Aegis of Mercer Island.

This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2509 Compliance Determination # 63699 Plan of Correction Aegis of Mercer Island Completion Date Page 2 of 5 Licensee: Aegis Senior Communities LLC 08/21/2025 As a result of the on-site visit(s), the department found that you are not in compliance with the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. Residential Care Services Date I understand that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. Administrator (or Representative) Date WAC 388-112A-0060 What are the training and certification requirements for volunteers and long-term care workers in assisted living facilities and assisted living facility administrators? (1) The following chart provides a summary of the training and certification requirements for a volunteer, an administrator or designee, and a long-term care worker in an assisted living facility: Who Status Facility orientation Safety/ orientation training Seventy-hour long-term care worker basic training Specialty training Continuing education (CE) Required credential (a) Long-term care worker in assisted living facility. (i) An ARNP, RN, LPN, NA-C, HCA, NA-C student or other professionals listed in WAC 388-112A- 0090 . Required per WAC 388-112A-0200 (1). Not required. Not required. Required per WAC 388- 112A-0400 . Not required of ARNPs, RNs, or LPNs in chapter 388-112A WAC. Required. Twelve hours per WAC 388-112A-0611 for NA-Cs, HCAs, and other professionals listed in WAC 388-112A- 0090 , such as an individual with special education training with an endorsement granted by the superintendent of public instruction under RCW 28A.300.010 . Must maintain in good standing the certification or credential or other professional role listed in WAC 388-112A-0090 . (3) The following training requirements are not listed in the charts in subsection (1) of this section but are required under this chapter: (a) First aid and CPR under WAC 388-112A-0720 ; WAC 388-112A-0710 What is CPR/first-aid training? CPR/first-aid training is training that meets the guidelines established by the Occupational Safety and Health Administration (OSHA). Under OSHA guidelines, training must include hands on skills development through the use of mannequins or trainee partners. WAC 388-112A-0720 What are the CPR and first-aid training requirements? (2) Assisted living facilities. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2509 Compliance Determination # 63699 Plan of Correction Aegis of Mercer Island Completion Date Page 3 of 5 Licensee: Aegis Senior Communities LLC 08/21/2025 (a) Assisted living facility administrators who provide direct care and long-term care workers must have and maintain a valid CPR and first-aid card or certificate within thirty days of their date of hire. WAC 388-78A-2474 Training and home care aide certification requirements. (2) The assisted living facility must ensure all assisted living facility administrators, or their designees, and caregivers hired on or after January 7, 2012 meet the long-term care worker training requirements of chapter 388-112A WAC, including but not limited to: (d) Cardiopulmonary resuscitation and first aid; and (e) Continuing education. This requirement was not met as evidenced by: Based on interview and record review the facility failed to ensure 3 of 6 staff (Staff C, Staff F, and Staff G) completed all required training to perform their job duties and responsibilities. This failure placed all 70 residents at risk of unmet care needs from staff with incomplete training. Findings included… Review of facility’s personnel records showed the facility hired Staff C, Associate Care Director, on 08/06/2024; Staff F, Care Manager 2, on 10/18/2021; and Staff G, Medication Care Manager, on 01/09/2020. CARDIOPULMONARY RESUSCITATION AND FIRST AID (CPR) STAFF C Review of Staff C’s personnel records showed that Staff C completed First-Aid and CPR training through an online, web-based training program. The records showed no documentation of any hands-on skills development training, as required. During an interview on 08/15/2025 at 3:10 PM, Staff A, Senior General Manager/Administrator, stated that they were aware of First-Aid/CPR training requirements. Staff A stated that they were unaware that Staff C’s training did not include the required hands-on skills development training. CONTINUING EDUCATION (CE) STAFF F Review of Staff F’s personnel records showed that Staff F did not complete the required 12 hours of CE training from their December 2023 birthday and their December 2024 This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2509 Compliance Determination # 63699 Plan of Correction Aegis of Mercer Island Completion Date Page 4 of 5 Licensee: Aegis Senior Communities LLC 08/21/2025 birthday. STAFF G Review of Staff G’s personnel records showed that Staff G did not complete the required 12 hours of CE training from their April 2024 birthday and their April 2025 birthday. During an interview on 08/14/2025 at 1:30 PM, Staff A stated that they were aware of the CE training requirements. Staff A stated that they were unaware that Staff F and Staff G did not complete the 12 hours of CE training, as required. 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, Aegis of Mercer Island 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-2480 Tuberculosis Testing Required. (1) The assisted living facility must develop and implement a system to ensure each staff person is screened for tuberculosis within three days of employment. (2) For purposes of WAC 388-78A-2481 through 388-78A-2489 , "staff person" means any assisted living facility employee or temporary employee of the assisted living facility, excluding volunteers and contractors. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure 1 of 6 staff (Staff D) was screened for Tuberculosis (TB), as required. This failure placed all 70 residents at risk of exposure to TB, an infectious disease. Findings included… Review of facility’s personnel records showed the facility hired Staff D, Medication Care Manager, on 11/11/2024. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2509 Compliance Determination # 63699 Plan of Correction Aegis of Mercer Island Completion Date Page 5 of 5 Licensee: Aegis Senior Communities LLC 08/21/2025 Review of Staff D’s records showed Staff D completed a Quantiferon, Interferon-Gamma Release Assay (IGRA) blood test (blood test used to detect TB infection) on 12/16/2024, thirty-five days after being hired. During an interview on 08/14/2025 at 1:30 PM, Staff A, Senior General Manager/Administrator, stated that they were aware of the TB screening requirements. Staff A stated that they were unaware that Staff D was not screened for TB when hired. 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, Aegis of Mercer Island is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date This document was prepared by Residential Care Services for the Locator website. Aegis of Mercer Island # 2509 08/21/2025 Page 2 of 5 eFax: (253) 395-5071 Email: rcsregion2email@dshs.wa.gov Optional method: 20425 72nd Avenue S, Suite 400 Kent, WA 98032 • Complete correction(s) within 45 days, or sooner if directed by the Department, after review of your proposed correction dates. • Have your plan approved by the Department. Consultation(s): In addition, the Department provided consultation on the following deficiency or deficiencies not listed on the enclosed report. WAC 388-112A-1000 Which trainings require department approval of the curriculum and instructor? (1) Except for facility orientation training under WAC 388-112A-0200 (1), the department must preapprove the curriculum, including delivery mode, and instructors for all training required under this chapter. (4) The department will approve adult family home, enhanced services facilities, and assisted living facility training programs and instructors for orientation and safety training under WAC 388-112A- 0200 (2) and 388-112A-0220 when the home is licensed. The facility training program may make changes to its training program as described in WAC 388-112A-1210 . WAC 388-78A-2450 Staff. (2) The assisted living facility must: (c) Verify prior to hiring that staff persons have the required licenses, certification, registrations, or other credentials for the position, and that such licenses, certifications, registrations, and credentials are current and in good standing; (e) Ensure all resident care and services are provided only by staff persons who have the training, credentials, experience and other qualifications necessary to provide the care and services; (3) The assisted living facility must: (d) Maintain the following documentation on the assisted living facility premises, during employment, and at least two years following termination of employment: (i) Staff orientation and training or certification pertinent to duties, including, but not limited to: (A) Training required by chapter 388-112A WAC; Facility staff personnel records showed the staff department orientation and safety training certificates were signed by a facility staff member who was not a department approved instructor. During the full inspection, the facility scheduled audits of all facility This document was prepared by Residential Care Services for the Locator website. Aegis of Mercer Island # 2509 08/21/2025 Page 3 of 5 staff records and removed any orientation and safety training certificates of completion signed by the unapproved employee. WAC 388-78A-2220 Prescribed medication authorizations. (2) The documentation required above in subsection (1) of this section must include the following information: (a) The name of the resident; Residents prescribed medications in bottles, tube, and inhaler stored on the facility medication cart were not labeled with any resident’s name. During the full inspection, the staff labeled the medication bottles and tube with the resident name. The staff removed the inhaler from the medication cart. The facility implemented improved guidelines for medication storage to meet the regulation. WAC 388-78A-2950 Water supply. The assisted living facility must: (6) Provide all sinks in resident rooms, toilet rooms and bathrooms, and bathing fixtures used by residents with hot water between 105 F and 120 F at all times; and The hot water temperatures in four-bathroom sinks, used by residents and visitors, did not consistently reach 105 degrees Fahrenheit. During the inspection, the facility staff adjusted the temperature and brought the water temperature within range of the regulatory requirements. WAC 388-78A-2400 Protection of resident records. The assisted living facility must: (2) Maintain resident records and preserve their confidentiality in accordance with applicable state and federal statutes and rules, including chapters 70.02 and 70.129 RCW; Several boxes that contained residents’ health information were stored in two locked mechanical rooms, one on the third floor and one on the fourth floor of the facility. The facility maintenance and outside contractors were granted unsupervised access to the mechanical rooms, jeopardizing a potential breach of confidential information contained in the resident records. During the full inspection, facility staff removed the boxes of identifiable health records from the mechanical rooms and secured them in a designated area only authorized individuals have access to meet the regulatory requirements. WAC 388-78A-2290 Family assistance with medications and treatments. (3) If the assisted living facility allows family assistance with or administration of medications and treatments, and the resident and a family member(s) agree a family member will provide medication or treatment assistance, or medication or treatment administration to the resident, the assisted living facility must request that the family member submit to the assisted living facility a written plan for such assistance or administration that includes at a minimum: This document was prepared by Residential Care Services for the Locator website. Aegis of Mercer Island # 2509 08/21/2025 Page 4 of 5 (a) By name, the family member who will provide the medication or treatment assistance or administration; (b) A description of the medication or treatment assistance or administration that the family member will provide, to be referred to as the primary plan; (c) An alternate plan if the family member is unable to fulfill his or her duties as specified in the primary plan; (d) An emergency contact person and telephone number if the assisted living facility observes changes in the resident's overall functioning or condition that may relate to the medication or treatment plan; and (e) Other information determined necessary by the assisted living facility. (4) The plan for family assistance with medications or treatments must be signed and dated by: (a) The resident, if able; (b) The resident's representative, if any; (c) The resident's family member responsible for implementing the plan; and (d) A representative of the assisted living facility authorized by the assisted living facility to sign on its behalf. The facility failed to ensure the family medication assistance plans for two residents contained all the required elements for the plans. During the full inspection, the facility updated the plans to include all required components and obtained signatures from the residents or their representatives to meet the requirements. You Are Not: • Required to submit a plan of correction for the consultation deficiency or deficiencies stated in this letter and not listed on the enclosed report. You May: • Contact me for clarification of the deficiency or deficiencies found. In Addition, You May: • Request an Informal Dispute Resolution (IDR) review within 10 working days after you receive this letter. Your IDR request must include: o What specific deficiency or deficiencies you disagree with; o Why you disagree with each deficiency; and o Whether you want an IDR to occur in-person, by telephone or as a paper review. o Send your request to: Email: RCSIDR@dshs.wa.gov; or Fax: (360) 725-3225 This document was prepared by Residential Care Services for the Locator website. Aegis of Mercer Island # 2509 08/21/2025 Page 5 of 5 If You Have Any Questions: • Please contact me at (253)234-6020. Sincerely, Laurie Anderson, Community Field Manager Region 2, Unit D Residential Care Services Enclosure This document was prepared by Residential Care Services for the Locator website.

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEAL TH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20425 72nd Avenue S, Suite 400, Kent, WA 98032 Aegis Senior Communities LLC Aegis of Mercer Island 7 445 SE 24th Street Mercer Island, WA 98040 RE: Aegis of Mercer Island License# 2509 Dear Administrator: This letter addresses Compliance Determination(s) 40637 (Completion Date 05/01/2024) and 36710 (Completion Date 02/27/2024). The Department completed a follow-up inspection of your Assisted Living Facility on 05/01/2024 and found no deficiencies. Your facility meets the Assisted Living Facility licensing requirements. The Department found that deficiencies for the following licensing laws and regulations were corrected: WAC 388-78A-2700-1-a, WAC 388-78A-2380-3, WAC 388-78A-2170-1 The Department staff who did the on-site verification: Thomas Forkgen, ALF Licensor Michelle Yip, ALF Licensor If you have any questions, please contact me at (253)234-6020. Sincerely, Laurie Anderson, Field Manager Region 2, Unit D Residential Care Services This document was prepared by Residential Care Services for the Locator website. STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEAL TH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20425 72nd Avenue S, Suite 400, Kent, WA 98032 Statement of Deficiencies License #: 2509 Compliance Determination # 3671 0 Plan of Correction Aegis of Mercer Island Completion Date Page 1 of 7 Licensee: Aegis Senior Communities LLC 02/27/2024 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 the unannounced on-site full inspection on 02/13/2024, 02/13/2024, 02/16/2024 and 02/16/2024 of: Aegis of Mercer Island 7 445 SE 24th Street Mercer Island, WA 98040 The following sample was selected for review during the unannounced on-site visit: 9 of 83 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Thomas Forkgen, ALF Licensor Michelle Yip, ALF Licensor From: DSHS, Aging and Long-Term Support Administration Residential Care Services, Region 2 , Unit D 20425 72nd Avenue S, Suite 400 Kent, WA 98032 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. 03/07/2024 Residential Care Services Date I understand that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. This document was prepared by Residential Care Services for the Locator website. ~J.11.W,q 08:00:43 State of Washington 711 Statement of Defi.ciencies License#: 2509 Cornpliahce Determination# 3671 o Plan of Correction Aegis or Mercer Island Completion Date I Page 2 of 7 Licensee: Aegis Senior Communities LLC '· 02127/2024 ntative) WAC 388-78A-2700 Emergency and disaster preparedness. (1) The assisted living facility must: (a) Maintain the premises free of hazards; This requirement was not met as evidenced by: Based on observation and interview the facility failed to ensure 1 of 2 stairwells (Stairwell 1) were accessible to residents for emergency evacuation purposes. This failure placed all residents at risk of not being able to evacuate the facility building during an emergency. ' Findings included ... Review of the facility's document titled "Disaster Response Procedure: Evacuation", dated 08/17/2022, showed that ambulatory residents should be encouraged to exit via the stairs on their own if they can do so safely. The procedure showed that non-ambulatory residents or residents lhcJt required assistance utilized the evacuation chairs with staff assistance. Review of the f<!cility's undated Emergency Evacuation Plan showed the emergency stairwell exits were located at each end of the building. The plan showed that the emergency meeting areas were in each of the stairwells. The physical construction of the facility consisted of tour floors with two sti3irwells located on each end of the building. I I! During the environmental tour with Staff H, Maintenance Director. on 02/1;3/2024 at 2:30 PM, observation showed a plastic barrier installed with dust barri.er poles to hold the plastic in place. The barrier extended from the floor to the ceiiing. The barrier was localed on t0e fourth floor of the facility. The plastic barrier blocked the access to the fourth-floor stairwell. Observation showed a red zippered door that allowed access to the other side of the barrier was closed. Observation showed there were missing tiles from the ceiling. During an interview on 02/13/2024 between 2:30 PM and 4:00 PM, Staff~ stated that a sand pipe broke inside the facility in January of 2024 and was in process of repair. Sitaff H stated that the construction company needed to access the pipe through the ceiling. Staff H stated that the plastic barrier was installed to contain the dust debris from the construction. Staffl H stated that they had not considered the impact the barrier created for '1 ', II This document was prepared by Residential Care Services for the Locator website. 'UJ, 11,l'(}l'i 1:'.JO:l:'.Jl:'.J:11;1 State of Washington 8/1 Statement of Deficiencies License#: 2509 Compliance Determination# 3671 o Plan of Correction Aegis of Mercer Island Completion Date Page 3 of 7 Licensee: Aegis Senior Communities LLC 02/27/2024 access to the stairwell during an emergency evacuation. During an interview on 02/16/2024 at 10:40 AM, Staff H stated that the plastic barrier has been in place for a week. Staff H stated that the construction crew was scheduled to return and complete the job soon. ! ii During an interview on 02/28/2024 at 3:29 PM, Collateral Contact 1 (CC1), State Deputy Fire Marshal, stated that a plastic barrier that blocks an emergency egress o~ required additional steps to access the evacuation route would be considered a fire safety issLle andlwould need to be inspected. CC 1 stated that for elderly residents to perform the extra stef? of unzipping the access door to access the stairwell would cause a delay in evacLlation. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will t' ake active measures to correct this deficiency. By taking this action, Aegis of Me~cer Island is or will '1j lZ..y'.Z>-! . be in compliance with this law and/ or regtJlation on (Date) I In addition. I will implement a system to monitor and ensure continued compliance with I this requir . t. ' j ....... '3/ 1,2:/z.'-1_ --······ Date WAC 388-78A-2380 Freedom of movement. An assisted living facility must ensure all of the following conditions are present before moving residents into units pr buildings with ex.its that may restrict a resident's egress: · (3) The assisted living facility must have a system in place to inform and fiermit visitors, staff persons and appropriate residents how they may exit without sounding the alarm. This requirement was not met as evidenced by: Based on observation and inteNiew, the facility failed to inform visitors how to exit from the secured memory care unit. This failure placed visitors with insufficient information \o leave the secured unit without assistance. Findings included ... ObseNations of the. memory care ("Life's Neigl1borhood") unit on 02/13/2024 from 2:30 PM to 4:00 PM, on 02/14/2024 from 9:00 AM to 4:00 PM, on 02/15/2024 at 9:00 AM t0 3:30 PM, and on 02116/2024 from 9:00 AM to 11:00 AM, showed the unit llad three exits. Each exit used a coded box that opened the door to leave the unit. Observation showed that none of the exits provided instructions on how to exit the unit. This document was prepared by Residential Care Services for the Locator website. State of Washington 9/l Statement of Deficiencies License#: 2509 Compliahce Determination# 36710 Plan of Correction Aegis of Mercer Island 1 Completion Date , Page 4 of 7 Licensee: Aegis Senior Communities LLC 02/27/2024 During an interview on 02/13/2023, at 2:30 PM, Staff H, Maintenance Director, stated that there was no system in place that informed visitors how to exit the secured memory care unit. Staff H stated that visitors needed to ask the staff for assistance to exit. Staff H stated that for security reasons, they changed the code to Life's Neighborhood every month. Staff H stated that the montr11y change of the access code made it difficult to provide standard instructions to visitors. During an interview on 02/16/2024 ai 11:00 AM, Staff H stated that ihey were not sure how the facility would provide instructions to visitors that provided access to exit the unit. 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, Aegis of Me,cer Island is or will '--1 J .z.'-1 . be in compliance with this law and/ or regulation on (Date) '2 / In addition, I will implement a system to monitor and ensure continued :compliance with this requirement. .......... 3) lZ../zY .......... Date WAC 388-78A-2170 Required assisted living facility services. (1) The.assisted living facility must provide housing and assume general responsibility for the safety and well-being of each resident, as defined in this chapter, consistent with the resident's assessed needs and negotiated service agreement. 'I This requirement was. not ~et as evidenced by: . . . \ . , Based on observation, 1nterv1ew, and record review, the fac1l1ty failed to e1sure 2 of 12 residen.ts (Resident 9 and Resident 10) medical device was securely and safely installed for use. This failure placed Resident 9 and Resident 10 at risk for potential entrapment and inj:ury. Findings included ... BED ENABLER Review of the Department of Health and Social Services (DSHS) documei;it titled "Dear Assisted Living Facility Administrator", dated 05/15/2013, showed Assisted Living ~acHity Providers were issued this letter related to the safety risks associated with the use of all medical devices. The letter listed some examples of medical devices with known safety risks when usFd i.nclude transfer poles. Posey or lap belts, and side bed rails. Potential risks of medical devices miay 1ncJude strangling, suffocating, bodily injury, skin bruising, ' This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2509 Compliance Determination # 3671 0 Plan of Correction Aegis of Mercer Island Completion Date Page 5 of7 Licensee: Aegis Senior Communities LLC 02/27/2024 cuts, scrapes, agitation, feeling isolated or unnecessarily restricted. Review of the Department of Health and Social Services (DSHS) document titled Dear Assisted Living Facility Administrator/Provider, dated 02/25/2022, showed Assisted Living Facility Providers were issued this letter related recall of certain bed rails. The letter showed that in December 2021, the United States Consumer Product Safety Commission (CPSC) issued recalls for three brand specific quarter- and eighth-length bed rails that were commonly used to assist with transferring and positioning. The letter showed that CPSC found these devices can lead to consumer injury or death due to entrapment and asphyxiation. The letter showed that an occupational therapist/physical therapist may be able to find an alternative for transferring and positioning for those who need it. Review of the facility's policy titled "Resident Services\Supportive Devices with Restraining Qualities", dated 03/15/2023, showed that the facility was committed to providing a resident environment that was free of hazards and restrictions. The policy showed that a resident may choose to use enabler devices, such as bed side rails or transfer poles, as long as their use does not impede or endanger the resident. The policy showed that close attention should be paid to the design of the side rail/enabler device and the relationship of the device to other parts of the bed. The policy showed that some bed rail/enabler devices were recalled and should be replaced. The policy showed that gaps or spaces of two (2) inches or larger for any side rail/enabler device would be filled or covered with suitable materials to reduce the risk of entrapment. The policy showed side rails and enabler devices must be firmly attached such that they were not able to be pulled loose. RESIDENT 9 Review of the facility's Resident Characteristics Roster showed that the facility admitted Resident 9 in 2022. The Characteristics Roster did not document Resident 9 used a medical device (bed enabler). Observation of Resident 9's apartment on 02/15/2024 at 11 :20 AM, showed a Li-shaped half rail, 17 1/2 inches wide and 18 inches in length attached to the bed. Observation showed there no mesh or other type of cover over the gap of the rail bars. Observation showed the side rail was loose and moved with minimal pressure which created a gap, greater than six inches, between the mattress and the side rail. Observation showed Resident 9 moved the half rail with minimal effort. During an interview on 02/15/2024 at 11 :20 AM, Resident 9 stated that the side rail was loose and should be tightened up. Resident 9 stated that their daughter installed the rail and needed to bring in some straps to secure the side rail to the bed. Review of Resident 9's assessment, dated 06/20/2023, showed Resident 9 used a half side rail on the right side of the bed. The assessment showed Resident 9 used the side rail to assist with getting in and out of bed and for repositioning when in bed. The assessment showed that a work order was submitted to the maintenance department on 06/20/2023 to secure the side rail to the bed. The assessment showed that on 06/19/2023, the rail gaps greater than two inches were covered with a mesh. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2509 Compliance Determination # 3671 0 Plan of Correction Aegis of Mercer Island Completion Date Page 6 of7 Licensee: Aegis Senior Communities LLC 02/27/2024 Review of Resident 9's Individualized Service Plan, dated 02/13/2024, showed that Resident 9 used a half side rail on the right side of the bed. The service plan showed that Resident 9 refused a cover over the rail. Review of Resident 9's February 2024 electronic Medication Administration Record (eMAR) showed the Medication Technicians [Med Techs (unlicensed staff who dispense medications)] were to complete side rail safety checks every morning. The Med Techs were responsible to ensure the side rail was secured to the bed and ensure there was less than a two-inch gap between the side rail and mattress. During an interview on 02/16/2024 at 10:45 AM, Staff I, Registered Nurse, Health Services Director, stated that Resident 9 refused to have a mesh cover over the side rail. Staff I stated that the mesh cover prevented Resident 9 from grabbing any part of the side rail. Staff I stated that the risks of entrapment were explained to Resident 9 and their representative, and both understood and accepted the risk. Staff I stated that it was Resident 9's right to have the unsafe side rail. Staff I stated that the loose side rail was a safety concern, and they would have it fixed. Staff I stated that they would work around any refusal Resident 9 may have so the side rail could be secured. Resident 10 Record review of the facility's Resident Characteristics Roster showed that the facility admitted Resident 10 in 2020. The Characteristics Roster showed Resident 9 used a medical device (bed enabler). Observation on 02/16/2024 at 10:00 AM of Resident 10's apartment, showed a quarter side rail attached to the right side of Resident 10's bed. Observation showed a gap 7 inches wide and 20 inches long between the bars. Observation showed no mesh or other type of cover over the gap of the rail bars. Review of Resident 10's assessment, dated 04/21/2023, showed a quarter side rail was attached to the right side of the bed. The assessment showed Resident 10 used the side rail was to assist to get in and out of bed and for repositioning when in bed. The assessment showed that on 04/21/2023, a mesh cover was applied to the rails and the side rail was secured to the bed. Review of Resident 10's Individualized Service Plan dated 02/16/2024, showed that Resident 10 used a quarter side rail, attached to the right side of the bed. The service plan showed that Resident 10 used the side rails for bed mobility. The service plan showed staff were to ensure the side rail was secured and was not loose. The service plan showed that a mesh covering must be on the side rails for resident safety. Review of Resident 10's February 2024 eMAR showed a directive to the Med Techs to perform a side rail safety check every morning. The side rail safety check showed that the This document was prepared by Residential Care Services for the Locator website. uv, J 1,Ltll'f t1tl:l:JU:4J State of uashln9ton Statement of Deficiencies License#: 2509 Complia ce Determination# 3671 O Plan of Correction Aegis of Mercer Island Completion Date Page 7 of 7 Licensee: Aegis Senior Communities LLC 02/2712024 Med Techs were to ensure the side rail was covered. During an interview on 02/16/2024 at 10:45 AM, Slaff A, General Manag'.er and Staff I bolll asked if the Department of Social and Health Service provided guidelines on sid~ rail safety. Staff A and Staff I stated they were unaware of the "Dear Assisted Living Facility Administrator'', letters dated 05/15/2013 and 02/25/2022 regarding side rail safety. Staff A and Staff I irequested a copy of the letters. · Pian/Attestation Statement I hereby certify that I llave reviewed this report and have taken or wilt take active measures to correct this deficiency. By taking this action, Aegis of Mercer Island is or will '-l . '-J-12 - 2 be in compliance witll this law and I or regulation on (Date) In addition, I will implement a system to monitor and ensure continued,comp/iance with tllis re · ement This document was prepared by Residential Care Services for the Locator website. STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEAL TH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20425 72nd Avenue S, Suite 400, Kent, WA 98032 03/07/2024 Aegis Senior Communities LLC Aegis of Mercer Island 7445 SE 24th Street Mercer Island, WA 98040 RE: Aegis of Mercer Island# 2509 Dear Administrator: The Department completed a full inspection of your Assisted Living Facility on 02/27/2024 and found that your facility does not meet the Assisted Living Facility requirements. The Department: • Wrote the enclosed report; and • May take licensing enforcement action based on many deficiency listed on the enclosed report; and • May inspect your program to determine if you have corrected all deficiencies; and • Expects all deficiencies to be corrected within the timeframe accepted by the department. You Must: • Begin the process of correcting the deficiency or deficiencies immediately; • Contact the Field Manager for clarifications related to the Statement of Deficiencies (SOD); • Within 10 calendar days after you receive this letter, complete and return the enclosed 'Plan/Attestation Statement'; o Sign and date the enclosed report; o For each deficiency, indicate the date you have or will correct each deficiency; o Mail the Plan/Attestation Statement and report with original signatures to: Laurie Anderson, Field Manager Residential Care Services Region 2, Unit D 20425 72nd Avenue S, Suite 400 This document was prepared by Residential Care Services for the Locator website. Aegis of Mercer Island # 2509 02/27/2024 Page 2 of 3 Kent, WA 98032 • Complete correction(s) within 45 days, or sooner if directed by the Department, after review of your proposed correction dates. • Have your plan approved by the Department. Consultation(s): In addition, the Department provided consultation on the following deficiency or deficiencies not listed on the enclosed report. WAC 388-78A-2730 Licensee's responsibilities. (2) The licensee must: (b) Maintain and post in a size and format that is easily read, in a conspicuous place on the assisted living facility premises: (iii) A copy of the report, including the cover letter, and plan of correction of the most recent full inspection conducted by the department. The Assisted Living Facility did not post a copy of the last Department of Social and Health Services inspection report in an accessible place within the facility. The report was locked up in a drawer behind the concierge desk in an unmarked binder. There was no signage that showed anyone how to access the inspection report. During the on-site inspection the facility labeled the binder and posted a sign that showed the inspection report was available from the concierge upon request. You Are Not: • Required to submit a plan of correction for the consultation deficiency or deficiencies stated in this letter and not listed on the enclosed report. You May: • Contact me for clarification of the deficiency or deficiencies found. In Addition, You May: • Request an Informal Dispute Resolution (IDR) review within 10 working days after you receive this letter. Your IDR request must include: o What specific deficiency or deficiencies you disagree with; o Why you disagree with each deficiency; and o Whether you want an I DR to occur in-person, by telephone or as a paper review. o Send your request to: IDR Program Manager Department of Social and Health Services Aging and Long-Term Support Administration Residential Care Services This document was prepared by Residential Care Services for the Locator website. Aegis of Mercer Island # 2509 02/27/2024 Page 3 of 3 PO Box 45600 Olympia, WA 98504-5600 If You Have Any Questions: • Please contact me at (253)234-6020. Sincerely, Laurie Anderson, Field Manager Region 2, Unit D Residential Care Services Enclosure This document was prepared by Residential Care Services for the Locator website.

This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: Aegis of Mercer Island Provider Type: Assisted Living Facility License/Cert.#: 2509 Compliance Determination #: 34090 Intake ID: 110379 Investigator: Kailash Sharma Region/Unit #: RCS Region 2 / Unit D Investigation Date(s): 12/19/2023 through 01/19/2024 Complainant Contact Date(s): 01/19/2024, 12/19/2023 Allegation(s): Financial Exploitation. Fee and charges have increased significantly since admission. Charges were made for the care assistance not required. Investigation Methods: Sample: Total residents: 84 Resident sample size: 2 Closed records sample size: 0 Observations: General tour of the facility, lobby, common areas, dinning rooms, activities room, and staff resident interaction. Interviews: Executive Director, Health Service Director, Public Complainant. Record Reviews: Incident report, characteristic roster, change of condition policy, assessment, negotiated service plan, progress notes, medication records, fall history log. Investigation Summary: Facility cooperated with investigation, provided needed documents and information. Health Service Director (HSD) stated Named Resident had history of falls, continued to be at risk, and was placed on one to one assistance per Physical Therapist recommendation. HSD stated resident had gradually declined since they admitted. Service plan adjusted according to service required per assessment. Acting Executive Director stated facility collaborated care planning with family per policy, made adjustments in rate, credited some previous charges, per family's request. NR Representative disagreed with changes in care assistance reflected in care plan. NR Representative expressed dissatisfaction with care planning, and lack of negotiation for the care changes. Facility re-negotiated the service agreement with resident and resident representative participation. Facility credited resident for excess fees charged to the resident associated with the non-negotiated service plan. Consultation issued. Conclusion / Action: This document was prepared by Residential Care Services for the Locator website. Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A This document was prepared by Residential Care Services for the Locator website.

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20425 72nd Avenue S, Suite 400, Kent, WA 98032 Aegis Senior Communities LLC Aegis of Mercer Island 7445 SE 24th Street Mercer Island, WA 98040 RE: Aegis of Mercer Island License # 2509 Dear Administrator: This letter addresses Compliance Determination(s) 28573 (Completion Date 08/11/2023) and 24712 (Completion Date 06/01/2023). The Department completed a follow-up inspection of your Assisted Living Facility on 08/11/2023 and found no deficiencies. Your facility meets the Assisted Living Facility licensing requirements. The Department found that deficiencies for the following licensing laws and regulations were corrected: WAC 388-78A-2630-1-b The Department staff who did the on-site verification: Kailash Sharma, ALF Licensor If you have any questions, please contact me at (253)234-6020. Sincerely, Laurie Anderson, Field Manager Region 2, Unit D Residential Care Services This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: Aegis of Mercer Island Provider Type: Assisted Living Facility License/Cert.#: 2509 Compliance Determination #: 24712 Intake ID: 81172 Investigator: Kailash Sharma Region/Unit #: RCS Region 2 / Unit D Investigation Date(s): 05/16/2023 through 06/01/2023 Complainant Contact Date(s): 05/12/2023, 05/16/2023 Allegation(s): Injury of unknown origin in private area. Investigation Methods: Sample: Total residents: 75 Resident sample size: 2 Closed records sample size: 0 Observations: General tour of the facility, lobby, common areas, dining room, resident's apartment, resident to resident interaction, staff to resident interactions. Interviews: Public Complainant, family members, Named Resident, Executive Director, Health Service Director. Record Reviews: Incident report, investigation report, characteristic roster, progress notes, medication records, Event, incident policy, Skin management protocol, Abuse, neglect reporting and investigation policy, Face sheet, medication list, skin assessment, Individualized Service Plan, progress notes, Sexual Engagement Assessment, The Mini Cog assessment. Investigation Summary: Facility cooperated with the investigation, provided needed documents and staff participated in interviews. Executive Director stated other resident involved in allegation moved to different facility. Health Service Director stated allegations of bruising and sexual relationship were brought to their attention, investigated internally. Facility did not report to Complaint Resolution Unit (CRU). Named Resident (NR) denied any abuse. investigator stated incident investigated, alleged perpetrator restricted to visit NR. Facility failed to report CRU. Citation issued for failure to report allegation of sexual abuse. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written This document was prepared by Residential Care Services for the Locator website. Failed Provider Practice Not Identified / No Citation Written N/A This document was prepared by Residential Care Services for the Locator website. STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20425 72nd Avenue S, Suite 400, Kent, WA 98032 Statement of Deficiencies License #: 2509 Compliance Determination # 24712 Plan of Correction Aegis of Mercer Island Completion Date Page 1 of 3 Licensee: Aegis Senior Communities LLC 06/01/2023 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 05/16/2023, 05/16/2023 and 05/16/2023 of: Aegis of Mercer Island 7445 SE 24th Street Mercer Island, WA 98040 This document references the following complaint number(s): 81172 The following sample was selected for review during the unannounced on-site visit: 2 of 75 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Kailash Sharma, ALF Licensor From: DSHS, Aging and Long-Term Support Administration Residential Care Services, Region 2 , Unit D 20425 72nd Avenue S, Suite 400 Kent, WA 98032 As a result of the on-site visit(s), the department found that you are not in compliance with the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. Residential Care Services Date I understand that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2509 Compliance Determination # 24712 Plan of Correction Aegis of Mercer Island Completion Date Page 2 of 3 Licensee: Aegis Senior Communities LLC 06/01/2023 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 an incident of suspected sexual abuse for 1 of 75 residents (Resident 1). This failure placed Resident 1 at potential risk of sexual abuse and a diminished quality of life. Findings included… Review of the facility's undated policy titled "Abuse, Neglect reporting and investigation" showed that each staff person as mandated reporter will report when: "there is reasonable cause to suspect or believe that abuse, abandonment, exploitation, financial exploitation or neglect of a vulnerable adult has occurred by filing a report immediately after discovery of the incident for substantial injuries of unknown source and/or unwitnessed to Department Complaint Hotline". Review of the facility's progress notes for Resident 1, dated 04/19/2023, showed that the facility was notified by a family member that Resident 1 had a bruise on the left breast. During an interview on 05/16/2023 at 2:10 PM, Staff B, HSD, stated that they conducted a thorough investigation. Staff B stated that they did not think the bruise qualified as reportable to the state. Staff B stated that "it was an allegation". Staff B stated that Resident 1 denied any bruise. Staff B stated that Resident 1 refused to an examination. Staff B stated that Resident 1 denied that anybody hurt them. Staff B stated that based on Resident 1's report, Staff B decided not to report. Plan/Attestation Statement This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2509 Compliance Determination # 24712 Plan of Correction Aegis of Mercer Island Completion Date Page 3 of 3 Licensee: Aegis Senior Communities LLC 06/01/2023 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, Aegis of Mercer Island is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date This document was prepared by Residential Care Services for the Locator website.