The Cottages at Mill Creek.

Statement of Deficiencies License #: 1977 Compliance Determination # 66402 Plan of Correction THE COTTAGES AT MILL CREEK 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 the unannounced on-site full inspection on 09/30/2025, 10/01/2025 and 10/02/2025 of: THE COTTAGES AT MILL CREEK 13200 10TH DRIVE SE MILL CREEK, WA 98012 The following sample was selected for review during the unannounced on-site visit: 7 of 37 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Steven Kindle, Nursing Consultant Institutional Jodi Condyles, Nursing Consultant Institutional From: DSHS, Aging and Long-Term Support Administration 20425 72nd Avenue S, Suite 400 Kent, WA 98032 . Statement of Deficiencies License #: 1977 Compliance Determination # 66402 Plan of Correction THE COTTAGES AT MILL CREEK 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-2466 Background checks Washington state name and date of birth background check Valid for two years National fingerprint background check Valid indefinitely. (1) A Washington state name and date of birth background check is valid for two years from the initial date it is conducted. The assisted living facility must ensure: (a) A new DSHS background authorization form is submitted to the department's background check central unit every two years for all administrators, caregivers, staff persons, volunteers and students; and (b) There is a valid Washington state name and date of birth background check for all administrators, caregivers, staff persons, volunteers and students. (2) A national fingerprint background check is valid for an indefinite period of time. The assisted living facility must ensure there is a valid national fingerprint background check completed for all administrators and caregivers hired after January 7, 2012. To be considered valid, the national fingerprint background check must be initiated and completed through the department's background check central unit after January 7, 2012. This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure 1 of 2 staff (Staff F) had a valid Washington State name and date of birth background check completed every two years. This failure resulted in Staff F not having a cleared background check and placed residents at risk of being cared for by a staff person with a potentially disqualifying background. Findings included… Review of the ALF’s Criminal History Background Check policy dated 02/02/2015, . Statement of Deficiencies License #: 1977 Compliance Determination # 66402 Plan of Correction THE COTTAGES AT MILL CREEK Completion Date showed the facility would repeat background inquiry requests for every individual who had unsupervised access to residents every two years. Review of the ALF’s employee files showed the following: Staff F, Caregiver, was hired on 05/10/2022. Staff F had a Washington State name and date of birth background check dated 08/18/2022 that was valid until 08/18/2024. Review of another Washington State name and date of birth background check showed it was not completed until 10/25/2024, which was 68 days late. On 10/02/2025 at 3:01 PM, Staff G, House Manager, stated that they were not aware of the requirement to complete a background check every two years and had not completed them. 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 MILL CREEK 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. This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure 2 of 4 staff (Staff B and Staff D) completed tuberculosis (TB) testing within three days of hire. This failure placed residents at risk of exposure to a communicable disease. Findings included… Review of the ALF’s employee files showed the following: . Statement of Deficiencies License #: 1977 Compliance Determination # 66402 Plan of Correction THE COTTAGES AT MILL CREEK Completion Date Staff B, Medication Technician (MT), was hired on 04/08/2025. There was no documentation in Staff B’s file that they had TB testing within three days of hire. Staff D, MT, was hired on 03/17/2025. There was no documentation in Staff D’s file that they had TB testing within three days of hire. On 10/02/2025 at 8:45 AM, Staff D stated that they did not do any TB testing within three days of their hire date. On 10/02/2025 at 3:00 PM, Staff G, House Manager, stated that they thought Staff B’s chest Xray they did in 2024 was good for their TB testing at hire, and for Staff D they had sent them to a clinic for a blood test over two months after hire because they had told them they had a previous positive TB test. 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 MILL CREEK 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-2484 Tuberculosis Two step skin testing. Unless the staff person meets the requirement for having no skin testing or only one test, the assisted living facility choosing to do skin testing, must ensure that each staff person has the following two-step skin testing: (1) An initial skin test within three days of employment; and (2) A second test done one to three weeks after the first test. This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure 1 of 4 staff (Staff C) completed the initial step of two-step tuberculosis (TB) testing within three days of hire, and a second test done one to three weeks after the first test. This failure placed residents at risk of exposure to a communicable disease. Findings included… . Statement of Deficiencies License #: 1977 Compliance Determination # 66402 Plan of Correction THE COTTAGES AT MILL CREEK Completion Date Review of the ALF’s employee files showed the following: Staff C, Caregiver, was hired on 05/19/2025. Staff C’s TB testing documentation showed that they completed the first step of TB testing on 06/26/2025, 38 days after their hire date, and there was no second step TB test documentation available for review. On 10/01/2025 at 2:23 PM, Staff C stated that they did their first step TB testing when they were told to do it, and that they were not told to do a second step. On 10/02/2025 at 3:00 PM, Staff G, House Manager, stated that they had sent Staff C out to a clinic for their first step of TB testing, but they did that late. Staff G also stated that Staff C never followed up to do their second step TB test. 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 MILL CREEK 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-2474 Training and home care aide certification requirements.

