The Cottages at Lacey.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . . 31 STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT P.DMINISTRATION $00 NE 13~th Ave Ste 200, Vanc·oµver, WA 98684 Statement of Deficiencies License #: 2443 Compliance Determination:# 6 3541 Plan of Cor.rection The Cottages at Lacey Completion ·oate Page 1 of6 Ucensee: Lacey Special care Community LLC 10/27/2025 You are requjred to be in .compllance at al.I tirnes with all licensing laws and regulations to maintain your Assisted Living Facility license. The department c.ernpleted data collection for an unannounced on-site complaint investi.gatioh on 08/04/2025 of: The Cottages at L;3cey 8570 Martin Way E Lacey, WA 98516 This document references the followln_g complaint numb~r(s); 18765.2 The following sample was selected for review during the unannounced on-site visit 4 of 56 current resicients anq 3 forr:ner residents. The department staff that investigated the As·sisted Living Facility: Pamela Horlick, NCI RN Complaint Investigator From: DSHS, Aging and Long-Term Support Administration $00 NE 136th Ave Ste 200 Vancouver, WA 98684 . ->tate ot washington 41 Statement of Defici.encies License #.: 2443 Compliance Determination # 63541 Plan of Correction The Cottages at Lacey Completion Date As a result of the on-site visit(s), the department found that you are not in compliance with the ljcensing laws and regulqtions as stated in the cited deficiencies in the enclosed report. 11/04/2025 CareSi Residential Date I understc:1nd that to maintain an Assisted Living Facility license, the facility must be .in compliance with all the licensing laws and re.gulations at all times. 1 ' Date WAC 388-78A~2240 Nonavailability of medications, When the assisted living facility has assumed responsibility for obtaining a resid~nfs prescribed medications, the a$Sisted living facility must obtain them an a correct and timely manner. This requirement was not met as evidenced by: Ba_sed on interview and record review, the assis,ed living fa,cility (ALF) fajled to ensure medications were obtained from the pharmacy after a physician ordered them to treat an infection tor 1 of 3 residents (Resident 1). This fajlure resulted in the facility falling to acquire the medication and Resident 1 (R1) not being treated in the facility for the infection which led to a worsening in the resident's condition requiring hospitalization. Findings included ... Record review of facility policy titled, "Medication Unavailable," revi•sed on 06/22/2021. showed that the assisted living facilfty (ALF) was to order/reorder medications fbr resi.dents that are receiving mediation services in a timeframe and manner that promotes health and if medications were unavailabJe, facility staff wou·ld attempt to determine the cause for unavailability and take steps in attempt to obtain needed medications, including repeated contact with physician/pharmacy and all effort$ wot,1ld be documented in the resident record and the resident/responsible party and resident physician would be. notified. Record review of facility records showed th?1t: R 1 was admitted on /2025 with various diagnoses including and . . 11.05.2025 11 :25:06 State of 14ashington 5/ Statert1ent of Deficiencies License #-: 2443 Comp_!iance Determination # 6354·1 Plan of Correction The Cottages at Lacey Completion Date Page 3: of 6 Licensee: Lacey Special Gare Community LLC 10/27i2025 Record review of facility resident records titled, "Service Plan Report," dc!ted /2025, showed that facility staff w~re to order and maintain all medications and assist resident me_dications as per physician o_rder and that st~ff q.re to orde_r all medicine and ensure R1 ts receiving the right medication at the rig.ht dosage and to notify director of nursing services (DNS) and primary care physician (PCP_) if R 1 is refusing medications. Review of R1's progress notes, dated 07/15/2025, documented that R1 wa$ experiencing a change of condition, behavior changes, speech was difficult to understand, refusing to eat/drink and had difficulty taking medications. Review of R1's progress notes, dated 07/16/2025. documented that a medical provider came in to assess R1 in the morning ano R1 r~fused toe.at or drink. Record review of bispatchHealth (a mobile healthcare provider) documentation, dated 07/16/2025, documented that R1 was seen by a physician's assistant (PA)_ on 07/16/2025 at 08:29 AM. The reason for the visit was UTI, cloudy urine, lethargy, and anxiety. R1 had reside.d at the facility for a week and started having worsening symptoms yesterday, consistent with previous UTl's they have ha_d. Otherwise, R1 was healthy, The diagnosis was and document~d that urosepsis wa$ unlik·ely given non-toxic appearance with stable vital signs. Cefdinir (an antibiotic drug used to treat bacterial infections) 300 milligrams (mg) capsules were ordered on 07/16/2025 to be taken every 12 hours for seven days for UTL Staff were to push fluids and follow-up .as needed if symptoms worsen or fail to irnprove. Record review o.f the prescription sent to R1's pharma.cy, written on 07i16/2025, showed an order for Cefdinir 300 mg capsule to be given once every 12 hours for seven days for UTI and was received by R1 's pharmacy on 07i16/2025. R1 's birthdate on the prescription order did n_ot match the correct birthd_ate for R1 . Record review of a pharmacy document titled., "Permission to Bill Facility for Non--Covered Medications/ · dated 07/17/-2025, showed a fax was .sent to the facility to request the. facility be bill.ed for the antibiotic. A second attempt to request the facility be billed for the antibiotic was-made by the pharmacy on 07/18/2025, Listed on the fax was R1's name. correct date of birth and the antibiotic order details_ Review of R1's Medication Administration Record (MAR), from 07/16/2025-thtough /2028, showed an order for Cefdi.nir 300 mg with directions to take one capsule by mouth every 12 hours for seven days .for UTL Further review of R1's MAR showed the order for Cefdinir was labeled as pending confirmation, with a start date of 07/16/2025 at 1 :51 PM and no documentation on th.e MAR indicating the medication was administe1"ed'. . ~tate or washington 61 Statement of Deficiencies License#: 2443 Compliance Determination # 63541 Plan of Correction The Cottages at Lacey Completion Date Review of R t's progress note, dated 07/17/2025, documented that R 1 stayed i'n bed all shift and did not eat preakfast or lunch. The pharmacy was contacted regardfrig the antib1otic (cefdinir) and stated they did not receive the p~perwork an.d. that Staff B, Director of Nursing (DON), was notified. Staff C, Resident Care Coordinator (RGC) reached out to the phc;!rmacy and discovered that the pharmacy had the wrong birth date documented for R 1 and then the pharmacy staff stated that they didn't know why the antibioUc wasn't sent but that they will send it tonight. Review of email communication, dated 07/18/2025, documented that Staff C, Resident Gare Coordinator (RCC)., responded to a pharmacy email providing addftional information as requested. Review of R1 's pro§ress notes, d~ted. 07/18/2025, documented th~t R 1 was combative with staff during care and did hot eat breakfast or lunch and refused to leave their room. Review of R1's progress notes, dated 07i19/2025, documer:ited that R1 seemed weak ano :couldn't communicate thoroughly. Review of R 1.rs progress notes, dated 07/20/2025, documented that R 1 was "on a steep decline" and that ·they· a re ve.ry_ drowsy and $leepy· and not e·ating. Review of R 1' s progress notes, dated /2025. dO"cumented. that R 1' s primary care physician (PCP) was at the ALF to '€<Stablish care and R 1 was diagnose-0 with a and had not received antibiotics from the pharmacy despite speaking with the pharmacy on 07/17/2025 and being toJd it would be s·ent out, medication did not arrive at the facility qnd R1 was transported to the hpspital. Record review of R1 's facility r.ecords, on 08/04/2025, showed no qocumentation that R 1' s family or PCP was notified ofmfssed medication or issues surrounding obtaining the medication, nor did ft show further attempts documented that the ALF reached out to the pharmacy after 07/18/2025. On 08/04/2025 at 3: 11 PM, Staff A, Exe,cutive Director, stated that R 1 s PCP could have been notified when R 1 hadn't received the antibiotic that was ordered. Staff A stated that it was not appropriate for a resident to go five to six days without medications after it was ordered ~nd stated that R1 's UTI treatment, due to the ALF not receiving the antiblbtic. had been delayed.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written . N/A . Statement of Deficiencies License #: 2443 Compliance Determination # 63859 Plan of Correction The Cottages at Lacey 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-2660 Resident rights. The assisted living facility must: (1) Comply with chapter 70.129 RCW, Long-term care resident rights; (2) Ensure all staff persons provide care and services to each resident consistent with chapter 70.129 RCW; (4) Promote and protect the residents' exercise of all rights granted under chapter 70.129 RCW; (7) Not allow any staff person to abuse or neglect any resident. This requirement was not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure staff promoted care for residents in a manner that maintained or enhanced the residents dignity and respect for 1 of 1 residents (Resident 4 [R4]) when R4 was not allowed to have free access to their own apartment. This failure resulted in R4’s being kept from accessing their room when they wanted and contributed to R4 exhibiting signs of distress and anxiety and having a decreased quality of life. Findings included… Revised Code of Washington (RCW) 70.129.020 “Exercise of rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident and assist the resident which include: (2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights.” . Statement of Deficiencies License #: 2443 Compliance Determination # 63859 Plan of Correction The Cottages at Lacey Completion Date room, but they would just try and redirect them. Staff F stated they were not to lock any residents out of their room and only locked a resident’s room if they requested the door to be locked. In an interview on 08/08/2025 at 1:47 PM, Staff D, Medication Technician, stated R4 was allowed to go into their room anytime they desired. Staff D stated it was not the facility’s common practice to lock the residents’ rooms to keep them out of there. In an interview on 08/08/2025 at 2:06 PM, Staff E, Director of Nursing, stated it was not common for R4 to have their door locked or staff to lock R4’s door. In an interview on 08/08/2025 at 2:35 PM, Staff A, Executive Director, acknowledged that Staff B and Staff C were not to lock R4’s bedroom door to keep R4 out of their room. This is a recurring deficiency previously cited on 08/10/2022. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, The Cottages at Lacey is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 December 27, 2024 ELECTRONIC-FACSIMILE Administrator The Cottages at Lacey 8570 Martin Way E Lacey, WA 98516 Assisted Living Facility License # 2443 Licensee: Lacey Special Care Community LLC IMPOSITION OF CIVIL FINES Dear Administrator: On December 17, 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 The Cottages at Lacey, located at 8570 Martin Way E, 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 December 17, 2024. Civil Fines WAC 388-78A-2610 (1)(2)(c)(d)(e) Infection control. $1,000.00 The licensee failed to ensure the facility staff members washed their hands per the acceptable standards for three staff members reviewed. The facility also failed to ensure one laundry room had appropriate infection control for soiled linens. These failures placed 51 residents and 31 staff at risk of contracting and spreading communicable diseases. This is an uncorrected and recurring deficiency previously cited on October 14, 2024, April 5, 2024, January 18, 2024, June 22, 2023, and March 27, 2023, for subsections (1)(2)(c)(e). Administrator The Cottages at Lacey License # 2443 December 27, 2024 Page 2 WAC 388-78A-2950 (6) Water supply. $500.00 The licensee failed to ensure the facility’s hot water temperature had been maintained between 105 and 120 degrees Fahrenheit (F) for two areas reviewed. This failure placed 51 residents and 31 staff at risk for potential skin burns, discomfort, and decreased quality of life. This is an uncorrected deficiency previously cited on October 14, 2024. WAC 388-78A-3100 (1)(2)(3)(4) Safe storage of supplies and equipment. $500.00 The licensee facility failed to secure potentially hazardous supplies accessible to memory care residents for two locations within the facility. This failure placed 51 residents at risk for ingesting potentially toxic materials. This is an uncorrected and recurring deficiency previously cited on October 14, 2024, and January 18, 2024. WAC 388- 78A-2320 (2)(b)(3)(c) Intermittent nursing services systems. $600.00 The licensee failed to ensure facility staff had the required nurse delegation training and credentials for two staff reviewed. The facility also failed to maintain and provide current nurse delegation documents for three residents. These failures resulted in three residents receiving medications from unqualified caregivers and placed them at risk for unmet medical care needs. This is an uncorrected deficiency previously cited on October 14, 2024. NOTE: These/This is/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. Administrator The Cottages at Lacey License # 2443 December 27, 2024 Page 3 Return the signed and dated SOD to: Cory Cisneros, Field Manager Region 3, Unit E 6639 Capitol Blvd SW Point Plaza West Tumwater, WA 98501 Phone: (253) 254-3190 / 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. 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. Administrator The Cottages at Lacey License # 2443 December 27, 2024 Page 4 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 $2,600.00 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, WA 98507-9501 (360) 664-5919 / FAX: (360) 664-8401 OFRMMISVendor@dshs.wa.gov If the Office of Financial Recovery has not received your payment within twenty-eight (28) days after receipt of this letter, interest will begin to accrue immediately on the balance, at the rate of one percent per month. If you do not submit a hearing request or make payment within twenty-eight (28) days, the balance due will be recovered. Administrator The Cottages at Lacey License # 2443 December 27, 2024 Page 5 If you have any questions, please contact Cory Cisneros, Field Manager, at (253) 254-3190. Sincerely, Rathana Duong 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 SN

Allegations were substantiated and corrective actions issued. No notification made to the Department after allegations of neglect received. Failed practice identified. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written . N/A . . . . .

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

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

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: The Cottages at Lacey Provider Type: Assisted Living Facility License/Cert.#: 2443 Compliance Determination #: 21875 Intake ID: 73391 Investigator: Paul Aube Region/Unit #: RCS Region 3 / Unit E Investigation Date(s): 03/30/2023 through 05/03/2023 Complainant Contact Date(s): Allegation(s): 1. Quality of Care/Treatment: Facility report of physical and mental abuse to a resident, from a staff member. 2. Resident/Patient/Client Rights: Facility report of physical and mental abuse to a resident, from a staff member. Investigation Methods: Sample: Total residents: 41 Resident sample size: 6 Closed records sample size: 3 Observations: Residents Activities Dining Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Nursing staff Residents Management Record Reviews: Personnel files Facility policies Medical records Medication Administration Records Progress Notes Care Plans Investigation Summary: 1. Quality of Care/Treatment: Facility failed to follow policy and conduct an investigation of physical, verbal, abuse from staff and notify the department when an allegation of abuse was made. Failed practice identified. 2. Resident/Patient/Client Rights: Facility failed to follow policy and conduct an investigation of physical, verbal, abuse from staff and notify the department when an allegation of abuse was made. Failed practice identified. . Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . .

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

Conclusion / Action: . Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: The Cottages at Lacey Provider Type: Assisted Living Facility License/Cert.#: 2443 Compliance Determination #: 21079 Intake ID: 71227 Investigator: Celeste Vashey Region/Unit #: RCS Region 3 / Unit E Investigation Date(s): 03/22/2023 through 03/27/2023 Complainant Contact Date(s): Allegation(s): 1) Facility reported concern regarding the death of a resident. Investigation Methods: Sample: Total residents: 40 Resident sample size: 3 Closed records sample size: 1 Observations: Staff to resident interactions Resident to resident interactions Interviews: Nursing staff Family members Record Reviews: Incident investigation Facility policies Medical records Investigation Summary: 1) Based on record review and interview no failed practice found regarding the death of the resident. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: The Cottages at Lacey Provider Type: Assisted Living Facility License/Cert.#: 2443 Compliance Determination #: 21079 Intake ID: 73099 Investigator: Celeste Vashey Region/Unit #: RCS Region 3 / Unit E Investigation Date(s): 03/22/2023 through 03/27/2023 Complainant Contact Date(s): Allegation(s): 1) Concern the facility was not conducting regular showers for the resident. Investigation Methods: Sample: Total residents: 40 Resident sample size: 3 Closed records sample size: 1 Observations: Residents Resident rooms Interviews: Nursing staff Family members Record Reviews: Facility policies Investigation Summary: 1) Failed practice found based on interview, observation, and record review. The facility failed to conduct twice weekly showers as agreed upon in the Negotiated Service Agreement. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . . . . . . . . . . . .