Aegis of Marymoor.

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 MARYMOOR 4585 WEST LAKE SAMMAMISH PARKWAY NE REDMOND, WA 98052 RE: AEGIS OF MARYMOOR License# 2209 Dear Administrator: This letter addresses Compliance Determination(s) 55100 (Completion Date 02/20/2025) and 51880 (Completion Date 12/26/2024). The Department completed a follow-up inspection of your Assisted Living Facility on 02/20/2025 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-2160, WAC 388-78A-24681-2, WAC 388-78A-3010-8-e, WAC 388-78A-2600-2-I The Department staff who did the on-site verification: Jane Hermano, NCI Kathy Young, Licensor If you have any questions, please contact me at (253)312-1446. Sincerely, Jamie Singer, Field Manager Region 2, Unit D Residential Care Services This document was prepared by Residential Care Services for the Locator website. c<>P.· R l?/'ll/2024 12:24 PM T0:12533955070 FROM:8556396300 ~(; 0 I LtfL<t IL. i(/JJtfi u 12.31.2025 10:19:24 State of Washington 7120 TATE OF WASHINGTON DEPARTMENT O SOCIAL AND HEALTH SERVICES AGING AND LO G-TERM SUPPORT ADMINISTRATION 20425 7211d A enue S, Suite 400, Kent, WA 98032 Statemen\.6fbeficiencies License #: 2209 . Compliance Determination# 51880 Plan of Correction A GIS OF MARYMOOR Completion Dale Page 1 of 7 Licen ee: Aegis Senior Communities LLC 12126/2024 You are required to be in compliance tall times with all licensing laws and regulations to maintain your Assisted Living Facility icense. The department completed data colle tion for the unannounced on-site full inspection on 12/1712024 and 12/20/2024 of AEGIS OF MARYMOOR 4565 WEST LAKE SAMMAMISH PA 't<WAY NE REDMOND. WA 98052 The following sample was selected fo review during the unannounced on-site visit: 8 of 50 current residents and O former reside ts. The department staffthat inspected ti e Assisted Living Facility: Jane Hermano, NCI Kathy Young, Licensor From: DSHS, Aging and Long-Term Suppor Administration Residential Care Services. Region 2 , Unit D 20425 7211d Avenue S, Suite 4D0 Kent, WA 98032 As a result of the on-site visit(s), the epartment found that you are not in compliance with the licensing laws and regulations as sta ed in the cited deficiencies in the enclosed report. L.um./44~ 12131/2024 Residential Care Service Date 1 understand that to maintain an Assi ted Living Facility license. the facility must be in compliance with all the licensing law and regulations at all times. This document was prepared by Residential Care Services for the Locator website. c<>P.· 7 l?/'ll/2024 12:24 PM T0:12533955070 FROM:8556396300 ~(; 0 I LLIL<t IL. i(/JJtfl 12.31.2025 10:19:24 State oF Washington 8/20 Statement or Deficiencies License#: 2209 Compliance Determination# 51880 Plan of Correction EGIS OF MARYMOOR Completion Date Page2 of7 Lice see: Aegis Senior Communities LLC 12/26/2024 ·-~-- 0 4 : ~ ~ Admin~~tor (or Representat ve) WAC 388-78A-2160 lmplementatio of negotiated service agreement. The assisted living facility must provide the care and ervices 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 r services are scheduled. This requirement was not met as e idenced by: Based on observation, interview. and record review. the facility failed to implement the Individualized Service Plan (ISP) for 1 of 2 Memory are residents (Resident 8). This failure placed Resident 8 at risk of a decreased quality of life from lack of care and services as written in the service plan. Findings included ... Review of Resident 8's Individualized Service Plan, dated 07/06/2021, showed Residents used a wheelchair for primary mobility. The I P showed care staff were required to check the wheelchair to ensure it worked safely. The ISP instr cted care staff to notify the nurse or Care Director when the wheelchair needed to be repaired or r placed. Observation on 12/2012024 at 11 42 M, showed staff used a Broda wheelchair (a wheelchair designed to prevention skin breakdo n through use of multiple tilt positions that relieve pressure from prominent areas of the body) to ring Resident 8 into the memory care dining room. Observation showed Resident 8 asle pin the wheelchair, which was 1ilted back. The leg rest was made with a series of plastic straps a ross a U-shaped metal frame. The bottom strap was stretched out of shape and hung three to four in hes below the frame. Observation showed the broken strap caused Resident B's calves to press n the bottom of the frame, rather than be suspended. During an interview on 12120/2024 at 1:56 AM, Staff J, Care Director, stated that about three weeks ago, Resident 8 discharged from hos ice (end of life care) services and returned their wheelchair to the hospice agency at that time. Staff stated that the facility found a wheelchair in storage that was that was left by a former resident. Sta J stated that the facility provided Resident 8 with this wheelchair. During an interview on 12/23/2024 at 0:40 AM, Staff J stated that they were unaware the wheelchair was damaged Staff J stat d that Resident B's ISP instructed staff to report the damaged wheelchair. This document was prepared by Residential Care Services for the Locator website. '!ffi,i;., I ILlf,t~~/2024 12:24 PM T0:12533955070 FROM:8556396300 Li/L'+ 0 12.31.2025 10:19:24 State oF Washington 9/20 Statement of Defrcien~ies License #: 2209 Compliance Determination# 51880 Plan of Correction A ,GIS OF MARYMOOR Completion Date Page 3 of7 Licen ,ee: Aegis Senior Communities LLC 12/2612024 During an interview on 12/23/2024 at 0:40 AM, Staff A, General Manager, stated that the facility used standard language in resident 11 Ps to instruct staff to report equipment damage to the Care Director or nurse. Staff A stated that I esident S's ISP contained this standard language. Pla1 /Attestation Statement I hereby certify that I have reviewe this report and have taken or will take active measures to correct this deficiency By taking this action, AEGIS OF MARYMOOR is or ?...Ii bni-s . will be in compliance with this law ind/ or regulation on (Date) I In addition. I will implement a system to monitor and ensure continued compliance with this requirement --~ .J _~t2:.-~- - . 12{11 /1--02.-'{ Administrator (or Representative) Date WAC 388-78A-24681 Background checks Employment Provisional hire Pending results of national fingerprint background check. The assisted living facility may provisionally employ a caregiver and an administrator hi.rE dafter January 7, 2012 for one hundred and twenty-days and allow the caregiver or adminis rator to have unsupervised access lo residents when: (2) The results of the national fingerp int background check are pending. This requirement was not met as e idencecJ by: Based on observation, interview, and record review, the facility failecJ to ensure 2 of the 4 newly hired care staff (Staff C and Staff G), ompletect the national fingerprint background check within 120 days of hire. This failure placed all 50 residents at risk of abuse, neglect, or exploitation. Findings included .. STAFF C Review of fi:lcility·s staff roster showe the facility hired Staff Casa Care Manager 1 (CM1) on 06/07/2024. Staff c·s final fingerprint results were due by 10105/2024. Review of the Care Manager 1 job description. revised 02/26/2016. showed the CM1 provided direct personal care to the residents. Review of the facility's care staff schel:ule, from 10/06/2024 through 12/03/2024, showed Staff C worked five shifts. This document was prepared by Residential Care Services for the Locator website. '!ffi,i;., I ILlf,t~~/2024 12:24 PM T0:12533955070 FROM:8556396300 L§lL'+ 12.31.2025 10:19:24 State or Washington 10/20 Statement of Deficiencies License #: 2209 Compliance Determination# 51880 Plan of Correction A:GIS OF MARYMOOR Completion Date Page4 of7 Licen,ee: Aegis Senior Communities LLC 12/26/2024 Review of Staff C's employee file sho Ned Staff C failed to show for a fingerprint appointment on 07/02/2024. The record showed that taff C completed their fingerprint background check on 07/16/2024. The records showed the ingerprint check was rejected, as the prints could not be read. There was no documentation that she wed Staff C completed the process. During an interview on 12118/2024 at 10:25 AM, Staff A, General Manager, stated that they were aware of the situation with Staff C. St ff A stated that it had happened before with other newly hired staff. Staff A stated that they unsure cf how to resolve the situation when staff fingerprints were rejected. STAFF G Review of facility's staff roster showe the facility hired Staff Gas a Medication Care Manager {MCM) on 01/16/2024 Staff G's final ingerprint results were due by 05/15/2024. Review of the Medication Care Mana er job description. revised 02/2612016. showed the MCM assisted residents with medications and activities of daily living. Review of the facility's care staff schE dule, from 10/03/2024 through 12120/2024, showed Staff G worked 38 shifts. Observation on 12118/2024 between 0:15 AM and 11 :00 AM, showed Staff G provided medication assistance to three residents. Review of Staff G's employee file she wed the facility received notification on 01116/2024 and 07/1912024, that the fingerprint chec for Staff G was rejected. as the prints could not be read. There was no documentation that showed 1 taff G completed the fingerprint background check process. c During an interview on 12/1812024, aff H, Business Office Manager, stated that they were aware that Staff G continued to work direct! with residents without a final fingerprint background check. Pia 1/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficienc . By taking this action, AEGIS OF M/1.