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 April 17, 2025 ELECTRONIC-FACSIMILE Administrator THE COTTAGES AT MILL CREEK 13200 10TH DRIVE SE MILL CREEK, WA 98012 Assisted Living Facility License # 1977 Licensee: MILL CREEK SPECIAL CARE COMMUNITY LLC IMPOSITION OF CIVIL FINE Dear Administrator: On April 8, 2025, the Department of Social and Health Services (DSHS), Residential Care Services completed a Complaint Investigation at your facility. This letter constitutes formal notice of a civil fine on the license for your assisted living facility, also known as THE COTTAGES AT MILL CREEK, located at 13200 10TH DRIVE SE, MILL CREEK, 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 fine on the license is based on the following violation of the RCW and/or WAC as described in the attached Statement of Deficiencies (SOD) report dated April 8, 2025. Civil Fine WAC 388-78A-2210 (2)(b) Medication services. $400.00 The licensee failed to ensure one resident received all their medications as prescribed. This failure resulted in the resident not receiving their prescribed medications. The failure resulted in the resident not receiving all their medications and placed them at risk for health complications. This is a recurring citation previously cited on April 28, 2022, and March 19, 2024. NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Administrator THE COTTAGES AT MILL CREEK License # 1977 April 17, 2025 Page 2 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: Kim Ripley, Field Manager Region 2, Unit A 3906 172nd St NE Suite 100 Arlington, WA 98223 Phone: (206) 794-8568 / Fax: (360) 651-6940 rcsregion2email@dshs.wa.gov Appeal Rights: You have two appeal rights: Informal Dispute Resolution (IDR) and an Administrative Hearing. Each has a different request timeline. Informal Dispute Resolution [RCW 18.20.195] You have an opportunity to challenge the deficiencies and/or enforcement actions through the state's IDR process. All IDR requests must be in writing and include: • The deficiencies you are disputing; and • The method of review you prefer (face-to-face, telephone conference or documentation review). The written request must be received by the 10th working day from receipt of this letter. 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 Administrator THE COTTAGES AT MILL CREEK License # 1977 April 17, 2025 Page 3 Formal Administrative Hearing You may contest the civil fine by requesting a formal administrative hearing to challenge the deficiency, which resulted in the civil fine. 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 fine is due to the Office of Financial Recovery twenty-eight (28) calendar days after receipt of this letter. Mail a check for $400.00 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 MILL CREEK License # 1977 April 17, 2025 Page 4 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 Kim Ripley, Field Manager, at (206) 794-8568. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 2, Unit A RCS Regional Administrator, Region 2 HCS Regional Administrator, Region 2 DDA Regional Administrator, Region 2 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW HP

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Ii □ □ 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 #: 1977 Compliance Determination # 56588 Plan of Correction THE COTTAGES AT MILL CREEK 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 03/19/2025 and 04/01/2025 of: THE COTTAGES AT MILL CREEK 13200 10TH DRIVE SE MILL CREEK, WA 98012 This document references the following complaint number(s): 168524 The following sample was selected for review during the unannounced on-site visit: 3 of 32 current residents and 2 former residents. The department staff that investigated the Assisted Living Facility: Wesler Dumecquias, Community Complaint Investigator From: DSHS, Aging and Long-Term Support Administration 20425 72nd Avenue S, Suite 400 Kent, WA 98032 . Statement of Deficiencies License #: 1977 Compliance Determination # 56588 Plan of Correction THE COTTAGES AT MILL CREEK 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-2250 Alteration of medications. The assisted living facility must generally provide medications in the form they are prescribed when administering medications or providing medication assistance to a resident. The assisted living facility may provide medications in an altered form consistent with the following: (1) Alteration includes, but is not limited to, crushing tablets, cutting tablets in half, opening capsules, mixing powdered medications with foods or liquids, or mixing tablets or capsules with foods or liquids. (2) Residents must be aware that the medication is being altered or added to their food. (3) A pharmacist or other practitioner practicing within their scope of practice must determine that it is safe to alter a medication. (4) If the medication is altered, documentation of the appropriateness of the alteration must be on the prescription container, or in the resident's record. (5) Alteration of medications for self-administration with assistance is provided in accordance with chapter 246-888 WAC. This requirement was not met as evidenced by: Based on interview and records review, the Assisted Living Facility (ALF) failed to provide the medication in the prescribed form for 1 of 2 Residents, (Resident 1) when staff gave the medications crushed without an order. The failure resulted in Resident 1 receiving their medications in an altered form without physician order and placed Resident 1 at risk for increased possibility of medication interaction and less effectivity. Findings included… . Statement of Deficiencies License #: 1977 Compliance Determination # 56588 Plan of Correction THE COTTAGES AT MILL CREEK Completion Date Resident 1 Review of Face sheet showed Resident 1 moved into the ALF on /2025 with multiple diagnoses including . Review of Service plan dated 12/20/2024 showed resident 1 was on medication assistance. The ALF staff would administer all medications as per physician order. Review of Medication Administration Record (MAR) dated February 2025 showed Resident 1 had the following prescribed medications: a. Amlodipine Tablet (tab) 10 milligrams (mg) one tab daily ( by mouth) as calcium channel blocker; b. Aspirin 81 mg tab chewable one tab daily (by mouth) as analgesic (Prophylactic); c. Calcium-Cit/Vit D3 315mg/200units (u) tablet two tablets daily (by mouth) for antacid(supplement); d. Carvedilol 6.2 mg tab two times daily (by mouth) as beta blocker. e. Melatonin tab 1 mg, one tablet at bedtime (by mouth) as sleep aid. f. Acetaminophen 325 mg tab, two tab by mouth as needed for pain. The MAR did not show an instruction to crush and mix the medication with liquids or food. Review of ‘AFTER VISIT SUMMARY” dated /2025 showed there was no order to crush and mix the medication with liquids or foods or the reason for altering the form of the medication before administering. On 03/19/2025 at 4:25 PM, Staff D, Medication Technician (Med Tech), stated that they had been crushing Resident 1’s medication and mixing it with pudding. Staff D stated that there was no physician order to crush and mix the medication with food. Staff D stated that the Resident Care Coordinator (RCC) at that time instructed them to crush the medications for Resident 1. On 03/19/2025 at 4:41 PM, Staff E, Med Tech stated that they crushed the medications and mixed it with pudding, ice cream or shakes before giving it to Resident 1. Staff E stated that there was no physician order to crush the mediations. Staff E stated that Staff B, Resident coordinator, told them to crush Resident 1 medications before they were administered them. Staff E stated that they did not inform the resident that they were crushing their medication and mixing it with food because Resident 1 would not understand due to dementia. On 03/19/2025 at 5:00 PM, Staff B stated that they told the MTs to crush the medications and mix it with pudding before giving it to Resident 1. Staff B stated that they did not have a physician order, but they followed what the hospital told them . Statement of Deficiencies License #: 1977 Compliance Determination # 56588 Plan of Correction THE COTTAGES AT MILL CREEK Completion Date about how Resident 1 takes their medications. 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 MILL CREEK 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-2210 Medication services. (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 : (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 interview and record review, the Assisted Living facility (ALF) failed to ensure 1 of 2 residents (Resident 1) received all their medications as prescribed. This failure resulted in Resident 1 not receiving their prescribed medications. The failure resulted in Resident 1 not receiving all their medications and placed them at risk for health complications. Findings included… Review of the ALF’s current policy titled “Medication Services” undated showed the ALF would assist and/or administer prescription and over-the-counter medications as allowed by state statute/regulations and will maintain records of such assistance/administration. Resident 1 Review of Face sheet showed Resident 1 was moved into the ALF on /2025 with . Statement of Deficiencies License #: 1977 Compliance Determination # 56588 Plan of Correction THE COTTAGES AT MILL CREEK Completion Date multiple diagnoses including . Review of Service plan dated 12/20/2024 showed resident 1 was on medication assistance. The ALF staff would administer all medications as per physician order. Review of Medication Administration Record (MAR) dated February 2025 showed Resident 1 had the following prescribed medications: a. Amlodipine Tablet (tab) 10 milligrams (mg) one tab daily ( by mouth) as calcium channel blocker; b. Aspirin 81 mg tab chewable one tab daily (by mouth) as analgesic (Prophylactic); c. Calcium-Cit/Vit D3 315mg/200units (u) tablet two tablets daily (by mouth) for antacid(supplement); d. Carvedilol 6.2 mg tab two times daily (by mouth) as beta blocker. e. Melatonin tab 1 mg, one tablet at bedtime (by mouth) as sleep aid. f. Acetaminophen 325 mg tab, two tab by mouth as needed for pain. Review of the MAR dated February 2025 showed Resident 1 did not receive their Carvedilol and Melatonin from 02/19/2025 through /2025. The record showed Amlodipine, Aspirin and the Cal- cit/vit D3 supplement ran out on 02/20/2025 through /2025 when Resident 1 passed away. On 03/19/2025 at 3:42 PM, Staff B, Resident Care Director, stated that Resident 1 used their facility pharmacy.

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: THE COTTAGES AT MILL Provider Type: Assisted Living Facility CREEK License/Cert.#: 1977 Intake ID: 159036 Compliance Determination #: 51741 Region/Unit #: RCS Region 2 / Unit A Investigator: Wesler Dumecquias Investigation Date(s): 12/13/2024 through 02/12/2025 Complainant Contact Date(s): Allegation(s): The Named Resident (NR) had an unwitnessed fall with injury. Investigation Methods: Sample: Total residents: 32 Resident sample size: 7 Closed records sample size: 1 Observations: Residents Activities Dining Resident care equipment Staff to resident interactions Resident to resident interactions Interviews: Nursing staff Residents Family members Record Reviews: Hospital records Incident investigation Facility policies care plan Investigation statements Progress notes MAR Investigation Summary: The Named Resident (NR) had a cognitive impairment. The Assisted Living Facility (ALF) investigated the incident and determined the NR was found on the floor lying on their back. The ALF staff saw the NR walking in the hallway before the incident happened. The ALF staff failed to follow the service plan for not providing assistance when they saw the NR resident walking on their own despite being aware that the NR required the assistance. A citation for non compliance with WAC 388-78A-2160. Implementation of Negotiated Service Agreement. . Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . I&] □ □ . 02.25.2025 16:26:10 state of Washington 5/1 STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALT H SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 3906-172nd St N~, Suite #100, Arlington, WA 98223 Statement of Deficiencies License #: 1977 Compliance Determination # 517 41 Plan of Correction THE COTTAGES AT MILL CREEK Completion Date Page 1 of4 Licensee: MILL CREEK SPECIAL CARE COMMUNITY LLC 02/12/2025 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 unannounc.ed on-site complaint investigation on 12/13/2024 and 01/15/2025 of: THE COTTAGES AT MILL CREEK 13200 10TH DRIVE SE MILL CREEK, WA 98012 This document references the following complaint number(s): 156826, 157116, 159036, 159129, 159599 The following sample was selected for review during the unannounced on-site visit: 7 of 32 current residents and 1 former residents. The department staff that investigated the Assisted Living Facility: Wesler Dumecquias, Community Complaint Investigator From: DSHS, Aging and Long-Term Support Administration 3906-172nd St NE, Suite #100 Arlington, WA 98223 . 02.25.2025 16:26:10 State of Washington 6/1 Statement of Deficiencies License#: 1977 Compliance Determination # 517 41 Plan of Correction THE COTTAGES AT MILL CREEK Completion Date Page2 of4 Licensee: MILL CREEK SPECIAL CARE COMMUNITY LLC 02/12/2025 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. 02/25/2025 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. Date WAC 388-78A-2160 Implementation of negotiated service agreement. The assisted living facility must provide the care and services as agreed upon in the negotiated service agreement to each resident unless a deviation from the negotiated service agreement is mutually agreed upon between the assisted living facility and the resident or the resident's representative at the time the care or services are scheduled. This requirement was not met as evidenced by: Based on the interview and record review, the Assisted Living Facility (ALF) failed to follow and implement the negotiated service plan (NSP) for 1 of 1 resident (Resident 1) who needed assistance with ambulation. These failures resulted in three falls and injuries and placed the resident at risk for continued falls and injuries, and placed all residents who needed assistance with ambulation at risk of harm and injury. Findings included ... Review of an undated Face Sheet showed Resident 1 was admitted on /2024 with multiple diagnoses including and . Review of NSP dated 11/01/2024 showed Resident 1 needed a four- wheeled walker for assistance with ambulation. which should always be kept next to them. The NSP showed Resident 1 needed moderate assistance with ambulation. The ALF staff were required to assist Resident 1 during ambulation because they were at high risk for falls and would try to ambulate independently. . 02.25.2025 16:26:10 State of Washington 7/1 Statement of Deficiencies License#: 1977 Compliance Determination # 5'1741 Plan of Correction THE COTTAGES AT MILL CREEK Completion Date Page 3 of4 Licensee: MILL CREEK SPECIAL CARE COMMUNITY LLC 02/12/2025 Review of an incident report dated 11/22/2024 showed Resident ·1 was observed walking in between two chairs located in the common area. Resident 1 fell and sustained a head injury. On 11/22/2024 at 3:31 PM, Staff C, Caregiver stated that they observ.ed Resident 1 walking and trying to get ttm:;)l-1gh between two chairs near the fireplace. Staff C stated that Resident 1 tends to wander and needed assistance with ambulation. Staff C stated that Resident 1 did not have their walker at that time and often forgot to use it. Staff C said they did not help Resident 1 when they saw them walking because they were in the kitchen putting away dishes. Review of an incident report dated 11/25/2024 showed Staff D, Resident Care Coordinator, saw Resident 1 walking quietly and slowly near the front door of their cottage. Staff D stated that as they stopped to speak to .the caregiver, they heard a loud thud and yelling. Staff D stated that they found Resident 1 was on the floor and a bump on their head was observed. On 02/12/2025 at 11 :39 AM, Steff D stated that Resident 1 tended to wander and required a walker, as they shuffle without it. Although Staff D stated that they could not recall if Resident 1 was using their walker at that time, they observed them holding unto the couch. Staff D stated that Resident 1 needed assistance with ambulation. Staff D stated they were not able to help Resident 1 when they saw them because the incident happened quickly as they spoke with the caregiver. Review of an incident report dated 12/11/2024 showed Resident 1 was found by Staff E, Caregiver, on the floor after they heard another resident screaming at the hallway. Resident 1 complained of neck pain and had bleeding at the back of their head. On 02/12/2025 at 11 :49 AM, Staff E stated that Resident 1 had a walker but would not use it because they could not remember it. Staff Estated that Resident 1 could walk on their own but kept on falling and there would be nothing that they could have done. Staff Estated that when they saw Resident 1 walking, they were using their walker but then left it. Staff E stated that they did not help Resident 1 at that time because they could walk on their own and could not stay to watch Resident 1 all the time because they wander. . 02.25.2025 16:26:10 State of Washington 8/'t Statement of Deficiencies License#: 1977 Compliance Determination# 51741 Plan of Correction THE COTTAGES AT MILL CREEK 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, THE COTTAGES AT MILL CREEK is or will be in compliance with this law and I or regulation on (Date) '"'14u¥I ;e;; as· 3 1=2..i/ao1s In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) ~

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Ii □ □ Investigation Summary Report Provider/Facility: THE COTTAGES AT MILL Provider Type: Assisted Living Facility CREEK License/Cert.#: 1977 Intake ID: 136607 Compliance Determination #: 44005 Region/Unit #: RCS Region 2 / Unit A Investigator: Wesler Dumecquias Investigation Date(s): 07/11/2024 through 08/23/2024 Complainant Contact Date(s): Allegation(s): The Named Resident (NR) broke the Assisted Living Facility's (ALF) back patio fence on 06/28/2024, jumped over it and left the ALF. The Police located and brought back the NR. Investigation Methods: Sample: Total residents: 39 Resident sample size: 3 Closed records sample size: 1 Observations: Residents Activities Dining Resident rooms Interviews: Nursing staff Residents Family members Maintenance staff Record Reviews: Incident investigation Facility policies progress notes. PCP referral Staffing Investigation Summary: The Assisted Living Facility (ALF) investigated the incident 0n 06/28/2024 and determined that the Named Resident (NR) jumped over the ALF's fence while the ALF staff prepared the residents' breakfast. The ALF called 911, and the Police found the NR with the help of the family's tracker that the NR was wearing. The ALF failed to ensure the ALF staff monitored the NR at all times according to the ALF's alert charting in the NR's progress notes when the NR was able to leave the ALF unnoticed. The ALF did not report all the incidents to the department's Aging and Disability Services Administration Complaint Resolution Unit hotline. Failed practice was identified. A citation was issued for noncompliance with WAC 388-78A-2630 (1) . (a) Reporting abuse and neglect and WAC 388-78A-2450 (1) (a) Staff. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Ii □ □ Investigation Summary Report Provider/Facility: THE COTTAGES AT MILL Provider Type: Assisted Living Facility CREEK License/Cert.#: 1977 Intake ID: 136990 Compliance Determination #: 44005 Region/Unit #: RCS Region 2 / Unit A Investigator: Wesler Dumecquias Investigation Date(s): 07/11/2024 through 08/23/2024 Complainant Contact Date(s): 07/11/2024 Allegation(s): 1. The Named Resident (NR) had been getting out and went missing three times while in the Assisted Living Facility (ALF). 2. The ALF's staff all went on break and the NR was able to break the fence of the ALF with their bare hands and left unnoticed. Investigation Methods: Sample: Total residents: 39 Resident sample size: 3 Closed records sample size: 1 Observations: Residents Activities Dining Resident care equipment Resident rooms Interviews: Nursing staff Residents Family members Maintenance staff Record Reviews: Incident investigation Facility policies progress notes. PCP referral Staffing Investigation Summary: 1. The Named Resident (NR) had been actively exit-seeking since moving into the Assisted Living Facility (ALF) on /2024. The ALF staff stated during interviews that they could not have kept the NR safe because the NR constantly looked for a way to escape. Records showed the NR had attempted to flee the secured unit many times but staff was able to redirect them. The ALF had three incident reports of the NR leaving the ALF. The ALF staff caught the NR several other times outside the secured Cottage. The ALF failed to provide the level of supervision that was in . the NR's negotiated service plan when the NR was able to get out of their Cottage multiple times. The ALF did not report the incident to the department's Aging and Disability Services Administration Complaint Resolution Unit hotline. Failed practice was identified. A citation was issued for noncompliance with WAC 388-78A-2630 (1) (a) Reporting abuse and neglect and WAC 388-78A-2450 (1) (a). Staff. 2. The ALF staff were not on break at the time of any of the three documented incidents. The process for staff taking a break was to have another staff cover. The staff person working in the NR's cottage was not on break, but was assisting another resident. The ALF failed to ensure the ALF staff monitored the NR at all times according to the ALF's alert charting and as in the NR's progress notes. Failed practice was identified and a citation was issued for noncompliance with WAC 388-78A-2630 (1) (a) Reporting abuse and neglect and WAC 388-78A-2450 (1) (a) Staff. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Ii □ □ . STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALT H SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 3906-172nd St NE, Suite #100, Arlington, WA 98223 Statement of Deficiencies License #: 1977 Compliance Determination # 44005 Plan of Correction THE COTTAGES AT MILL CREEK 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 07/11/2024 and 08/05/2024 of: THE COTTAGES AT MILL CREEK 13200 10TH DRIVE SE MILL CREEK, WA 98012 This document references the following complaint number(s): 136261, 136607, 136990, 138355 The following sample was selected for review during the unannounced on-site visit: 3 of 39 current residents and 1 former residents. The department staff that investigated the Assisted Living Facility: Wesler Dumecquias, Community Complaint Investigator From: DSHS, Aging and Long-Term Support Administration 3906-172nd St NE, Suite #100 Arlington, WA 98223 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. . Statement of Deficiencies License #: 1977 Compliance Determination # 44005 Plan of Correction THE COTTAGES AT MILL CREEK Completion Date 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 This requirement was not met as evidenced by: Based on observation, interview, and record review, the Assisted Living Facility (ALF) failed to report to the department's Aging and Disability Services Administration Complaint Resolution Unit hotline when 1 of 1 resident (Resident 1) left the ALF's secured memory care unit unsupervised on two occasions. These failures resulted in an unreported incident preventing the Department from reviewing the ALF's response when Resident 1 left the secure memory care facility and placed Resident 1 at risk for harm. Findings included ... The ALF's policy on "ELOPEMENT- Missing Resident," dated 10/07/2020, showed the Executive Director or the License Nurse would report elopement to the Department of Social Health and Services Hotline (DSHS HOTLINE) within 24 hours when a resident leaves the ALF secured unit without supervision. The policy defined elopement as leaving protected and safe surroundings with no focused designation or the inability to return safely after exiting the facility. Resident 1 was admitted on /2024 with multiple diagnoses including ( ) and ( ). A review of the progress notes dated 06/23/2024 showed Resident 1 eloped from the community around 8:00 PM after trying several times to escape. The Police brought Resident 1 back around 9:00 PM. A review of the ALF's elopement incident report dated 06/29/2024 showed Staff F, Med Tech/Caregiver, discovered Resident 1 was missing from their room. The Paramedics . Statement of Deficiencies License #: 1977 Compliance Determination # 44005 Plan of Correction THE COTTAGES AT MILL CREEK Completion Date located the NR and was brought back to the ALF. On 07/14/2024 at 2:42 PM, Staff B, Director of Nursing, stated that they were not able to report to the DSHS HOTLINE the missing resident incidents on 06/23/2024 because they forgot and the incident on 06/29/2024 because they were out of town. A DSHS Hotline Tracking System review showed the missing resident incidents on 06/23/2024 and 06/29/2024 were not reported. This is a recurring deficiency previously cited on 04/06/2022. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency.

Statement of Deficiencies (SOD) report; and • May take licensing enforcement action based on any deficiency listed on the enclosed report; and • May inspect the facility to determine if you have corrected all deficiencies. 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 Next to each deficiency, sign and date certifying that you have or will correct each cited deficiency; and o Mail the Plan/Attestation Statement and report with original signatures to: . MILL CREEK SPECIAL CARE COMMUNITY LLC THE COTTAGES AT MILL CREEK # 1977 03/19/2024 Kimberley Ripley, Field Manager Region 2, Unit A 3906-172nd St NE, Suite #100 Arlington, WA 98223 • 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. You May: • Receive a letter of enforcement action based on any deficiency listed on the enclosed report. 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: IDR Program Manager Department of Social and Health Services Olympia, WA 98504-5600 If You Have Any Questions: • Please contact me at (360)651-6846. Sincerely, Kimberley Ripley, Field Manager Region 2, Unit A Enclosure . STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 3906-172nd St NE, Suite #100, Arlington, WA 98223 Statement of Deficiencies License #: 1977 Compliance Determination # 37196 Plan of Correction THE COTTAGES AT MILL CREEK 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 the unannounced on-site full inspection and complaint investigation on 02/21/2024, 02/21/2024 and 02/28/2024 of: THE COTTAGES AT MILL CREEK 13200 10TH DRIVE SE MILL CREEK, WA 98012 This document references the following complaint numbers: 119709, 119115. The following sample was selected for review during the unannounced on-site visit: 10 of 37 current residents and 1 former residents. The department staff that inspected the Assisted Living Facility: Christine Banta, ALF Licensor Jodi Condyles, ALF Licensor From: DSHS, Aging and Long-Term Support Administration 3906-172nd St NE, Suite #100 Arlington, WA 98223 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. . Statement of Deficiencies License #: 1977 Compliance Determination # 37196 Plan of Correction THE COTTAGES AT MILL CREEK Completion Date Administrator (or Representative) Date WAC 388-78A-3090 Maintenance and housekeeping. (1) The assisted living facility must: (a) Provide a safe, sanitary and well-maintained environment for residents; (b) Keep exterior grounds, assisted living facility structure, and component parts safe, sanitary and in good repair; This requirement was not met as evidenced by: Based on observation and interview, the Assisted Living Facility (ALF) failed to provide a safe, sanitary, well-maintained environment for 4 of 4 cottages (Cottage A, B,C, and D). This failure resulted in all 37 residents living in an unsanitary environment and placed them at risk of injury and a decreased quality of life. Findings included… On 02/21/2024 at 10:10AM, an ALF facility tour was completed. The ALF consisted of four single level cottages that were all secured memory care units. The following was observed: Cottage A - Cascade At 10:11AM, the hand railing located in the main facility hallway had dust, dirt, food particles and pieces of tissue setting on them. At 10:11AM, six brown circular splatter stains ranging from 1/4 to 3/4 inch wide, were observed directly below the handrailing and alarm control panel in the living room. On 02/21/2024 at 10:14 AM, Staff A, Executive Director, stated that night shift caregivers were supposed to be doing the cleaning, including the rails. Staff A stated that they would get it cleaned right away. Cottage B – Olympic At 10:24 AM, dried pieces of tissue paper 2 inches x 2 inches were covering the emergency . Statement of Deficiencies License #: 1977 Compliance Determination # 37196 Plan of Correction THE COTTAGES AT MILL CREEK Completion Date alarm control panel in the living room. On 02/21/2024 at 10:24 AM, Staff A stated that they did not why it had bits of tissue on it. At 10:28 AM, a 4-inch x 3-inch round hole was in the plaster board behind the washing machine exposing ply board and a dirt and dust crusted plastic water pipe. At 10:33 AM, a 4-inch x 4-inch round hole in the plywood exposing the drain access point under the handwashing sink in the community bathroom, leaving the water piping exposed. At 10:36 AM, the shower room door had a 5-inch diagonal crack under the doorknob exposing sharp edges of the door’s wood panel. On 02/21/2024 at 10:37 AM, Staff A stated that the replacement door was arriving on 02/22/2024. In an interview on 02/28/2024 at 12:15 PM, Staff G, Caregiver, stated that a resident had become upset and kicked the shower room door cracking it. Cottage C – Rainier At 10:59 AM, a 4-inch x 5-inch piece of rubber base board trim was missing to the left of the bathroom door. At 11:04 AM, the laundry room washing machine, counter and sink were stained with pink and brown, dried laundry soap. At 11:09 AM, the drain underneath the kitchen sink was covered in a yellow/brown coating, with pieces of food particles stuck to the plastic mesh covering the drain. Small flies were in the drain, on the plastic mesh covering and were flying around inside the cabinet. When the door was initially opened, flies were on the left side cabinet door. At 11:11 AM, a 55-inch x 36-inch gray utility mat on the floor at the entrance of the kitchen had three corners curled up creating a trip hazard. Cottage D – Pacific . Statement of Deficiencies License #: 1977 Compliance Determination # 37196 Plan of Correction THE COTTAGES AT MILL CREEK Completion Date At 11:23 AM, the drain underneath the kitchen sink was stained with a brownish/yellow substance that appeared dried in some spots and wet in others. At 11:25 AM, the 96-inch x 1-inch front trim of the kitchen counter was missing exposing dried glue used to adhere the counter tops. At 11:31 AM, a 26-inch x 4-inch piece of rubber base board trim, to the left of the main entrance of the cottage hallway was missing, 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 MILL CREEK 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-2610 Infection control. (1) The assisted living facility must institute appropriate infection control practices in the assisted living facility to prevent and limit the spread of infections. (2) The assisted living facility must: (e) Perform all housekeeping, cleaning, laundry, and management of infectious waste according to current acceptable standards for infection control; This requirement was not met as evidenced by: Based on observation, record reviews and interviews, the Assisted Living Facility (ALF) failed to implement safe infection control practices when 4 of 6 staff (Staff A, C, D and E) had not been fit tested for a N95 respirator, and 1 of 4 medication carts (Cottage B's medication cart) had a sharps container with a lid that did not lock. --- Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . . . Statement of Deficiencies License #: 1977 Compliance Determination # 41794 Plan of Correction THE COTTAGES AT MILL CREEK Completion Date Administrator (or Representative) Date WAC 388-78A-2350 Coordination of health care services. (1) The assisted living facility must coordinate services with external health care providers to meet the residents' needs, consistent with the resident's negotiated service agreement. This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to follow the primary care physician's (PCP) recommendation for 1 of 1 resident (Resident 1) when Resident 1's PCP recommended sending Resident 1 to urgent care or the emergency room for an evaluation. This failure resulted in Resident 1 not getting evaluated, their symptoms addressed, or their needs met during an emergency. The failure placed all other residents at risk for unmet care needs during an emergency. Findings included… The service agreement dated 04/24/2024 showed Resident 1 required staff assistance to coordinate care with physicians and outside providers. On 5/24/2024 at 2:05 PM, Staff C, Resident Care Coordinator, stated that Resident 1 was coughing when they went in to work in Resident 1's cottage on 05/10/2024 at around 9:00 AM. Staff C stated that Resident 1 did not eat dinner the day before and did not eat breakfast. Resident 1 took some Ensure on the day before. Staff C stated that they informed Staff B, Director of Nursing Services, and faxed the PCP the morning of 05/10/2024. On 05/24/2024 at 3:20 PM, Staff E, Caregiver, stated that on 05/10/2024, Resident 1 was not feeling well when they saw them in the morning. Staff E stated that Resident 1 told them they had chest pain before breakfast and had a hard time breathing at 8:45 AM after breakfast. Staff E stated that they informed Staff D, Med Tech, who went to check Resident 1's blood pressure and pulse. Staff E stated that Resident 1 refused to eat lunch. Progress notes (Notes) dated 05/10/2024 showed the Resident 1 was not feeling well, had a cough, was wheezing, and did not eat their dinner the day before. A written statement from the investigation Report dated 05/10/2024 at 9:20 AM showed Staff D notified Staff C that Resident 1 was coughing. Staff C stated she sent a telefacsimile . Statement of Deficiencies License #: 1977 Compliance Determination # 41794 Plan of Correction THE COTTAGES AT MILL CREEK Completion Date (FAX) the PCP about Resident 1 coughing and having issues with their breathing. A FAX showed Staff C faxed the PCP on 2024 at 9:11 AM, stating that Resident 1 was not doing well, was coughing, their breathing was off, and they had not eaten well and missed their dinner the day before. A FAX receipt report dated 2024 showed the PCP's reply was received on 2024 at 10:15 AM, an hour and 4 minutes after the initial fax was sent on 2024 at 9:11 AM. The PCP's reply showed the note, "Recommend to urgent care or ER to evaluate," and was signed by Resident 1's PCP. The Incident report dated 2024 showed Resident 1 was found by Staff E, caregiver, unresponsive with no breathing and no pulse at around PM. The report showed Resident 1 had been coughing and was not at their baseline before they passed away. On 06/14/2024 at 11:00 AM, Staff C stated that nobody

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 MILL Provider Type: Assisted Living Facility CREEK License/Cert.#: 1977 Intake ID: 104376 Compliance Determination #: 32280 Region/Unit #: RCS Region 2 / Unit A Investigator: Wesler Dumecquias Investigation Date(s): 11/08/2023 through 12/21/2023 Complainant Contact Date(s): Allegation(s): The Named Resident (NR) was missing. Investigation Methods: Sample: Total residents: 39 Resident sample size: 6 Closed records sample size: 1 Observations: Identified resident Residents Activities Dining Resident rooms Staff to resident interactions Resident to resident interactions Front door alarm and locking system Interviews: Identified resident Nursing staff Residents Family members Maintenance staff Executive Director Record Reviews: Incident investigation Facility policies Staff patterns care plans Assessment Progress notes Investigation Summary: The Assisted Living Facility (ALF) failed to monitor and ensure the whereabout of the Named Resident (NR) according to the Negotiated Service Plan. The NR was able to get out of the secured unit without the knowledge of the ALF staff. It was determined that the front door in the NR cottage does not lock and the Alarm do not work. Failed . Practice was identified. A citation was issued for non compliance with WAC 388-78A-2450 (1) (a) (b) Staff. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . . Statement of Deficiencies License #: 1977 Compliance Determination # 32280 Plan of Correction THE COTTAGES AT MILL CREEK Completion Date Administrator (or Representative) Date WAC 388-78A-2450 Staff. (1) Each assisted living facility must provide sufficient, trained staff persons to: (a) Furnish the services and care needed by each resident consistent with his or her negotiated service agreement; (b) Maintain the assisted living facility free of safety hazards; and This requirement was not met as evidenced by: Based on observation, interview, and record review, the Assisted Living Facility (ALF) failed to have enough staff to keep 2 of 2 residents (Resident 2 and 5) safe in the memory care cottages A and B. This failure resulted in Residents 2 and 5 leaving the ALF unnoticed from an unsecured door and placed all residents residing in the cottages at risk for leaving the ALF. Findings included… Review of the ALF's Disclosure of Services dated 03/2017 showed the ALF will have the following security services to help protect the residents with cognitive impairments and wandering behaviors: - Restricted use of exit doors in a designated portion of the building designed to serve residents with dementia. - Restricted use of exit doors throughout the building. - Outside area available with restricted egress. Resident 2 Resident 2 was admitted on /2023 with multiple diagnoses including . . Statement of Deficiencies License #: 1977 Compliance Determination # 32280 Plan of Correction THE COTTAGES AT MILL CREEK Completion Date Review of Negotiated Service Plan (NSP) dated 06/21/2023 showed Resident 2 ambulated independently regardless of any assistive device and had exit-seeking and wandering behaviors. Resident 2 required supervision and monitoring by the ALF staff 4x/hour. The ALF staff were to know the whereabouts of Resident 2. The NSP showed Resident 2 had a diagnosis of requiring restricted egress. Resident 2 had a history of exit-seeking. The ALF staff were to ensure that all secure doors were closed and latched securely when entering or exiting the building. Review of Incident investigation dated 11/06/2023 showed Resident 2 went missing and could not be located by the ALF staff in the ALF’s vicinity after being last seen around 4:20 PM prompting the ALF staff to call 911. The ALF staff were told by 911 that Resident 2 was found by the Police and was at the hospital. The Police transported Resident 2 back to the ALF. Review of Resident Roster dated 11/08/2023 showed Resident 2 resided in Cottage B. On 11/08/2023 at 3:15 PM, Cottages A and B were observed to be in the same building but had separate secured and locked front entrances. The Cottages were equipped each with unlocked and unsecured back doors which lead to a common secured patio shared by Residents of Cottages A and B and were easily accessible by staff and residents. On 11/08/2023 at 3:38 PM, Staff F, Caregiver/Med Tech, who worked evening shift in Cottage A, stated that Resident 2, who resides in Cottage B hangs out and is often in Cottage A. On 11/08/2023 at 3:18 PM, Staff E, Med Tech/Caregiver stated that she saw Resident 2 at about 3:30 PM on 10/29/2023 when she went to Cottage A looking for bread. On 11/27/2023 at 2:37 PM Staff G, Caregiver stated that there was a prior incident that happened on the same day 10/29/2023 where she found Resident 2 in the parking lot past 2:00 PM. Staff G stated that she checked the door in Cottage A. The door was not locked and there was no alarm sounding. Staff G stated that she called Staff C, Resident Care Manager and informed her about the incident and the broken front door in Cottage A. On 11/08/2023 at 3:38 PM, Staff F, Caregiver/Med Tech, who worked evening shift in Cottage A on 10/29/2023, stated that he was informed by Staff E that the front door in Cottage A was broken and there was no alarm. Staff F stated that he tested the door in Cottage A and the door opened without an alarm. Staff F stated that because he was made aware that Resident 2 went out of the Cottage earlier on 10/29/2023 but they did not know how and with the door not alarming in Cottage A, he took the table and chairs and blocked the back door that connects Cottages A and B so that Resident 2 could not come to Cottage A. Staff F was assisting a resident in their room in cottage A. Staff F stated that he could not always keep an eye on the residents in his assigned Cottage especially if he was doing another task. Staff F did not call another staff to keep an eye on the residents in . Statement of Deficiencies License #: 1977 Compliance Determination # 32280 Plan of Correction THE COTTAGES AT MILL CREEK Completion Date Cottage A because the other care staff were also busy. Staff F stated that he did not know that Resident 2 went out of the Cottage during his shift. Resident 5 Resident 5 was admitted on /2022 with multiple diagnosis including . Review of Resident Roster dated 11/08/2023 showed Resident 5 resided in Cottage A. Review of Negotiated Service Plan (NSP) dated 10/09/2023 showed Resident 5 uses a 4-wheeled walker and needed minimal assistance with ambulation. The NSP showed Resident 5 had a diagnosis of and required restricted egress. The NSP showed staff were to monitor and supervise Resident 5 1-2x per shift. Review of Incident report dated 11/05/2023 showed Resident 5 was found outside of the Cottage in the parking lot sitting on the ground near a car parked. On 12/07/2023 at 3:13 PM, Resident 5 stated that they left the cottage by walking through the front door. Resident 5 stated that they pushed the front door and opened it. Resident 5 stated that there were no staff in the Cottage at that time to have stopped them from getting out. Resident 5 stated that they left to go walk outside. On 12/07/2023 at 3:34 PM, Staff F, Caregiver/ Med Tech stated that on 11/05/2023 he left Cottage A to help another Care staff in Cottage B and that was the time Resident 5 went out. Staff F stated that he did not ask other staff to watch Cottage A while he went to help in Cottage B because everyone was busy. Staff F stated that he did not hear any alarm go off. On 12/07/2023 at 3:22 PM, the front door in Cottage A was observed unlocked and when pushed, the alarm did not turn on. Staff F, Caregiver/MedTech and Staff H, Resident Care Coordinator came and tested the front door, and the door was not locking as well as the Alarm did no turn on. On 12/07/2023 at 4:10 PM, Staff I, Maintenance Director came and fixed the door. Staff I .

Findings included ... Resident 1 was admitted to the facility in /2017 with multiple diagnoses including . On 12/18/2023 at 12:57 PM, Resident 1 was observed in tl7e dining room in their wheelchair_ Resident 1 was sitting on a ROHO cushion. On 12/18/2023 at 1 :09 PM, Collateral Contact 1. Outside healthcare representative, stated that wh.enever they were in the ALF, they would check to make sure Resident 1. was sitting on the ROHO cushion. Review of the undated Negotiated Service Agreement (NSA) did not show Resident 1 was admitted to Hospice services. The NSA also did not indicate that Resident 1 used a ROHO cushion wllen they are sitting in th.eir wheelchair. On 12/18/2023 at 11:07 AM, Staff A, Executive Director, stated that they tt1ought the NSA was updated by t~1e agency nurse who had been working at that time. On 01/04/2024 at 10:25 AM, Staff C, Regional Executive Director, stated that they did not . Statement of Deficiencies LicenJ~e #: 1977 Compliance Determination # 34076 Plan of Correction THE COTTAGES AT MILL CREEK Completion Date have a Hospice Care Plan available for review. Staff C stated that they would reach out to the Hospice Care Team and request a copy. Review of the hospice progress note, dated 03/31/2023, included an order for a ROHO cushion. The progress note showed Resident 1 was admitted to hospice services on 12/5/2023. This is an uncorrected deficiency previously cited on 08/16/2023. PtanJAttestation 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 MILL CREEK is or will be in compliance with this law and I or regulation on (Date)_ _____ In addition, l will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date Investigation Summary Report Provider/Facility: THE COTTAGES AT MILL Provider Type: Assisted Living Facility CREEK License/Cert.#: 1977 Intake ID: 85928 Compliance Determination #: 25953 Region/Unit #: RCS Region 2 / Unit A Investigator: Robin Windhausen Investigation Date(s): 06/28/2023 through 08/16/2023 Complainant Contact Date(s): 06/27/2023 Allegation(s): 1. No staff could be located in the unit when an outside provider's staff visited the Named Resident(NR). 2. The NR's break was locked on the wheelchair during the visit. 3. The NR appeared uncomfortable while seated in their wheelchair. Investigation Methods: Sample: Total residents: 38 Resident sample size: 3 current residents Closed records sample size: 1 closed rec Observations: Residents, the resident environment, staff and resident interactions, meals and activities. Interviews: Residents, Resident representatives, Collateral contacts, Direct care staff and administrative staff. Record Reviews: Clinical and administrative records, and facility policies. Investigation Summary: 1. Staff were available during unannounced facility visit. No issues were identified with availability of staff were noted during unannounced visit. The facility staff reported recent changes in staffing had been made by adding another med tech in the evening. 2. The NR had a wheelchair (WC) with a broken brake stuck in a locked position. The provider had facilitated a new WC for the NR. The new WC was observed during the unannounced visit; however the NR was not provided with a ROHO cushion as ordered by Hospice. The NR's negotiated service agreement (NSA) did not include the ROHO cushion. The facility was cited for noncompliance with WAC 388-78A-2350(7)(a) Coordination of Healthcare services. 3. The NR did not display signs of discomfort while observed in their WC. A Negotiated Service Agreement did not accurately identify a Sampled Resident's care needs. The facility was cited for noncompliance with WAC 388-78A-2100 (1)(2)(b) Ongoing assessments. 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 AGING AND LONG-TERM SUPPORT ADMINISTRATION 3906-172nd St NE, Suite #100, Arlington, WA 98223 ·····tice11se #:·1911··················co11ipiianceoeteimi11at1011·#2sgs'.3 Statement of Deficiencies Plan of Correction THE COTTAGES AT MILL CREEK Completion Date You are required to be in compliance at au 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 06/28/2023, 06/28/2023, 07/05/2023, 08/12/2023 and 07/12/2023 of: THE COTTAGES AT MILL CREEK 13200 10TH DRIVE SE MILL CREEK, WA 98012 This document references the following complaint number(s): 85928 The following sample was selected for review during the unannounced on-site visit 3 of 38 current residents and 1 former residents. The department staff that investrgated the Assisted Living Facility: Robin Windhausen, Long Term Care Surveyor From: DSHS, Aging and Long-Term Support Administration 3906-172nd St NE, Suite #100 Arlington, WA 98223 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. 08/29/2023 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. . -S---t-a---t-e---m----e--n---t- --o--f- --D---e---f-i-c--i-e---n---c--i-e- s -----L---i-c--e--n---s--e--- -#---:-- -1---9--7--7 ----------C---o---m---p---l-i-a---n-c--e-- --D---e---t-e--rm----i-n---a--t--i-o--n--- -#--- --2--5---9--5---3--- Plan ot Correction THE COTTAGES AT MILL CREEK Completion Date -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- WAC 388•78A-2100 On-going assessments. The assisted living facility must: (2) Complete an assessment specifically focused on a resident's identified problems and related issues: (b) 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 observation, interview, and record review, the facility failed to ensure the Assessment was updated for 1 of 4 Residents (Resident 3) when the Assessment no longer addressed Resident 1' s current needs. Failure to ensure the NSA accurately described Resident 3's inability to ambulate independently placed Resident 3 at risk for unmet care needs and a diminished quality of life. Finding included ... Resident 3 Resident 3 was admitted to the facility on /2020 with multiple medical diagnoses including . The facility assessment dated 05/04/2023 showed Resident 3 was able to walk with one person contact guard with or/ without Durable Medical equipment (a variety of items, such as walkers, wheelchairs, and oxygen tanks.) The NSA dated 07i12/2023 indicated Resident 3 was able to walk and directed staff to provided set up/stand-by/cueing for safe ambulation. On 07/05/2023 at 3:05 PM, Staff F, Caregiver, stated that Resident 3 was no longer able to walk. Staff F could not recall when Resident 3 last walked. On 07/12/2023 at 2:45 PM, Staff A. Executive Director, and Staff .8, Resident Care Manager completed observations of Resident 3. Staff A stated that the NSA should be updated when it no longer met the resident's needs. Plan/Attestation Statement . -S---t-a---t-e---m----e--n---t- --o--f- --D---e---f-i-c--i-e---n---c--i-e- s -----L---i-c--e--n---s--e--- -#---:-- -1---9--7--7 ----------C---o---m---p---l-i-a---n-c--e-- --D---e---t-e--rm----i-n---a--t--i-o--n--- -#--- --2--5---9--5---3--- Plan ot Correction THE COTTAGES AT MILL CREEK Completion Date -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 MILL CREEK 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 compliance with this requirement. --------------------------------· Administrator (or Representative) Date WAC 388-78A-2350 Coordination of health care services. (7) When coordinating care or services, the assisted living facility must: (a) Integrate relevant information from the external provider into the resident's preadmission assessment and reassessment, and when appropriate, negotiated service agreement; and This requirement was not met as evidenced by: Based on observation. interview, and record review the Assisted Living Facility (ALF) failed to integrate information into the negotiated service agreement (NSA) when the provider ordered a Roho cushion (a heavy duty air filled cushion for treatment and prevention of pressure ulcers) for 1 of 4 residents (Resident 1) . Failure to ensure the Roho cushion was incorporated into the Negotiated Service Agreement resulted in the Roho cushion not being used and placed Resident 1 at risk for unmet care needs and a diminished quality of life. Finding included ... Resident 1 was admitted to the facility in 2017 with multiple diagnoses including . Review of the physician orders showed that Resident 1 was placed on hospice 4/21/2022. Review of a delivery invoice dated 12/22/2023 showed an air-filled "Roho" cushion, and a pump to inflate it was delivered to the facility for Resident 1.

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

findings during unannounced visit. 5. Record review showed that the facility began to address the NR's weight loss and notified the Primary care physician (PCP) regarding the NR's weight loss as early as 01/27/2023. The facility monitored and documented the NR's weight as ordered. The NR was ordered Lactaid as well as Lactose free supplement. 6. Record review showed that the NR was on services. The facility does not process increases or changes in the rent for Residents. Home and Community Services Social Services Supervisor stated that all correspondence about NR's financial responsibility has been sent to NR and POA. The increase in rent was based on the NR's monthly income. 7. The facility failed to provide independent or self-directed activities consistent with sampled residents' interest and the negotiated service agreement. Failed practice identified. WAC 388- 78A-2180 Activities. 8. The facility failed to follow the Communicable Diseases Center's (CDC) recommended infection control practices. Failed practice identified. WAC 388-78A-2610 Infection Control. 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 MILL Provider Type: Assisted Living Facility CREEK License/Cert.#: 1977 Intake ID: 78507 Compliance Determination #: 22658 Region/Unit #: RCS Region 2 / Unit A Investigator: Wesler Dumecquias Investigation Date(s): 04/18/2023 through 05/23/2023 Complainant Contact Date(s): 04/17/2023, 05/19/2023 Allegation(s): It was alleged: 1. The facility was discharging Named Resident (NR) immediately. 2. The facility was unable to meet the needs of NR. The facility was not doing any activity and residents were just sitting. 3. During unannounced visit, facility had a COVID-19 outbreak. Investigation Methods: Sample: Total residents: 38 Resident sample size: 5 Closed records sample size: 1 Observations: Residents Resident to resident interactions Staff to resident interactions Interviews: Family members Residents Nursing staff Administrator Record Reviews: Incident investigation Facility policies Charting notes Care Plan MAR Investigation Summary: 1. The facility issued a discharged notice to the NR due to the facility being unable to meet the NR needs. The NR has urgent medical needs that the facility cannot meet and the health and safety of other residents were endangered. Records show that the NR had previous behavioral issues that the facility communicated with the primary care physician and the family. The facility called 911 due to the NR breaking doors, boxes, forcibly entering into other residents room and throwing a cup of water to staff. The facility was not able to redirect NR to keep NR and other residents safe. The facility called 911 and NR was taken to the emergency room (ER). NR was transferred to a . geropsych unit and on restraint for further management of behavior. The facility stated that it will not be taking back the NR. The NR was given discharge notice on 4/12/2023. The discharged notice did not identify a location for placement once the NR becomes stable and predictable. The NR was admitted on the PACE program on 04/01/2023. In an interview and an email, PACE accepted full responsibility to locate for housing. Consultation done. 2. Interview and record showed that the facility was in contact with the primary care physician and the family regarding NR behavioral management. The facility made arrangement with the family for NR to transition with a new PCP for closer and better communication under the PACE (Program of All-inclusive Care for the Elderly) program. The facility were monitoring residents' behavior and safety. The facility failed to provide independent or self-directed activities consistent with sampled residents' interest and the negotiated service agreement. Failed practice identified. WAC 388-78A-2180 (1)(a)(b)(2), Activities. 3. The facility failed to follow the Washington State Department of Health’s (DOH) recommended infection control practices. Failed practice identified. WAC 388-78A-2610 (1) , Infection Control. 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 MILL Provider Type: Assisted Living Facility CREEK License/Cert.#: 1977 Intake ID: 72684 Compliance Determination #: 21573 Region/Unit #: RCS Region 2 / Unit A Investigator: Wesler Dumecquias Investigation Date(s): 03/24/2023 through 04/26/2023 Complainant Contact Date(s): Allegation(s): It was alleged... The Named Resident (NR) eloped. Investigation Methods: Sample: Total residents: 40 Resident sample size: 3 Closed records sample size: 1 Observations: Identified resident Residents Activities Resident rooms Staff to resident interactions Resident to resident interaction Interviews: Identified resident Nursing staff Residents Family members Administrator Record Reviews: Incident investigation Facility policies Physician order summary Physician order Assessment Progress notes Care plan Medication administration records Admission agreement Investigation Summary: It was determined: The facility investigated the incident and stated that the NR had been agitated prior to leaving the ALF. The facility found out that the NR may have climbed over the fence at . the back of the cottage and left. NR was found wet on a rainy evening and brought back by the police. The ALF placed the NR on alert charting and increased check-ins. The ALF moved the table that was used to climb over the fence. Interview and review of records showed that the NR had missed medications for agitation due to the ALF not ensuring the reorders were obtained. Failed practice identified. WAC 388-78A-2240 Nonavailability of medications. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . . .