegations of abuse or neglect will be treated as serious and will be investigated, documented and reported per the standards set forth in this policy and procedure…Failure to follow the policy and procedure as set forth will be considered a serious violation of employee responsibilities and will result in disciplinary action up to and including discharge.” Under section “Definitions,” it stated, “Neglect: for the purpose of this policy, Neglect means the active or passive failure to provide the basic care or services necessary to maintain the health and safety of an adult, when that failure results in physical harm, significant emotional harm, unreasonable discomfort, or serious loss of personal dignity to the adult; or creates the risk of serious harm to the adult. The expectation for care may exist because of an assumed responsibility or a legal contractual agreement, including, but no limited to, where an individual has a fiduciary responsibility to assure the continuation of necessary care or services. An adult, who in good faith, is voluntarily under treatment solely by spiritual means in accordance with the tenets and practices of a recognized church or religious denomination shall, for this reason alone, not be considered subjected to abuse by reason of neglect as defined in these rules.” Under the section, titled, ”C. Reporting Witnessed or Suspected Abuse or Neglect,” stated, “ The alleged abuse will be immediately reported by the person who witnessed it, to the supervisor on duty, or the Administrator, and to the appropriate state agency, following the guidelines for mandatory reporting…An incident report will be completed, and the state mandated reporting will be completed and submitted in accordance with state regulations.” Record review of the “Department of Social And Health Services” document, Completion date 08/05/2024, showed “As a result of the on-site visit(s) the department found that you are not in compliance with the licensing laws and regulations [including WAC (Washington Administrative Code) 388-78A-2630] as stated in the cited deficiencies in the enclosed report. 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.

Findings included ... Record review of the "Department of Social Arid Health Services" document, Completion date 03/28/2025, showed "As a result of the on~site visit(s) th~ d~pa.rtm~nt found that you are not in compliance with the licensing Jaws ·and regulations [including WAC (Washington Administrative Code) 388-78A-3100] as stated in the cited deficiencies in the enclosed report. I understand that to maintain an .Asslsted Livlng Facility license, the facility must be in compliance. with all the. licensing laws and regulations at all times." The administrator section showed Staff C, Former Administrator, signed the docume.n:t on 04/11/2025. Staff C signed·the "Plan/Attestation Statement" for all citatforrs cited that read "I hereby certify that I hav~ reviewed this report c!nd have taken qr will i;ake active measures to correct this deficiency. By taking this action, [the facility} is or will. be in compliance with this law and/or regulation on 04/27/2025.>l Statement of Deficiencies License #: 2600 Compliance Determination # 59785 Plan of Correction Memory Care At The Lodges Completion Date 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. 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-3100 Safe storage of supplies and equipment. The assisted living facility must secure potentially hazardous supplies and equipment commensurate with the assessed needs of residents and their functional and cognitive abilities. In determining what supplies and equipment may be accessible to residents, the assisted living facility must consider at a minimum: (1) The residents' characteristics and needs; (2) The degree of hazardousness or toxicity posed by the supplies or equipment; This requirement was not met as evidenced by: Based on observation, interview, and record review, the facility failed to secure potentially hazardous supplies accessible to memory care residents for 2 of 2 buildings reviewed (Lodge 1 and Lodge 2). This failure placed all 41 of 41 residents at risk for access to and potential ingestion/exposure of harmful chemicals. Findings included… Record review of the “Department of Social And Health Services” document, Completion date 03/28/2025, showed “As a result of the on-site visit(s) the department found that you are not in compliance with the licensing laws and regulations [including WAC (Washington Administrative Code) 388-78A-3100] as stated in the cited deficiencies in the enclosed report. 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.” The administrator section showed Staff C, Former Administrator, signed the document on 04/11/2025. Staff C signed the “Plan/Attestation Statement” for all citations cited that read “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 facility] is or will be in compliance with this law and/or regulation on 04/27/2025.” . Statement of Deficiencies License #: 2600 Compliance Determination # 59785 Plan of Correction Memory Care At The Lodges Completion Date Record review of the facility Resident Characteristics Roster, dated 05/19/2025, showed the facility had 41 of 41 residents identified as having Dementia (a disease that impairs memory, thinking, and the ability to perform daily activities) or cognitive impairment. During an interview on 05/19/2025 at 09:48AM, Staff B, Clinical Support Specialist, was asked what actions were taken to ensure harmful chemicals were properly stored and kept out of reach of residents after their previous citation. Staff B stated, “There was an In-service [staff education] done… Locks were purchased and placed… Management is also doing daily walkthroughs making sure things are locked up, and there is nothing in there.” In an observation on 05/19/2025 at 10:11AM, in Lodge 2, a secured memory care building, observed in a resident common area with cabinets and a sink, child locks were placed on the cabinet bars. Some locks were observed to be in place, and engaged, but other locks were observed to be left unlocked, and left hanging on the cabinet bars. The cabinet below the sink was left unlocked. In the unlocked cabinet were three bottles of blue window cleaner which read, “Keep out of reach of children,” and one can of disinfectant which read, “Keep out of reach of children.” In an observation on 05/19/2025 at 10:14AM, in Lodge 1, a secured memory care building, observed in a resident common area with cabinets and a sink, child locks placed on the cabinet bars. Some locks were observed to be in place, and engaged, but other locks were observed to be left unlocked, and left hanging on the cabinet bars. The upper right cabinet was left unlocked. In the unlocked cabinet was one bottle of hand sanitizer, and 2 bottles of lotion. The cabinet below the sink was also left unlocked. In the unlocked cabinet was one bottle of hand sanitizer, one bottle of antibacterial liquid hand soap, and one can of disinfectant which read, “Keep out of reach of children.” In an interview on 05/19/2025 at 12:15 PM, Staff A, Director of Operations-West/Interim Executive Director, stated that the chemicals should have been stored in the cabinets with the locks engaged and in place. This is an uncorrected deficiency previously cited on 03/28/2025. . . 05.30.2025 15:13:14 State of Washington 617 Staterr1ent of Deficiencies License #: 2600 Compliance Determination # 59785 Plan of Correction Memory Care At The Lodges Completion Date .Page 4 of 4 Licensee: Greenlake Management Lacey, LLC 05/22i2025 Plan/Attestation Statement I hereby certify that I have reviewed this report and have ta.ken or will take active mea.~ures to correct thi:;; defiGiency. By taking this action, Memory Care A.t T. e Lodges is or will be in compliance with this law and I or regulation on (Date)__,,=~~-'¥--"'"""""......,__ In addition, I will implement a system to monitor and ensure continued compH~nce with this requlr~ . I ~~ t)~ffe,Zy' Administrator (or Representative) Date Statement of Deficiencies License #: 2600 Compliance Determination # 59785 Plan of Correction Memory Care At The Lodges Completion Date 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, Memory Care At The Lodges 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 . . Investigation Summary Report Provider/Facility: Memory Care At The LodgesProvider Type: Assisted Living Facility License/Cert.#: 2600 Intake ID: 170841 Compliance Determination #: 56738 Region/Unit#: RCS Region 3 I Unit E Investigator: Paul Aube Investigation Date(s): 03/21/2025 through 03/28/2025 Complainant Contact Date(s): Allegation(s): 1. Quality of Care/Treatment: Public report of a resident-to-resident altercation in the community. 2. Physical Environment: Public allegation of uncleanly environment, and broken resident furnishings. 3. Administration/Personnel: Public report of concerns with staffing in the facility. Investigation Methods: Sample: Total residents: 46 Resident sample size: 15 Closed records sample size: 1 Observations: Identified resident Residents Activities Dining Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Identified resident Residents Nursing staff Family members Housekeeping staff Management Record Reviews: Facility policies Negotiated Service Agreements Incident Reports Incident investigation Progress Notes Hospital Records Investigation Summary: 1. Quality of Care/Treatment: Facility investigated incident, and protected residents . per policy. Facility made appropriate notifications, and monitored residents per policy. No failed practice. 2. Physical Environment: Facility observed to have unclean conditions in resident living areas. Observations also made of broken closet door in resident room. Claims substantiated. Failed practice identified. 3. Administration/Personnel: Staffing concerns were addressed under Statement of Deficiencies dated 02/13/2025. Facility is in their plan of correction phase to address non compliance. Conclusion / Action: ~ Failed Provider Practice Identified/ Citation(s) Written D Failed Provider Practice Not Identified / No Citation Written □ NIA . Investigation Summary Report Provider/Facility: Memory Care At The LodgesProvider Type: Assisted Living Facility License/Cert.#: 2600 Intake ID: 1707 41 Compliance Determination #: 56738 Region/Unit#: RCS Region 3 I Unit E Investigator: Paul Aube Investigation Date(s): 03/21/2025 through 03/28/2025 Complainant Contact Date(s): Allegation(s): 1. Resident/Patient/Client Neglect: Public allegation of facility failing to treat medical concerns of residents. 2. Physical Environment: Public allegation of uncleanly environment. 3.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: Memory Care At The LodgesProvider Type: Assisted Living Facility License/Cert.#: 2600 Intake ID: 168186 Compliance Determination #: 55370 Region/Unit #: RCS Region 3 / Unit E Investigator: Paul Aube Investigation Date(s): 02/26/2025 through 03/07/2025 Complainant Contact Date(s): Allegation(s): 1. Quality of Care/Treatment: Public report of facility failing to obtain and provide medications, resulting in resident hospitalization. 2. Nursing Services: Public report of facility failing to obtain and provide medications, resulting in resident hospitalization. Investigation Methods: Sample: Total residents: 51 Resident sample size: 5 Closed records sample size: 0 Observations: Identified resident Residents Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Nursing staff Family members Kitchen staff Laundry staff Management Record Reviews: Medical records Facility policies Incident investigation Negotiated Service Agreements Medication Administration Records Progress Notes/Alert Charting Hospital Records Investigation Summary: 1. Quality of Care/Treatment: Facility failed to obtain, and administer resident medications as ordered by their provider. This failure resulted in residents being hospitalized. Failed practice Identified. 2. Nursing Services: Facility failed to obtain, and administer resident medications as . ordered by their provider. This failure resulted in residents being hospitalized. Failed practice Identified. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: Memory Care At The LodgesProvider Type: Assisted Living Facility License/Cert.#: 2600 Intake ID: 168010 Compliance Determination #: 55370 Region/Unit #: RCS Region 3 / Unit E Investigator: Paul Aube Investigation Date(s): 02/26/2025 through 03/07/2025 Complainant Contact Date(s): Allegation(s): Quality of Care/Treatment: Facility Report of a resident-to-resident altercation in the community. Investigation Methods: Sample: Total residents: 51 Resident sample size: 5 Closed records sample size: 0 Observations: Identified resident Residents Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Nursing staff Family members Kitchen staff Laundry staff Management Record Reviews: Medical records Facility policies Incident investigation Negotiated Service Agreements Medication Administration Records Progress Notes/Alert Charting Hospital Records Investigation Summary: Quality of Care/Treatment: Facility failed to monitor residents, and failed to follow policies and procedures after incident occurred in the community. Regarding monitoring of residents, these issues were addressed under Statement of Deficiencies dated 11/18/2024. Regarding policies and procedures, these issues were addressed under Statement of Deficiencies dated 02/13/2025. Facility is in their plan of correction phase to address non compliance. The facility also failed to . provide documentation, as requested by the department, during an investigation. Failed practice identified. 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 800 NE 136th Ave Ste 200, Vancouver, WA 98684 Statement of Deficiencies License #: 2600 Compliance Determination # 55370 Plan of Correction Memory Care At The Lodges 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 an unannounced on-site complaint investigation on 02/26/2025 and 02/27/2025 of: Memory Care At The Lodges 1530 Carpenter Rd SE Lacey, WA 98503 This document references the following complaint number(s): 165100, 168186, 168309, 168010 The following sample was selected for review during the unannounced on-site visit: 5 of 51 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Paul Aube, ALF NCI From: DSHS, Aging and Long-Term Support Administration 800 NE 136th Ave Ste 200 Vancouver, WA 98684 . . Statement of Deficiencies License #: 2600 Compliance Determination # 55370 Plan of Correction Memory Care At The Lodges Completion Date 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. 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-2210 Medication services. (1) An assisted living facility providing medication service, either directly or indirectly, must: (a) Meet the requirements of chapter 69.41 RCW Legend drugs Prescription drugs, and other applicable statutes and administrative rules; and (b) Develop and implement systems that support and promote safe medication service for each resident. (2) The assisted living facility must ensure the following residents receive their medications as prescribed, except as provided for in WAC 388-78A-2230 and 388-78A-2250 : (a) Each resident who requires medication assistance and his or her negotiated service agreement indicates the assisted living facility will provide medication assistance; and (b) If the assisted living facility provides medication administration services, each resident who requires medication administration and his or her negotiated service agreement indicates the assisted living facility will provide medication administration. This requirement was not met as evidenced by: Based on record review and interview, the facility failed to implement safe medication practices to ensure residents received their medications as prescribed for 2 of 2 residents (Resident 4 [R4], and Resident 5 [R5]). This failure resulted in R4 being hospitalized and contributed to R5’s hospitalization due to missed medications. Findings included… Review of a facility policy titled, “Medication Non-Availability,” last reviewed on . Statement of Deficiencies License #: 2600 Compliance Determination # 55370 Plan of Correction Memory Care At The Lodges Completion Date 02/15/2024, it stated, “The Community will make every reasonable effort to ensure that medications are available as prescribed, for each resident. A system will be in place to facilitate timely medication refills for residents whose medications are purchased from the Community's preferred pharmacy provider.” In section titled “Procedure,” it stated, “An automatic cycle refill system is encouraged to ensure timely refills of resident medication whenever feasible, and if available from the Community's preferred pharmacy provider.” Review of the Cleveland Clinic article titled “Hypoxemia,” last reviewed on 06/15/2022, stated, “Hypoxemia is when oxygen levels in the blood are lower than normal. If blood oxygen levels are too low, your body may not work properly. Someone with low blood oxygen is considered hypoxemic… Hypoxemia can happen if you can’t breathe in enough oxygen or if the oxygen you breathe in can’t get to your blood… Depending on the severity and duration, hypoxemia can lead to mild symptoms or lead to death. Mild symptoms include headaches and shortness of breath. In severe cases, hypoxemia can interfere with heart and brain function. It can lead to a lack of oxygen in your body’s organs and tissues (hypoxia).” In the section titled, “How is hypoxemia treated?” it stated, “Medications or other treatments can help raise your blood oxygen level… Treatments, which focus on the underlying cause, may include: Inhalers with bronchodilators or steroids to help people with lung disease…” Review of the Cleveland Clinic article titled “Blood Oxygen Level,” last reviewed on 02/18/2022, stated, “A pulse oximeter can also measure blood oxygen saturation levels through a small clip that’s usually placed on your finger or toe. An oximeter reading only indicates what percentage of your blood is saturated with oxygen, known as the SpO2 level, as well as your heart rate…For most people, a normal pulse oximeter reading for your oxygen saturation level is between 95% and 100%... A lower-than-normal blood oxygen level is called hypoxemia. Since oxygen is essential to all of your body’s functions, hypoxemia is often concerning. The lower the oxygen level, the greater likelihood for complications in body tissue and organs.” During an interview on 02/26/2025 at 12:59PM, Staff B, the Health and Wellness Director/Licensed Nurse, was asked when floor staff would initiate a re-order for medications running out on a resident who was on their cycle fill through their in-house pharmacy. Staff B stated, “I tell them within 7 days.” <R4> Review of R4’s Face Sheet dated 02/26/2025, showed that R4 was admitted to the facility on /2023. Review of an unsigned Negotiated Service Agreement for R4, undated, showed under “Medications” that R4 required “Significant (Total) Assist by Med Tech [Medication Technician].” Under the “Medication Administration” section, under “Goals” it stated, “Resident will have medications administered per physician’s orders.” Under “Interventions” it stated, “Administer resident medications per physician’s orders as noted on the MAR [Medication Administration Record]”. .

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Home and Community Living Administration PO Box 45600, Olympia, WA 98504-5600 August 5, 2025 ELECTRONIC-FACSIMILE Administrator Memory Care At The Lodges 1530 Carpenter Rd SE Lacey, WA 98503 Assisted Living Facility License # 2600 Licensee: Greenlake Management Lacey, LLC IMPOSITION OF CIVIL FINES Dear Administrator: On July 23, 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 Memory Care At The Lodges, located at 1530 Carpenter Rd SE, Lacey, 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 July 23, 2025. Civil Fines WAC 388-78A-2130 (1)(a)(b)(c)(2) Service agreement planning. $300.00 The licensee failed to complete an initial negotiated service agreement (NSA) after a resident moved to the community for one resident. This failure placed the resident at risk for unmet care needs and a decreased quality of life. This is an uncorrected deficiency previously cited on May 21, 2025. Administrator Memory Care At The Lodges License # 2600 August 5, 2025 Page 2 WAC 388-78A-2090 (1)(a)(b)(c)(2)(a)(b)(c)(3)(4)(a)(b)(5)(a)(b)(c)(6) $400.00 (a)(b)(c)(d)(e)(7)(a)(b)(c)(i)(ii)(d)(8)(a)(b) (i)(ii)(9)(10)(11)(a)(b)(c) Full assessment topics. The licensee failed to complete an initial assessment within 14 days after a resident moved to the community for one resident. This failure placed the resident at risk for unmet care needs and a decreased quality of life. This is an uncorrected deficiency previously cited on May 21, 2025. 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: Clinton Fridley, RN, Field Manager Region 3, Unit E 6639 Capitol Blvd SW Point Plaza West Tumwater, WA 98501 Phone: (360) 450-1218/ Fax: (360) 664-8451 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. Administrator Memory Care At The Lodges License # 2600 August 5, 2025 Page 3 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 $700.00 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 Memory Care At The Lodges License # 2600 August 5, 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 Clinton Fridley, Field Manager, at (360) 450-1218. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 3, Unit E 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

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 800 NE 136th Ave Ste 200, Vancouver, WA 98684 Statement of Deficiencies License #: 2600 Compliance Determination # 53470 Plan of Correction Memory Care At The Lodges 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 an unannounced on-site complaint investigation on 01/23/2025 of: Memory Care At The Lodges 1530 Carpenter Rd SE Lacey, WA 98503 This document references the following complaint number(s): 162823 The following sample was selected for review during the unannounced on-site visit: 0 of 0 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Paul Aube, ALF NCI From: DSHS, Aging and Long-Term Support Administration 800 NE 136th Ave Ste 200 Vancouver, WA 98684 . Statement of Deficiencies License #: 2600 Compliance Determination # 53470 Plan of Correction Memory Care At The Lodges Completion Date 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. 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 observation, interview, and record review, the facility failed to maintain fire safety per the state fire marshal regulations for 1 of 1 facility reviewed. These failures placed 29 of 29 residents, staff, and visitors' life and safety at risk in the event of a fire. Findings included… Internation Fire Code (IFC) 0406.6 2021 Record Keeping “Records shall be maintained of required emergency evacuation drills and include the following information: 1.Identity of the person conducting the drill. 2.Date and time of the drill. 3.Notification method used. 4.Employees on duty and participating. 5.Number of occupants evacuated. 6.Special conditions simulated. 7.Problems encountered. 8.Weather conditions when occupants were evacuated. 9.Time required to accomplish complete evacuation.” . Statement of Deficiencies License #: 2600 Compliance Determination # 53470 Plan of Correction Memory Care At The Lodges Completion Date (IFC 706.1 2018) Maintaining protection. “Dampers protecting ducts and air transfer openings shall be inspected and maintained in accordance with NFPA [National Fire Protection Association] 80 and NFPA 105. Other products or materials used to protect the openings for ducts and air transfer openings shall be securely attached to or bonded to the construction containing the duct or air transfer opening, without visible openings through or into the cavity of the construction. Any damaged products or materials protecting duct and air transfer openings shall be repaired, restored or replaced.” (IFC 903.5 2021) Testing and Maintenance. “Sprinkler systems shall be tested and maintained in accordance with Section 901.” (IFC 904.13.5.2 2021) Extinguishing System Service. “Automatic fire-extinguishing systems shall be serviced not less frequently than every six months and after activation of the system. Inspection shall be by qualified individuals, and a certificate of inspection shall be forwarded to the fire code official upon completion.” (IFC 907.8 2018) Inspection, testing and maintenance. “The maintenance and testing schedules and procedures for fire alarm and fire detection systems shall be in accordance with Sections 907.8.1 through 907.8.5 and NFPA 72. Records of inspection, testing and maintenance shall be maintained.” (IFC 907.8.3 2021) Smoke Detector Sensitivity. “Smoke detector sensitivity shall be checked within one year after installation and every alternate year thereafter. After the second calibration test, where sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4-percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to not more than 5 years. Where the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.” (IFC 1032.10.1 2021) Activation Test “Emergency lighting equipment shall be tested monthly for a duration of not less than 30 seconds. The test shall be performed manually or by an automated self-testing and self-diagnostic routine. Where testing is performed by self-testing and self-diagnostics, a visual inspection of the emergency lighting equipment shall be conducted monthly to identify any equipment displaying a trouble indicator or that has become damaged or otherwise impaired.” (IFC 1031.10.2 2021) Power Test “Battery-powered emergency lighting equipment shall be tested annually by operating the equipment on battery power for not less than 90 minutes.” . Statement of Deficiencies License #: 2600 Compliance Determination # 53470 Plan of Correction Memory Care At The Lodges Completion Date (NFPA 80 Fire Door Inspection and Testing) “5.2.1 Inspection and testing. Upon completion of the installation, door, shutters and window assemblies shall be inspected and tested in accordance with 5.2.4. 5.2.4 Periodic Inspection and Testing. 5.2.4.1 Periodic Inspection and testing shall be performed not less than annually. 5.2.2.4 A Record of all inspections and testing shall be provided that includes, but its not limited to, the following information: 1. Date of inspection. 2. Name of facility. 3. Address of facility. 4. Name of person(s) performing inspections and testing. 5. Company name and address of inspecting company. 6. Signature of inspector on record. 7. Individual record of each inspected and tested fire door assembly. 8. Opening identifier and location of each inspected and tested fire door assembly. 9. Type and description of each inspected and tested fire door assembly. 10. Verification of visual inspection and functional operation. 11. Listing of deficiencies in accordance with 5.2.3, Section 5.3 and Section 5.4. And the following shall be checked: 1. Labels are clearly visible and legible. 2. No open holes or breaks exist in surfaces of wither the door or frame. 3. Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. 4. The door, frame, hinges, hardware are noncombustible threshold are secured, aligned and in working order with no visible signs of damage. 5. No parts are missing or broken. 6. Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7. 7. The self-closing device is operational: that is, the active door completely closes when operated from the full open position. 8. If a coordinator is installed, the inactive lead close before the active lead. 9. Latching hardware operates and secures the door when it is in the closed position. 10. Auxiliary hardware items that interfere or prohibit operation are not installed on the door frame. 11. No field modification to the door assembly have been performed that void the label. 12. Meeting edge protection, gasketing and edge seals where required, are inspected to verify their presence and intertie. 13. Signage affixed to a door meets the requirements listed in 4.1.4.” Review of an undated facility policy titled, “Smoke/Fire Damper,” showed, “Each damper shall be tested and inspected 1 year after installation. The test and inspection frequency shall be every 4 years, except in hospital, where frequency shall be every 6 years. Local jurisdictions identify minimum testing qualifications. Place fire and smoke damper inspection documents behind this tab.” Review of an undated facility policy titled, “Sprinkler Systems,” showed, “Sprinkler Systems are required to be serviced annually. Place your annual report behind this tab. Sprinkler systems must have a 5-year internal pipe inspection. Place your last 5-year inspection report behind this tab. Sprinkler systems are required to be inspected quarterly. Place your quarterly inspection report behind this tab.” . Statement of Deficiencies License #: 2600 Compliance Determination # 53470 Plan of Correction Memory Care At The Lodges Completion Date Review of an undated facility policy titled, “Fire Alarm Systems,” showed, “Fire Alarms are required to be serviced annually. Place your fire alarm annual servicing report behind this tab.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . . . .

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