\RYMOOR is or will be in compliance with this law ind/ or regulation on (Date) 1, r /' p , ·101.S . In addi1ion, I will implement a syst m to monitor and ensure continued compliance with this requirement. This document was prepared by Residential Care Services for the Locator website. '!ffi,i;., I ±9L'+ IL1fLt~~12024 12:24 PM T0:12533955070 FROM:8556396300 IV 12.31.2025 10:19:24 State of Washington 11/20 Statement of Deficiencies License#: 2209 Compliance Determination# 51880 Plan of Correction Ai=GIS OF MARYMOOR Completion Date Pages of 7 Licen~ee: Aegis Senior Communities LLC 12/2612024 /?-/51/z..oV-j Administrator (or Representative) Date WAC 388-78A-3010 Resident units. The a.ssisted living facility resident units must have the following: (8) Miscellaneous: Each sleeping roe 11 must have: (e) A lockable drawer, cupboard or ot~er secure space measuring a least one-half cubic foot with a minimum dimension of four inches: This requirement was not met as e✓idenced by; Based on observation and interview, he facility failed to provide 3 of 6 sampled assisted living residents (Resident 1, Resident 2, an l Resident 3) with the appropriate equipment to access the lockable storage in their apartments. his failure placed Resident 1. Resident 2, and Resident 3 at risk of financial exploitation. possible heft. and loss of privacy Findings included ... RESIDENT 1 Review or Resident 1 's records shov.'.ed the facility admitted Resident 1 in 2023 Observation of Resident 1's apartment on 12/2012024 at 9:53 AM, showed Resident 1 had a drawer in the bathroorn with a lock. The dra1 er was unlocked. During an interview at this time, Resident 1 stated that the facility never supplied them with a key to the drawer. RESIDENT 2 Review of Resident 2's records shov.ed the facility admitted Resident 2 in 2024. Observation of Resident 2's apartmeht on 12120/2024 at 8:46 AM, showed Resident 2 had two drawers in the bathroom, both with leeks. Both drawers were unlocked. During an interview at this time. Resident 2 stated that the facili y never provided them with a key. Resident 2 stated that they wanted a key ta lock the drawers RESIDENT 3 Review of Resident 3's records shoved the facility admitted Resident 3 in 2024. This document was prepared by Residential Care Services for the Locator website. '!ffi,i;., I ±&L'+ ILlfLt~~/2024 12:24 PM T0:12533955070 FROM:8556396300 I I 12.31.2025 10:19:24 State of Washin9ton 12/20 =~-~~c-,~-~------t-------.~-------,.-.=;::--------,.====-c.·-- Statement of Deficiencies License#: 2209 Compliance Determination# 51880 Plan of Correction A~GIS OF MARY MOOR Completion Date Page 6 of7 Licen ee: Aegis Senior Communities LLC 12/2612024 Observation of Resident 3's apartmer ton 12/20/2024 at 12:DB PM, showed Resident 3 had two drawers in the bathroom and one dra, ver in the kitchen, all with locks. The three drawers were all unlocked_ During an interview at this t me. Resident 3 and their representative, stated that the facility never provided any keys to the drawe s_ Resident 3 stated that they wanted the keys to lock the drawers_ Pia /Attestation Statement I hereby certify that I have reviewe this report and have taken or will take active m_easures to co_rrect this deficiency By taking this_ action, AEGIS_ 0/F. Ml}RYMO_?R is or will be 1n compliance with this law, nd / or regulation on (Date) Z Z L'loz.::::, . r I In addition. I will implement a system to monitor and ensure continued compliance with this requirement. 12-/31 /z,01,'{ Administrator (or Representative) Date WAC 3.88-78A-2600 Policies and pDcedures. (2) The assisted living facility must d € velop, implement and train staff persons on policies and procedures to address what staff per ons must dn: (I) To manage residents' medications consistent with WAC 388-78A-2210 through 388-78.A-2290 ; sending medications with a resident\ hen the resident leaves the premises; This requirement was not met as e 1idenced by: Based on observation, interview, and record review, the facility failed to ensure staff followed the policy used for accurate inventory of esident narcotic medications on 2 of 3 medication carts (second floor medication cart and thir j floor medication cart). This failure placed all 51 residents at risk of financial exploitation related to possible missing medications and potential medication errors for missed medicati.on from unaccour led, unavailable medications. Findings included ... Review of the facility's policy titled,"( ontrolled!Scheduled Medication Protocol (All States)', dated 10/2312019, showed that the facility f !lowed federal regulations and required an accurate inventory of controlled medications as defined nder the Drug Enforcement Administration. The policy showed a daily inventory check ensured acco.mtability for the correct medication administered to tt1e resident and helped identify early on any dive sion of medications with the potential for abuse. The policy required two staff follow the step-by-i tep controlled drug count instruction to count and verify each controlled medications at the beginni g and end of each shift. The policy required the two staff signed the facility's bound inventory r arcotic book. This document was prepared by Residential Care Services for the Locator website. '!ffi,i;.,, ±&L'+ ILl~t~~/2024 12:24 PM T0:12533955070 FROM:8556396300 IL 13/20 State of Washington 12.31.2025 10:19:24 Statement of Defrciencies License#: 2209 Compliance Determination# 51880 Plan of Correction A GIS OF MARYMOOR Completion Date Page 7 of7 Licen ee: Aegis Senior Communities LLC 12!2612024 Observations of the second floor and he third-floor medication carts on 12/19/2024 at 945 AM and 10:00 AM. showed each cart contain< a narcotic lock box that contained several single dose medication cards. The narcotic medication cards found inside the locked boxes were hydrococtone (for severe chronic pain). oxycodone for moderate to severe pain), alprazolam (for anxiety or panic disorder). lorazepam (for anxiety), tra nadol (for moderate to moderately severe pain). Tylenol with codeine (for mild to moderate pain), and pregabalin (for nerve pain). Review of the facility's record on cont oiled substance daily count, showed there were three shifts for each date. Review of the facility's second floor medication cart for October 2024, November 2024, and December 2024 shift audit rec::orc s showed there were 25 shifts without any staff signatures. Review of the third-floor medication c ,rt for October 2024, November 2024, and December 2024 shift audit records showed there werE three shifts without any staff signatures. During an interview on 12/18/2024 at 10:12 AM, Staff G, Medication Care Manager (MCM), stated that both MCMs were required lo sig, in on the shift daily count record, after each count of controlled a medication was confirmed and comoleted. During an interview on 12/19/2024 at 1:55 PM, Slaff B. Health Services Director, stated that medications kept in the narcotic lock Joxes were counted and recorded at each shift change. Staff B stated that they expected the two sta f on each shift sign the narcotic book. Staff B stated that they were unaware staff did not follow the controlled drug count process, as required. Plan/Attestation Statement I hereby certrfy that I have reviewE d this report and have taken or will take active measures to correct this deficienc . By taking this action, AEGIS- - O z F .. / M al A z R .. Y o M z. O s OR i . s or will be in compliance with this law 311d / or regulation on (Date) i In addition, I will implement a syst m to monitor and ensure continued compliance with this requirement. ~ ~ Administrator (or Representative) / This document was prepared by Residential Care Services for the Locator website. c<>P.· ? l?/'ll/2024 12:24 PM T0:12533955070 FROM:8556396300 ~(; 0 1 d1L<t IL. i(/JJtfl L 12.31.2025 10:19:24 State of Washington 3/20 TATE OF WASHINGTO,\J DEPARTMENT F SOCIAL AND HEAL TH SERVICES AGll~GANO L NG-TERM SUPPORT ADMINISTRATION 20425 72nd A enue S, Suite 400, Kent, WA 98032 1213112024 Aegis Senior Communities LLC AEGIS OF MARYMOOR 4585 WEST LAKE SAMMAMISH PA KVVAY NE REDMOND, WA 98052 RE: AEGIS OF MARYMOOR # 2209 Dear Administrator: The Department completed a full insp ction of your Assisted Living Facility on 12/26/2024 and found that your facility does not meet he Assisted Living Facility requirements The Department: • Wrote the enclosed report; and • May take licensing enforcement acli n 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 correc ed within the timeframe accepted by the department. You Must: • Begin the process of correcting the eficiency or deficiencies immediately; • Contact the Field Manager for clarifi ations related to the Statement of Deficiencies (SOD): • Within 10 calendar days after you re eive this letter, complete and return the enclosed 'Plan/Attestation Statement': o Sign and date the enclosed report; o For each deficiency, indicate the d le you have or will correct each deficiency; o Mail the Plan/Attestation Statemen and report with original signatures to Laurie Anderson, Field Manager Residential Care SerJices Region 2, Unit D 20425 72nd Avenue S, Suite 400 This document was prepared by Residential Care Services for the Locator website. c<>P.· Cl l?/'ll/2024 12:24 PM T0:12533955070 FROM:8556396300 ~(; 0 I d:fL<t IL. i(/JJtfl 12.31.2025 10: 19:24 State of Washington 4/20 AEGIS OF MARYMOOR # 2209 12/2612024 Page 2 of 4 Kent, WA 98032 • Complete correction(s) within 45 da s, or sooner if directed by the Department. after review of your proposed correction dates. • Have your plan approved by the De artment. Consultation(s ): In addition, the Department provided onsultation on the following deficiency or deficiencies nol listed on the enclosed report WAC 388-78A-2480 Tuberculosis esting Required. (1) The assisted living facility must de elop and implement a system to ensure each staff person is screened for tuberculosis within three days of employment. The facility failed to ensure all staff co pleted a Tuberculosis test within three days of hire, as required. During the full inspection. T test records were collected from all the staff that showed the facility completed TB testing of all sta to meet the regulatory requirements WAC 388-78A-2620 Pets. If an assi led living facility allows pets to live on the premises, the assisted living facility must: (2) Ensure animals living on the assis ed living facility premises: (a) Have regular examinations and im unizations. appropriate for the species, by a veterinarian licensed in Washington state; (b) Are certified by a veterinarian to b free of diseases transmittable to humans; The facility failed to ensure a pet that esided within the community received a regular veterinarian examination and vaccinations. During the full inspection, the facility obtained the records for the pet that showed the pet was current with veterinarian examination and vaccinations. WAC 388-78A-3100 Safe storage of supplies and equipment. The assisted living facility must secure potentially hazardous suppl es and equipment commensurate with the assessed needs of residents and their functi nal and cognitive abilities. In determining what supplies and equipment may be accessible o residents, the assisted living facility must consider at a minimum: (2) The degree of hazardousness or t xicity posed by the supplies or equipment; (3) Whether or not the supplies and e uipment are commonly found in a private home, such as hand soap or laundry detergent; and The facility failed to ensure all chemic Is were secured in the outdoor kitchen storage shed. During the full inspection, the facility locked t e shed and provided an in-service to staff that reviewed the facility's chemical storage policy. This document was prepared by Residential Care Services for the Locator website. c<>P.· 4 l?/'ll/2024 12:24 PM T0:12533955070 FROM:8556396300 ~(; 0 I Li.1L<t IL. i(/JJtfi '+ 12.31.2025 10:19:24 State oF Washington 5/20 AEGIS OF MARYMOOR # 2209 12/26/2024 Page 3 of 4 WAC 388-78A-2220 Prescribed me ication authorizations. (2) The documentation required abov in subsection (1) of this section must include the following information (a) The name of the resident; The facility failed to ensure all over th counter medicabons on facility medication carts were labeled with the resident's name. During the f II inspection, the staff correctly labeled all medication bottles with the resident's name and apartm nt number. WAC 388-78A-3090 Maintenance a d housekeeping. (1) The assisted living facility must: (a) Provide a safe, sanitary and well-, aintained environment for residents; The facility failed to ensure one roof ccess hatch was locked. The facility failed to ensure that air vents in one resident laundry area, ore unoccupied resident's apartment, a11d one housekeeping closet worked. During the licensing in pection, the three air vents were fixed, and the one roof hatch was padlocked. You Are Not: • Required to submit a plan of correct on for the consultation deficiency or deficiencies stated in this letter and not listed on the enclos d report. You May: • Contact me for clarification of the d ficiency or deficiencies found. In Addition, You May: • Request an Informal Dispute Reso ution (IDR) review within 1D working days after you receive this letter. Your I DR request ust include: o What specific deficiency or deficie cies you disagree with; o Why you disagree with each ctefic ency; and o Whether you want an IDR to occu in-person, by telephone or as a paper review. o Send your request to: IDR Program Manager Department of Social and Health Se ices Aging and Long-Term Support Admini \ration Residential. Care Services PO Box 45600 Olympia, WA 98504-5600 If You Have Any Questions: • Please contact me at (253)234-602 This document was prepared by Residential Care Services for the Locator website. 12024 12:24 PM T0:12533955070 FROM:8556396300 '!ffi,i;.,, LtiL'+ ILlM,~~ v 12.31.2025 10:19:24 State of Washington 6/20 AEGIS OF MARYMOOR # 2209 12/2612024 Page 4 of 4 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. 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 MARYMOOR 4585 WEST LAKE SAMMAMISH PARKWAY NE REDMOND, WA 98052 RE: AEGIS OF MARYMOOR License# 2209 Dear Administrator: This letter addresses Compliance Determination(s) 69143 (Completion Date 11/21/2025) and 65570 (Completion Date 09/24/2025). The Department completed a follow-up inspection of your Assisted Living Facility on 11/21/2025 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-2210-2-a The Department staff who did the on-site verification: Deborah Carlis, Complaint Investigator If you have any questions, please contact me at (206)305-3489. Sincerely, ch::=.nager Region 2, Unit D Residential Care Services Residential Care Services Investigation Summary Report Provider/Facility: AEGIS OF MARYMOOR Provider Type: Assisted Living Facility License/Cert.#: 2209 Compliance Determination #: 65570 Intake ID: 192920 Investigator: Deborah Corlis Region/Unit #: RCS Region 2 / Unit D Investigation Date(s): 09/12/2025 through 09/24/2025 Complainant Contact Date(s): 09/24/2025 Allegation(s): Medication error. Investigation Methods: Sample: Total residents: 53 Resident sample size: 3 Closed records sample size: 1 Observations: Facility environment, common areas, memory care unit, residents engaged in activities, resident and staff interactions. Interviews: Reporter, General Manager, Health Services Director, family/Power of Attorney. Record Reviews: Characteristic Roster, face sheet, individual service plan, electronic medication records, medication release records, progress notes, Power of Attorney documents, facility and family emails, Abuse and Neglect Policy, Assisting Residents with Medications Policy. Investigation Summary: The Assisted Living facility provided incorrect medication and instructions to family when taking Named Resident out of the facility, causing medications errors. Failed practice identified. See statement of deficiencies, completion date 09/24/2025 . Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A This document was prepared by Residential Care Services for the Locator website. 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 #: 2209 Compliance Determination # 65570 Plan of Correction AEGIS OF MARYMOOR Completion Date Page 1 of 3 Licensee: Aegis Senior Communities LLC 09/24/2025 You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for an unannounced on-site complaint investigation on 09/12/2025 of: AEGIS OF MARYMOOR 4585 WEST LAKE SAMMAMISH PARKWAY NE REDMOND, WA 98052 This document references the following complaint number(s): 192920 The following sample was selected for review during the unannounced on-site visit: 3 of 53 current residents and 1 former residents. The department staff that investigated the Assisted Living Facility: Deborah Corlis, Complaint Investigator From: DSHS, Aging and Long-Term Support Administration Residential Care Services, Region 2 , Unit D 20425 72nd Avenue S, Suite 400 Kent, WA 98032 This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. 09.25.2025 13:28:59 State of Washi111Jton 6/10 Statement of Deficiencies License#: 2209 Compliance Determination# 65570 Plan of Correction AEGIS OF MARYMOOR Completion Date Page 2 of 3 Licensee: Aegis Senior Communities LLC 09i24/2025 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. Ja111es Sher111a11 09-25-2025 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. 'Date WAC 388-78A-2210 Medication services. (2) The assisted living facility mLIst ensure the following residents receive their medications as prescribed, except as provided for in WAC 388-78A-2230 and 388-78A-2250 : (a) Each resident who requires medication assistance and his or her negotiated service agreement indicates the assisted living facility will provide medication assistance; and This requirement was not met as evidenced by: This requirement was not met as evidenced by: Based on interview and record review the facility failed to ensure 1 of 1 sample resident (Resident 1) received medication as prescribed when the resident was out of the facility with family. This failure resulted in medication errors for Resident 1. Findings include ... Record review of Resident 1' s Individual Service Plan dated 06124/2025 showed trained medication staff will assist to administer medications to the resident as ordered. Record review of Resident 1's Electronic Medication Administration Record (eMAR) dated August 2025 showed that the facility admitted Resident 1 on /2024 with a diagnosis of . The eMAR showed Resident 1 was prescribed two medications for their treatment of dementia. The eMAR further showed one entry on 08/27/2025 whict1 documented Resident 1 was out of facility with family at scheduled medication times. Statement of Deficiencies License #: 2209 Compliance Determination # 65570 Plan of Correction AEGIS OF MARYMOOR Completion Date Page 2 of 3 Licensee: Aegis Senior Communities LLC 09/24/2025 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 388-78A-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 : (a) Each resident who requires medication assistance and his or her negotiated service agreement indicates the assisted living facility will provide medication assistance; and This requirement was not met as evidenced by: This requirement was not met as evidenced by: Based on interview and record review the facility failed to ensure 1 of 1 sample resident (Resident 1) received medication as prescribed when the resident was out of the facility with family. This failure resulted in medication errors for Resident 1. Findings include… Record review of Resident 1’s Individual Service Plan dated 06/24/2025 showed trained medication staff will assist to administer medications to the resident as ordered. Record review of Resident 1’s Electronic Medication Administration Record (eMAR) dated August 2025 showed that the facility admitted Resident 1 on /2024 with a diagnosis of . The eMAR showed Resident 1 was prescribed two medications for their treatment of dementia. The eMAR further showed one entry on 08/27/2025 which documented Resident 1 was out of facility with family at scheduled medication times. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. 09.25.2025 13:28:59 State OF Washi111JtOn 7/10 Statement of Deficiencies License #: 2209 Compliance Determination# 65570 Plan of Correction AEGIS OF MARYMOOR Completion Date Page 3 of 3 Licensee: Aegis Senior Communities LLC 09/24/2025 Record review of Resident 1's Medication Release Record, given to the family, dated 08/27/2025 showed that the facility transcribed incorrect medication orders for two medications treating dementia. During an interview on 09/18/2025 at 02:39 PM, staff A, Executive Director and staff B, Wellness Director, were both unaware of the eMAR orders and the Medication Release Record instructions stating different instructions. Staff B investigated and sent email to Department Staff on 09123/2025 at 11 :33 AM, stating incorrect medication (wrong dosages) was sent with the family on 08127/2025. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, AEGIS OF MARYMOOR is or will be in compliance with this law and I or regulation on (Date) /0 i "1 !z oz_,c; I I In addition, I will implement a system to monitor and ensure continued compliance with this requirement. ~ ~ Jz?jz Administrator (or Representative) Date C, ~ Statement of Deficiencies License #: 2209 Compliance Determination # 65570 Plan of Correction AEGIS OF MARYMOOR Completion Date Page 3 of 3 Licensee: Aegis Senior Communities LLC 09/24/2025 Record review of Resident 1’s Medication Release Record, given to the family, dated 08/27/2025 showed that the facility transcribed incorrect medication orders for two medications treating dementia. During an interview on 09/18/2025 at 02:39 PM, staff A, Executive Director and staff B, Wellness Director, were both unaware of the eMAR orders and the Medication Release Record instructions stating different instructions. Staff B investigated and sent email to Department Staff on 09/23/2025 at 11:33 AM, stating incorrect medication (wrong dosages) was sent with the family on 08/27/2025. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, AEGIS OF MARYMOOR 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.

—: WA DSHS report: Investigations (01/2024)

This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. 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.