The Meridian at Stone Creek.

—: WA DSHS report: Investigations (01/2026)

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 March 19, 2025 CERTIFIED MAIL 9489 0090 0027 6383 2120 81 Administrator The Meridian at Stone Creek 1111 S 376th St Milton, WA 98354 Assisted Living Facility License # 2365 Licensee: Milton Meridian LLC IMPOSITION OF CIVIL FINE Dear Administrator: On March 6, 2025, the Department of Social and Health Services (DSHS), Residential Care Services completed a follow-up visit at your facility. This letter constitutes formal notice of a civil fine on the license for your assisted living facility, also known as The Meridian at Stone Creek, located at 1111 S 376th St, Milton, 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 March 6, 2025. Civil Fine WAC 388-78A-2040 (1) Other requirements. $600.00 The licensee failed to maintain compliance with the State Fire Marshal codes for Long Term Care facilities. This placed 76 residents at risk for harm in the event of an emergency. This is an uncorrected citation previously cited on December 9, 2024. NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Administrator The Meridian at Stone Creek License # 2365 March 19, 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: Manfay Chan, Field Manager Region 3, Unit D 9501 Lakewood Dr SW Suite E Lakewood, WA 98499 Phone: (253) 442-3013/ Fax: (253) 589-7240 rcsregion3email@dshs.wa.gov Appeal Rights: You have two appeal rights: Informal Dispute Resolution (IDR) and an Administrative Hearing. Each has a different request timeline. Informal Dispute Resolution [RCW 18.20.195] You have an opportunity to challenge the deficiencies and/or enforcement actions through the state's IDR process. All IDR requests must be in writing and include: • The deficiencies you are disputing; and • The method of review you prefer (face-to-face, telephone conference or documentation review). The written request must be received by the 10th working day from receipt of this letter. During the IDR process, you will have the opportunity to present written and/or oral evidence to dispute the deficiencies. Please email your request(s) and supporting documentation to: RCSIDR@dshs.wa.gov OR FAX to: 360-725-3225 Administrator The Meridian at Stone Creek License # 2365 March 19, 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 $600.00 payable to the ‘Department of Social and Health Services’, and if you have or have had a Medicaid resident(s), please include your ProviderOne ID Number # on the check, to: DSHS Office of Financial Recovery PO Box 9501 Olympia, WA 98507-9501 (360) 664-5919 / FAX: (360) 664-8401 OFRMMISVendor@dshs.wa.gov If the Office of Financial Recovery has not received your payment within twenty-eight (28) days after receipt of this letter, interest will begin to accrue immediately on the balance, at the rate of one percent per month. If you do not submit a hearing request or make payment within twenty-eight (28) days, the balance due will be recovered. Administrator The Meridian at Stone Creek License # 2365 March 19, 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 Manfay Chan, Field Manager, at (253) 442-3013. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 3, Unit D RCS Regional Administrator, Region 3 HCS Regional Administrator, Region 3 DDA Regional Administrator, Region 3 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW HP

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 June 23, 2025 ELECTRONIC-FACSIMILE Administrator The Meridian at Stone Creek 1111 S 376th St Milton, WA 98354 Assisted Living Facility License # 2365 Licensee: Milton Meridian LLC IMPOSITION OF CIVIL FINE Dear Administrator: On June 9, 2025, the Department of Social and Health Services (DSHS), Residential Care Services completed a follow-up visit at your facility. This letter constitutes formal notice of a civil fine on the license for your assisted living facility, also known as The Meridian at Stone Creek, located at 1111 S 376th St, Milton, 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 June 9, 2025. Civil Fine WAC 388-78A-2040 (1) Other requirements. $800.00 The licensee failed to maintain compliance with the State Fire Marshal codes for Long Term Care facilities. This failure placed 76 residents, visitors, and all staff in the facility at risk for harm in the event of an emergency. This is a recurring deficiency on December 9, 2024, and an uncorrected violation previously cited on March 6, 2025. NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Administrator The Meridian at Stone Creek License # 2365 June 23, 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: Manfay Chan, Field Manager Region 3, Unit D 9501 Lakewood Dr SW Suite E Lakewood, WA 98499 Phone: (253) 442-3013/ Fax: (253) 589-7240 rcsregion3email@dshs.wa.gov Appeal Rights: You have two appeal rights: Informal Dispute Resolution (IDR) and an Administrative Hearing. Each has a different request timeline. Informal Dispute Resolution [RCW 18.20.195] You have an opportunity to challenge the deficiencies and/or enforcement actions through the state's IDR process. All IDR requests must be in writing and include: • The deficiencies you are disputing; and • The method of review you prefer (face-to-face, telephone conference or documentation review). The written request must be received by the 10th working day from receipt of this letter. During the IDR process, you will have the opportunity to present written and/or oral evidence to dispute the deficiencies. Please email your request(s) and supporting documentation to: RCSIDR@dshs.wa.gov OR FAX to: 360-725-3225 Administrator The Meridian at Stone Creek License # 2365 June 23, 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 $800.00 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 Meridian at Stone Creek License # 2365 June 23, 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 Manfay Chan, Field Manager, at (253) 442-3013. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 3, Unit D RCS Regional Administrator, Region 3 HCS Regional Administrator, Region 3 DDA Regional Administrator, Region 3 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW SN

—: WA DSHS report: Investigations (05/2025) —: WA DSHS report: Investigations (05/2025) —: WA DSHS report: Investigations (05/2025)

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. STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION PO Box 99250, Lakewood, WA 98496 Statement of Deficiencies License #: 2365 Compliance Determination # 45907 Plan of Correction The Meridian at Stone Creek Completion Date Page 1 of 4 Licensee: Milton Meridian LLC 09/04/2024 You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for an unannounced on-site follow-up on 08/20/2024 and 08/27/2024 of: The Meridian at Stone Creek 1111 S 376th St Milton, WA 98354 This document references the following SOD dated: 09/04/2024 The following sample was selected for review during the unannounced on-site visit: 0 of 0 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Kathy Heinz, Long Term Care Surveyor Susan Carmichael, Nursing Consultant Institutional From: DSHS, Aging and Long-Term Support Administration Residential Care Services, Region 3 , Unit D PO Box 99250 Lakewood, WA 98496 As a result of the on-site visit(s) the department found that you are not in compliance with the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. Residential Care Services Date I understand that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2365 Compliance Determination # 45907 Plan of Correction The Meridian at Stone Creek Completion Date Page 2 of 4 Licensee: Milton Meridian LLC 09/04/2024 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: (c) Provide staff persons with the necessary supplies, equipment and protective clothing for preventing and controlling the spread of infections; This requirement was not met as evidenced by: Based on record review and interview, the facility failed to ensure 2 of 2 staff (Staff A & B) were qualified to medically evaluate staff prior to fit testing (a test designed to verify a respirator fits a user correctly). This failure placed all residents and staff at risk of exposure to infection during an outbreak of a communicable disease. Findings included... WAC 296-842-14005: Provide medical evaluations. Medical Evaluation Process: Step 1: Identify employees who need medical evaluations and determine the frequency of evaluations from Table 7. Include employees who: (a)Are required to use respirators. Note: You may use a previous employer's medical evaluation for an employee if you can: 1. Show the employee's previous work and use conditions were substantially similar to yours; and 2. Obtain a copy of the licensed health care professional's (LHCP's) written recommendation approving the employee's use of the respirator chosen by you. Step 2: Identify a licensed health care professional (LHCP) to perform your medical evaluations. Step 3: Make sure your LHCP has the following information before the evaluation is completed: (a) Information describing the respirators employees may use, including the weight and type. (b) How the respirators will be used, including: (i) How often the respirator will be used, for example, daily, or once a month; (ii) The duration of respirator use, for example, a minimum of one hour, or up to twelve hours; (iii) The employee's expected physical work effort; (iv) Additional personal protective clothing and equipment to be worn; This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2365 Compliance Determination # 45907 Plan of Correction The Meridian at Stone Creek Completion Date Page 3 of 4 Licensee: Milton Meridian LLC 09/04/2024 (v) Temperature and humidity extremes expected during use. (c) A copy of your written respiratory protection program and this chapter. Step 4: Administer the medical questionnaire in WAC 296-842-22005 to employees, OR provide them a medical exam that obtains the same information. Note: You may use online questionnaires if the questions are the same and requirements of this section are met. (a) Administer the examination or questionnaire at no cost to employees: (i) During the employee's normal working hours; or (ii) At a time and place convenient to the employee. (b) Maintain employee confidentiality during examination or questionnaire administration: (i) Do not view employee's answers on the questionnaire; (ii) Do not act in a manner that may be considered a breach of confidentiality. Note: Providing confidentiality is important for securing successful medical evaluations. It helps make sure the LHCP gets complete and dependable answers on the questionnaire. (c) Make sure employees understand the content of the questionnaire. (d) Provide the employee with an opportunity to discuss the questionnaire or exam results with the LHCP. Step 5: Provide follow-up evaluation for employees when: (a) The LHCP needs more information to make a final recommendation; or (b) An employee gives any positive response to questions 1-8 in Part 2 OR to questions 1-6 in Part 3 of the DOSH medical evaluation questionnaire in WAC 296-842-22005. Note: Follow-up may include: 1. Employee consultation with the LHCP such as a telephone conversation to evaluate positive questionnaire responses; 2. Medical exams; 3. Medical tests or other diagnostic procedures. Step 6: Obtain a written recommendation from the LHCP that contains only the following medical information: (a) Whether or not the employee is medically able to use the respirator; (b) Any limitations of respirator use for the employee; (c) What future medical evaluations, if any, are needed; (d) A statement that the employee has been provided a copy of the written recommendation. Review of the Washington State Board of Nursing Website dated 09/03/2024 showed the following question and answer: “Is it within the scope of practice of a licensed practical nurse to administer the OSHA (Occupational Safety and Health Administration) Respirator Medical Evaluation Questionnaire in accordance with the OSHA Respirator Protection Standard (29 CFR 1910.134) and perform a respiratory fit test?” “It is within the scope of the appropriately prepared and competent licensed practical nurse (LPN) to assist an authorized health care practitioner, or the registered nurse, in performing the OSHA Respirator Medical Evaluation Questionnaire and perform a respiratory fit test, following clinical practice standards.” During an interview on 08/20/2024 at 11:00 AM, Staff A (Executive Director) produced a This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2365 Compliance Determination # 45907 Plan of Correction The Meridian at Stone Creek Completion Date Page 4 of 4 Licensee: Milton Meridian LLC 09/04/2024 binder containing OSHA -Respirator Medical Eval Questionnaire forms filled out by staff working in the facility. Staff A said she, and Staff B (LPN), reviewed the forms and medically evaluated the staff prior to fit testing based on the answers reported on the questionnaire. Staff A said she thought she, and Staff B were qualified to medically evaluate staff to be fit tested. Review of the facilities "Qualitative Respirator Fit Test Record", dated 07/30/2024 and 08/01/2024, showed Staff A (Executive Director) fit test 23 staff without proper medical evaluation. There were no records from the facility that showed that Staff A was a LHCP to complete the medical evaluations. This is an uncorrected deficiency previously cited on 06/26/2024. 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 Meridian at Stone 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 This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 133789 Compliance Determination #: 42906 Region/Unit #: RCS Region 3 / Unit D Investigator: Kathy Heinz Investigation Date(s): 06/18/2024 through 06/26/2024 Complainant Contact Date(s): Allegation(s): The facility is not following COVID protocols. Investigation Methods: Sample: Total residents: 69 Resident sample size: 2 Closed records sample size: Observations: Personal Protection Supply General tour Residents Interviews: Executive Director Director of Nursing Record Reviews: COVID policy Narrative Charting Characteristic Roster Staff list Care plan Investigation Summary: Based on observation and interview, the facility failed to ensure a supply of respirators ( piece of equipment worn on the face to minimize exposure to airborne hazards and prevent the spread of infections) were available for use and staff were fit tested ( a test to verify that a respirator correctly fits the user) during an outbreak of an infectious disease. Failure to ensure staff are fit tested and have respirators available to them, placed all residents and staff at risk of contracting an infectious disease during an outbreak. Findings included... Observation on 06/20/2024 at 2:00 PM showed a room on the second floor used for storage, contained face shields, gowns, and COVID test kits. There were no N-95 respirators. This document was prepared by Residential Care Services for the Locator website. Staff A said on 06/20/2024 at 2:00 PM , the facility ran out of respirators during the most recent outbreak and an order had been placed with a large distribution company for N-95 respirators. 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. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website.

This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 133687 Compliance Determination #: 44313 Region/Unit #: RCS Region 3 / Unit D Investigator: Kathy Heinz Investigation Date(s): 07/17/2024 through 08/09/2024 Complainant Contact Date(s): Allegation(s): House keeping and maintenance services are not being provided Investigation Methods: Sample: Total residents: 60 Resident sample size: 12 Closed records sample size: 1 Observations: Resident rooms Resident to resident interactions Staff to resident interactions Food preparation Interviews: Maintenance staff Kitchen staff caregivers Executive Director Administrative Staff Record Reviews: Incident investigation Personnel files Staff training records Staff patterns care plans progress notes medication administration records Investigation Summary: Based on observation, and interview a citation was written under WAC 388-78A -3090 for failure to maintain a safe and sanitary environment. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written This document was prepared by Residential Care Services for the Locator website. N/A This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 136844 Compliance Determination #: 44313 Region/Unit #: RCS Region 3 / Unit D Investigator: Kathy Heinz Investigation Date(s): 07/17/2024 through 08/09/2024 Complainant Contact Date(s): Allegation(s): Financial exploitation Care and services were not provided Investigation Methods: Sample: Total residents: 60 Resident sample size: 12 Closed records sample size: 1 Observations: Residents Dining Resident rooms Staff to resident interactions Activities Identified resident Interviews: complainant Executive Director Resident Services Director Record Reviews: care plans progress notes task sheets Investigation Summary: 1. There was not enough evidence to support the allegation of financial exploitation 2. Based on interview and record review failed practice was identified and a citation was written under 388- 78A - 2130 (1) ( a) (b) (c) when the facility failed to develop an initial service plan. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written This document was prepared by Residential Care Services for the Locator website. N/A This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 136776 Compliance Determination #: 44313 Region/Unit #: RCS Region 3 / Unit D Investigator: Kathy Heinz Investigation Date(s): 07/17/2024 through 08/09/2024 Complainant Contact Date(s): Allegation(s): 1. Residents admitted with out a proper documents 2. Care and services not provided/ pendant call times are over fifteen minutes 3. Staff are not following policies and procedures for medication administration 4. Residents wait for long periods of time in the dining room 5. Housekeeping Services are not provided. 6. Staff lack training. Investigation Methods: Sample: Total residents: 60 Resident sample size: 12 Closed records sample size: 1 Observations: Residents Dining Activities Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Executive Director Family members Residents Staff Record Reviews: Medical records Incident investigation Personnel files care plans Investigation Summary: 1. There was no evidence to support the allegation 2. A citation was written for failing to develop a care plan and failing to have to care plans signed by the resident or their representative 3. A consultation was written for failing to secure an order prior to the administration of a topical. This document was prepared by Residential Care Services for the Locator website. 4. Dining observations failed to show Resident's waited for long periods of time. 5. A citation was written for failing to provide a safe and sanitary environment. The citation was written under a separate intake. 6. Citations were written for staff who failed to have required training documents. 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. Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 137436 Compliance Determination #: 44313 Region/Unit #: RCS Region 3 / Unit D Investigator: Kathy Heinz Investigation Date(s): 07/17/2024 through 08/09/2024 Complainant Contact Date(s): Allegation(s): Food safety Investigation Methods: Sample: Total residents: 60 Resident sample size: 12 Closed records sample size: 1 Observations: Kitchen Interviews: Food Services Director Executive Director Record Reviews: None Investigation Summary: Investigation Summary: Based on observations and interviews a citation was written under WAC 388-78A-2305 (1) for failure to maintain a sanitary environment in the kitchen. 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. Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 139797 Compliance Determination #: 44313 Region/Unit #: RCS Region 3 / Unit D Investigator: Kathy Heinz Investigation Date(s): 07/17/2024 through 08/09/2024 Complainant Contact Date(s): Allegation(s): Care and services not being provided for Identified Resident 1 and Identified resident 2. Investigation Methods: Sample: Total residents: 60 Resident sample size: 12 Closed records sample size: 1 Observations: Residents Activities Dining Resident care equipment Resident rooms Staff to resident interactions Interviews: Nursing staff Residents Family members complainant Record Reviews: investigation of incident involving the identified resident 2 Investigation Summary: Based on observation and interview, failed practice was identified and a citation was written under 388-78A-3090 (1) (a, c and d) maintenance and housekeeping. The facility conducted an investigation of the incident involving identified resident 2. 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. Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 127335 Compliance Determination #: 44313 Region/Unit #: RCS Region 3 / Unit D Investigator: Kathy Heinz Investigation Date(s): 07/17/2024 through 08/09/2024 Complainant Contact Date(s): Allegation(s): 1) Resident 10 had Norovirus while living in the facility 2) Resident 10 sustained an open wound while living in the facility Investigation Methods: Sample: Total residents: 60 Resident sample size: 12 Closed records sample size: 1 Observations: staff to resident interaction residents general observation of the facility Interviews: staff others not associated with the facility Record Reviews: resident records Investigation Summary: 1) Unable to substantiate failed facility practice 2) Based on interview and record review the Assisted Living Facility failed to take appropriate action when Resident 10 sustained an open area to their buttocks. Citation was written under 388-78A-2120-4 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. Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 125269 Compliance Determination #: 44313 Region/Unit #: RCS Region 3 / Unit D Investigator: Kathy Heinz Investigation Date(s): 07/17/2024 through 08/09/2024 Complainant Contact Date(s): Allegation(s): 1) Resident 10 sustained an open area while living in the facility Investigation Methods: Sample: Total residents: 60 Resident sample size: 12 Closed records sample size: 1 Observations: staff to resident interaction residents general observation of the facility Interviews: Staff others not associated with the facility Record Reviews: Resident records Investigation Summary: 1) Based on interview and record review the Assisted Living Facility failed to take appropriate action when Resident 10 sustained an open area to their buttocks. Citation was written under 388-78A-2120-4 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 PO Box 99250, Lakewood, WA 98496 AMENDED 08/22/2024 Milton Meridian LLC The Meridian at Stone Creek 1111 S 376th St Milton, WA 98354 RE: The Meridian at Stone Creek # 2365 Dear Administrator: This document references the following complaint numbers 133687, 134368, 136844, 136776, 137436, 139797, 127335, 125269. The Department completed a full inspection of your Assisted Living Facility on 08/09/2024 and found that your facility does not meet the Assisted Living Facility requirements. The Department: • Wrote the enclosed report; and • May take licensing enforcement action based on many deficiency listed on the enclosed report; and • May inspect your program to determine if you have corrected all deficiencies; and • Expects all deficiencies to be corrected within the timeframe accepted by the department. You Must: • Begin the process of correcting the deficiency or deficiencies immediately; • Contact the Field Manager for clarifications related to the Statement of Deficiencies (SOD); • Within 10 calendar days after you receive this letter, complete and return the enclosed 'Plan/Attestation Statement'; o Sign and date the enclosed report; o For each deficiency, indicate the date you have or will correct each deficiency; o Mail the Plan/Attestation Statement and report with original signatures to: Cory Cisneros, Field Manager This document was prepared by Residential Care Services for the Locator website. The Meridian at Stone Creek # 2365 08/09/2024 Page 2 of 3 Residential Care Services Region 3, Unit D PO Box 99250 Lakewood, WA 98496 • Complete correction(s) within 45 days, or sooner if directed by the Department, after review of your proposed correction dates. • Have your plan approved by the Department. Consultation(s): In addition, the Department provided consultation on the following deficiency or deficiencies not listed on the enclosed report. WAC 388-78A-2220 Prescribed medication authorizations. (1) Before the assisted living facility may provide medication assistance or medication administration to a resident for prescribed medications, the assisted living facility must have one of the following: (b) A written order from the prescriber; The facility failed to ensure a topical medication for a resident with a skin condition was ordered by their physician. Staff purchased an over-the-counter topical medication and applied the medication. The resident's physician wrote an order for a similar topical medication to be applied to the resident's skin. You Are Not: • Required to submit a plan of correction for the consultation deficiency or deficiencies stated in this letter and not listed on the enclosed report. You May: • Contact me for clarification of the deficiency or deficiencies found. In Addition, You May: • Request an Informal Dispute Resolution (IDR) review within 10 working days after you receive this letter. Your IDR request must include: o What specific deficiency or deficiencies you disagree with; o Why you disagree with each deficiency; and o Whether you want an IDR to occur in-person, by telephone or as a paper review. o Send your request to: IDR Program Manager Department of Social and Health Services Aging and Long-Term Support Administration Residential Care Services PO Box 45600 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 PO Box 99250, Lakewood, WA 98496 Statement of Deficiencies License #: 2365 Compliance Determination # 44313 Plan of Correction The Meridian at Stone Creek Completion Date Page 4 of 19 Licensee: Milton Meridian LLC 08/09/2024 You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for the unannounced on-site full inspection and complaint investigation on 07/17/2024, 07/18/2024, 07/19/2024, 07/22/2024, 07/25/2024 and 07/25/2024 of: The Meridian at Stone Creek 1111 S 376th St Milton, WA 98354 This document references the following complaint numbers: 133687, 134368, 136844, 136776, 137436, 139797, 127335, 125269. The following sample was selected for review during the unannounced on-site visit: 12 of 60 current residents and 1 former residents. The department staff that inspected the Assisted Living Facility: Shirley Grew, LTC Surveyor Kathy Heinz, Long Term Care Surveyor Woodetta Maulana, From: DSHS, Aging and Long-Term Support Administration Residential Care Services, Region 3 , Unit D PO Box 99250 Lakewood, WA 98496 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 This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2365 Compliance Determination # 44313 Plan of Correction The Meridian at Stone Creek Completion Date Page 5 of 19 Licensee: Milton Meridian LLC 08/09/2024 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-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 record reviews and interview, the facility failed to ensure 3 of 4 sampled staff (Staff A, C and D) were screened for tuberculosis (TB, a communicable disease), within three days of hire. This failure placed all 59 of 59 residents at risk for potential exposure to a communicable disease. Findings included... Review of the facility staff roster, dated 07/16/2024, showed: Staff A (Executive Director) was hired on 05/13/2024. Review of her personnel file on 07/22/2024 failed to show documentation she had been screened for TB. Staff C (Memory Care Director) was hired on 03/25/2024. Review of her personnel file on 07/22/2024 failed to show documentation she had been screened for TB. Staff D (Resident Services Coordinator) was hired on 02/21/2024. Review of her personnel file on 07/22/2024 failed to show documentation she had been screened for TB. During an interview on 07/25/2024 at 3:00 PM, Staff A said that she, and Staff C and D, had not been screened for TB within three days of hire. This is a recurring deficiency previously cited on 09/08/2022. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2365 Compliance Determination # 44313 Plan of Correction The Meridian at Stone Creek Completion Date Page 6 of 19 Licensee: Milton Meridian LLC 08/09/2024 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 Meridian at Stone 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 388-112A-0720 What are the CPR and first-aid training requirements? (2) Assisted living facilities. (a) Assisted living facility administrators who provide direct care and long-term care workers must have and maintain a valid CPR and first-aid card or certificate within thirty days of their date of hire. This requirement was not met as evidenced by: Based on record review and interview, the facility failed to ensure 3 of 3 sampled staff (Staff B, C and D) obtained a CPR (Cardiopulmonary Resuscitation)/first-aid card within thirty days of hire. This failure placed all 59 of 59 residents at risk of potential decline of their health status during a medical emergency. Findings included… Review of the facility staff roster, dated 07/16/2024, showed: Staff B (Medication Technician) was hired on 06/16/2023. Review of her personnel file on 07/22/2024 failed to show she had obtained a CPR/first-aid card within thirty days of hire. Staff C (Memory Care Director) was hired on 03/25/2024. Review of her personnel file on 07/22/2024 failed to show she had obtained a CPR/first-aid card within thirty days of hire. Staff D (Resident Services Coordinator) was hired on 02/21/2024. Review of her personnel file on 07/22/2024, failed to show she had obtained a CPR/first-aid card within thirty days of hire. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2365 Compliance Determination # 44313 Plan of Correction The Meridian at Stone Creek Completion Date Page 7 of 19 Licensee: Milton Meridian LLC 08/09/2024 During an interview on 07/25/2024 at 3:00 PM, Staff A (Executive Director) said Staff B, C and D, did not possess CPR/first-aid cards. 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 Meridian at Stone 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-2462 Background checks Who is required to have. (2) The assisted living facility must ensure that the administrator and all caregivers employed directly or by contract after January 7, 2012 have the following background checks: (a) A Washington state name and date of birth background check; and (b) A national fingerprint background check. This requirement was not met as evidenced by: Based on record reviews and interview, the facility failed to ensure 1 of 4 sampled staff (Staff D) completed a Washington state name and date of birth criminal background check. This failure may have resulted in staff with a criminal history providing care to 59 of 59 residents. Findings included... Review of the facility staff roster, dated 07/16/2024, showed Staff D (Resident Services Coordinator) was hired on 02/21/2024. Review of Staff D's personnel file failed to show she had completed a Washington state name and date of birth criminal background check. During an interview on 07/25/2024 at 3:00 PM, Staff A (Executive Director) said Staff D had not completed a Washington state name and date of birth criminal background check. Plan/Attestation Statement This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2365 Compliance Determination # 44313 Plan of Correction The Meridian at Stone Creek Completion Date Page 8 of 19 Licensee: Milton Meridian LLC 08/09/2024 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 Meridian at Stone 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-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 hired after January 7, 2012 for one hundred and twenty-days and allow the caregiver or administrator to have unsupervised access to residents when: (1) The caregiver or administrator is not disqualified based on the results of the Washington state name and date of birth background check; and This requirement was not met as evidenced by: Based on record reviews and interview, the facility failed to ensure 1 of 4 sampled staff (Staff D) had completed a national fingerprint criminal print background check. This failure placed 59 of 59 residents at risk of receiving care from a staff with a criminal background. Findings included... Review of the facility staff roster, dated 07/16/2024, showed Staff D (Resident Services Coordinator) was hired on 02/21/2024. Review of Staff D's personnel file failed to show she had completed a national fingerprint criminal background check within 120 days of hire. During an interview on 07/25/2024 at 3:00 PM, Staff A (Executive Director) said that Staff D had not completed a national fingerprint criminal background check. 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 Meridian at Stone 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. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2365 Compliance Determination # 44313 Plan of Correction The Meridian at Stone Creek Completion Date Page 9 of 19 Licensee: Milton Meridian LLC 08/09/2024 Administrator (or Representative) Date WAC 388-78A-2500 Specialized training for mental illness. The assisted living facility must ensure completion of specialized training, consistent with chapter 388-112A WAC, to serve residents with mental illness, whenever at least one of the residents in the assisted living facility has a mental illness that is the resident's primary special need and is a person who has been diagnosed with or treated for an Axis I or Axis II diagnosis, as described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, and: This requirement was not met as evidenced by: Based on record review and interview, the facility failed to ensure 1 of 4 staff (Staff D) had completed mental health specialty training. This failure placed residents at risk of receiving care and services from untrained staff and at risk of a decreased quality of life. Findings included... Review of the facility staff roster, dated 07/16/2024, showed Staff D (Resident Services Coordinator) was hired on 02/21/2024. Review of Staff D's personnel file failed to show she had completed mental health specialty training within 120 days of hire. During an interview on 07/25/2024 at 3:00 PM, Staff A (Executive Director) said Staff D had not provided verification she had completed the training. 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 Meridian at Stone 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-2510 Specialized training for dementia. The assisted living facility must ensure completion of specialized training, consistent with chapter 388-112A WAC, to serve residents with dementia, whenever at least This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2365 Compliance Determination # 44313 Plan of Correction The Meridian at Stone Creek Completion Date Page 10 of 19 Licensee: Milton Meridian LLC 08/09/2024 one of the residents in the assisted living facility has a dementia that is the resident's primary special need and has symptoms consistent with dementia as assessed per WAC 388-78A- 2090 (7). This requirement was not met as evidenced by: Based on record review and interview, the facility failed to ensure 1 of 4 staff (Staff D) had completed dementia specialty training. This failure placed residents at risk of receiving care and services from untrained staff and at risk for decreased quality of life. Findings included... Review of the facility staff roster, dated 07/16/2024, showed Staff D (Resident Services Coordinator) was hired on 02/21/2024. Review of Staff D's personnel file failed to show she had completed dementia specialty training. During an interview on 07/25/2024 at 3:00 PM, Staff A (Executive Director) said Staff D had not provided documentation that she had completed dementia specialty training. 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 Meridian at Stone 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 388-112A-0611 Who in an assisted living facility is required to complete continuing education training each year, how many hours of continuing education are required, and when must they be completed? (1) The continuing education training requirements that apply to certain individuals working in assisted living facilities are described below. (a) The following long-term care workers must complete twelve hours of continuing education by their birthday each year: (iii) A certified nursing assistant; This requirement was not met as evidenced by: This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2365 Compliance Determination # 44313 Plan of Correction The Meridian at Stone Creek Completion Date Page 11 of 19 Licensee: Milton Meridian LLC 08/09/2024 Based on record review and interview, the facility failed to ensure 2 of 2 sampled staff (Staff B and C) had taken continuing education classes as required. This failure placed residents at risk of being cared for by untrained staff. Findings included... Review of the facility staff roster dated 07/16/2024 showed: Staff B (Medication Technician) was hired on 06/16/2023 and her date of birth was 04/20. Review of her personnel file on 07/22/2024 failed to show documentation of continuing education classes taken between 04/20/2023 and 04/20/2024. Staff C (Memory Care Director) was hired on 03/25/2024 and her date of birth was 08/31. Review of her personnel file on 07/22/2024 failed to show documentation of continuing education classes taken between 08/31/2022 and 08/31/2023. During an interview on 07/25/2024 at 3:00 PM, Staff A (Executive Director), said Staff C had not provided documentation of approved continuing education curriculum. 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 Meridian at Stone 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-2450 Staff. (2) The assisted living facility must: (c) Verify prior to hiring that staff persons have the required licenses, certification, registrations, or other credentials for the position, and that such licenses, certifications, registrations, and credentials are current and in good standing; This requirement was not met as evidenced by: Based on record reviews and interviews, the facility failed to ensure 1 of 4 sampled staff (Staff D) had a credential in good standing. This failure placed all 59 residents at risk of receiving care from inadequately trained staff. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2365 Compliance Determination # 44313 Plan of Correction The Meridian at Stone Creek Completion Date Page 12 of 19 Licensee: Milton Meridian LLC 08/09/2024 Findings included... Review of the facility staff roster, dated 07/16/2024, showed Staff D (Resident Services Coordinator) was hired on 02/21/2024. Review of Staff D’s personnel file showed they completed 75 hours of Department of Social and Health Services Long Term Care worker training on 05/24/2017. Staff D’s personnel file failed to show she had been certified as a long-term care worker following her training in 2017. During an interview on 07/24/2024 at 2:00 PM, Staff A (Executive Director), said Staff D told her she was "grandfathered in" (not required to obtain certification). Record review of the online Washington State Department of Health (DOH) credential verification website on 08/06/2024 showed no active credential by the department for Staff D. 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 Meridian at Stone 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 388-112A-0200 What is orientation training, who should complete it, and when should it be completed? There are two types of orientation training: Facility orientation training and long-term care worker orientation training. (1) Facility orientation. Individuals who are exempt from certification as described in RCW 18.88B.041 and volunteers are required to complete facility orientation training before having routine interaction with residents. This training provides basic introductory information appropriate to the residential care setting and population served. The department does not approve this specific orientation program, materials, or trainers. No test is required for this orientation. This requirement was not met as evidenced by: Based on record review and interview, the facility failed to ensure 3 of 3 sampled staff (Staff B, C, and D) completed facility orientation. This failure placed 59 of 59 residents at risk of receiving care and services from untrained staff. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2365 Compliance Determination # 44313 Plan of Correction The Meridian at Stone Creek Completion Date Page 13 of 19 Licensee: Milton Meridian LLC 08/09/2024 Findings included... Review of the facility staff roster, dated 07/16/2024, showed: Staff B (Medication Technician) was hired on 06/16/2023. Review of her personnel file on 07/22/2024 failed to show documentation she had completed facility orientation. Staff C (Memory Care Director) was hired on 03/25/2024. Review of her personnel file on 07/22/2024 failed to show documentation she had completed facility orientation. Staff D (Resident Services Coordinator) was hired on 02/21/2024. Review of her personnel file failed to show she had completed facility orientation. During an interview on 07/25/2024 at 3:00 PM, Staff A (Executive Director) said Staff B, C, and D had not completed facility orientation. 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 Meridian at Stone 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-2305 Food sanitation. The assisted living facility must: (1) Manage food, and maintain any on-site food service facilities in compliance with chapter 246-215 WAC, Food service; This requirement was not met as evidenced by: Based on observations and interviews, the Assisted Living Facility (ALF) failed to ensure food was stored properly and failed to maintain cleanliness for 2 of 2 kitchen areas reviewed (main ALF kitchen and memory care kitchenette). The ALF also failed to date mark food properly for 1 of 2 kitchen areas (memory care kitchenette) and failed to control insects in 1 of 2 kitchen areas (main ALF kitchen). These failures placed all 59 residents at risk for exposure to food-borne illnesses. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2365 Compliance Determination # 44313 Plan of Correction The Meridian at Stone Creek Completion Date Page 14 of 19 Licensee: Milton Meridian LLC 08/09/2024 Findings included… WAC 246-215-03351 Preventing contamination from the premises—Food storage (FDA Food Code 3-305.11). (1) Except as specified in subsections (2) and (3) of this section, food must be protected from contamination by storing the food: (a) In a clean, dry location; (b) Where it is not exposed to splash, dust, or other contamination; and (c) At least six inches (15 cm) above the floor. WAC 246-215-03526 Temperature and time control—Ready-to-eat, time/temperature control for safety food, date marking (FDA Food Code 3-501.17). (1) Except when packaging food using a reduced oxygen packaging method as specified under WAC 246-215-03540, and except as specified in subsections (5) and (6) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than twenty-four hours must be clearly marked to indicate the date or day by which the food must be consumed on the premises, sold, or discarded when held at a temperature of 41ºF (5ºC) or less for a maximum of seven days. The day of preparation must be counted as day one. WAC 246-215-06550 Methods—Controlling pests (FDA Food Code 6-501.111). The premises must be maintained free of infestations of insects, rodents, and other pests such that there is not a breeding population of pests in the facility. The presence of insects, rodents, and other pests must be controlled to minimize their presence on the premises by: (1) Routinely inspecting incoming shipments of food and supplies; (2) Routinely inspecting the premises for evidence of pests; (3) Using methods, if pests are found, such as trapping devices or other means of pest control as specified under WAC 246-215-07210, 246-215-07250, and 246-215-07255; and (4) Eliminating harborage conditions. WAC 246-215-06505 Methods—Cleaning, frequency and restrictions (FDA Food Code 6-501.12). (1) physical facilities must be cleaned as often as necessary to keep them clean. (2) Except for cleaning that is necessary due to a spill or other accident, cleaning must be done during periods when the least amount of food is exposed such as after closing. Memory Care (MC) Kitchenette In an observation and interview on 07/17/2024 at 12:30 PM, in the MC kitchenette, Staff G, Server, pulled plates out of a plate holder and coffee cups off a shelf and examined them. Staff G wiped multiple plates, flatware, and coffee cups with a cloth napkin and vinegar. Staff G said pieces of food settle on the dishes when they were being cleaned in the dishwasher. He said the dishes never appeared clean and vinegar will clean them. Observation of the MC kitchenette refrigerator showed the vents in the front of the refrigerator were splattered with matter. Matter covered the refrigerator shelves and This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2365 Compliance Determination # 44313 Plan of Correction The Meridian at Stone Creek Completion Date Page 15 of 19 Licensee: Milton Meridian LLC 08/09/2024 walls. The refrigerator contained undated macaroni salad. During an interview on 07/25/2024 at 1:00 PM, Staff A, Executive Director, said the “main kitchen” staff was responsible for cleaning the refrigerator in the MC unit. Main ALF Kitchen An observation on 07/18/2024 at 11:35 AM, and an observation on 07/19/2024 at 1:20 PM, showed one large cardboard box of graham crumbs open to air on a low shelf in the dry storage area of the kitchen. Graham crumbs were visible on the top flaps of the cardboard box as well as on the inner plastic. An observation on 07/18/2024 at 11:39 AM, and an observation on 07/19/2024 at 1:20 PM, showed four winged insects flying in a continuous circular pattern in the dry storage area. On both dates, licensor observed kitchen staff walking in and out of the dry storage area multiple times. An observation on 07/18/2024 at 1:13 PM, and an observation on 07/19/2024 at 1:25 PM, showed multiple boxes of frozen food products sitting directly on the floor of the walk-in freezer. During an interview on 07/19/2024 at 1:15 PM, Staff E, Food Services Director, said she was unaware that the box with graham crumbs was open. Staff E acknowledged the presence of flies in the dry storage room and said they thought the facility’s maintenance department was responsible for addressing this concern. Staff E stated that on 07/18/2024 and 07/19/2024 they received large deliveries of frozen food items. They said that the kitchen staff had been too busy to move the boxed frozen items off the floor of the walk-in freezer. In an observation and interview on 07/25/2024 at 1:15 PM, licensors showed the flying insects in the dry storage area to Staff A. The insects had multiplied in number since the previous observation, and several insects were observed flying through the main kitchen. Staff A said she had not been aware of the insects. In an observation and interview on 07/25/2024 at 1:20 PM, a thick black substance showed covering multiple ceiling tiles and vents directly above the main cooking area. Staff A acknowledged that the dirty ceiling tiles and vents in the kitchen were an issue. This is a recurring deficiency previously cited on 09/08/2022. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2365 Compliance Determination # 44313 Plan of Correction The Meridian at Stone Creek Completion Date Page 16 of 19 Licensee: Milton Meridian LLC 08/09/2024 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 Meridian at Stone 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-2150 Signing negotiated service agreement. The assisted living facility must ensure that the negotiated service agreement is agreed to and signed at least annually by: (1) The resident, or the resident's representative if the resident has one and is unable to sign or chooses not to sign; (2) A representative of the assisted living facility duly authorized by the assisted living facility to sign on its behalf; and (3) Any public or private case manager for the resident, if available. This requirement was not met as evidenced by: Based on record reviews and interviews, the Assisted Living Facility (ALF) failed to ensure that the negotiated service agreement (NSA) for 4 of 8 sampled residents (Residents 3, 5, 6, and 7 [R3, R5, R6, and R7]) was signed annually by the resident or their representative, and a representative of the assisted living facility. This failure placed the residents and their responsible party at risk for not being involved in their care decisions and the services being provided. Findings included… Resident 3 (R3) Record review of the facility's "Assisted Living Facility Resident Characteristic Roster and Sample Selection (Assisted Living)," undated, showed that R3 was admitted to the ALF on /2024. Review of R3’s NSA, dated 04/03/2024, showed no signature from R3 or R3’s representative, and no facility representative signature. Resident 5 (R5) Record review of the facility's "Assisted Living Facility Resident Characteristic Roster and Sample Selection (Memory Care)," undated, showed that R5 was admitted to the ALF on /2023. Review of R5’s NSA, dated /2023, showed no signature from R5 or R5’s representative, and no facility representative signature. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2365 Compliance Determination # 44313 Plan of Correction The Meridian at Stone Creek Completion Date Page 17 of 19 Licensee: Milton Meridian LLC 08/09/2024 Resident 6 (R6) Record review of the facility's "Assisted Living Facility Resident Characteristic Roster and Sample Selection (Memory Care)," undated, showed that R6 was admitted to the ALF on /2019. Review of R6’s NSA, dated 10/02/2020, showed no signature from R6 or R6’s representative, and no facility representative signature. Resident 7 (R7) Record review of the facility's "Assisted Living Facility Resident Characteristic Roster and Sample Selection (Memory Care)," undated, showed that R7 was admitted to the ALF on /2020. Review of R7’s NSA, dated 10/22/2020, showed no signature from R7 or R7’s representative, and no facility representative signature. During an interview on 07/22/2024 at 3:00 PM, Staff F, Resident Care Director, said the NSAs for R5, R6, and R7 were not signed. During an interview on 07/23/2024 at 9:30 AM, Staff A, Executive Director, said the NSA for R3 was not signed. 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 Meridian at Stone 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-2130 Service agreement planning. The assisted living facility must: (1) Develop an initial resident service plan, based upon discussions with the resident and the resident's representative if the resident has one, and the preadmission assessment of a qualified assessor, upon admitting a resident into an assisted living facility. The assisted living facility must ensure the initial resident service plan: (a) Integrates the assessment information provided by the department's case manager for each resident whose care is partially or wholly funded by the department or the health care authority; (b) Identifies the resident's immediate needs; and (c) Provides direction to staff and caregivers relating to the resident's immediate needs, capabilities, and preferences. This requirement was not met as evidenced by: This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2365 Compliance Determination # 44313 Plan of Correction The Meridian at Stone Creek Completion Date Page 18 of 19 Licensee: Milton Meridian LLC 08/09/2024 Based on interview and record reviews, the facility failed to develop an initial service plan for 1 of 1 newly admitted sampled residents (Resident 8 [R8]). This failure place residents at risk of having their care needs go unmet and a diminished quality of life. Findings included... Review of the facility’s Characteristic Roster (undated) showed R8 admitted to the facility on /2023. During interviews on 07/18/2024 at 9:00 AM and on 07/26/2024 at 2:30 PM, Collateral Contact 1 (CC1) said the facility conducted an assessment of R8's care needs immediately following a tour of the facility prior to moving in. CC1 told the staff present at the assessment, he wanted staff to assist R8 with dressing every morning and standby assistance with showers a few days a week. CC1 said he never saw, or signed a care plan until 2024. CC1 said on multiple occasions staff did not come and assist R8 with dressing in the morning and he had to help R8 get dressed. Review of R8's Needs and Services Plan (care plan) showed an initial care plan was developed on /2024, 29 days after R8 admitted. The plan was signed by CC1 on /2024, 125 days after the plan developed. During an interview on 07/23/2024 at 9:30 AM, Staff A, Executive Director, said she cannot explain why care plans were not developed. 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 Meridian at Stone 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-2120 Monitoring residents' well-being. The assisted living facility must: (4) Take appropriate action in response to each resident's changing needs. This requirement was not met as evidenced by: This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2365 Compliance Determination # 44313 Plan of Correction The Meridian at Stone Creek Completion Date Page 19 of 19 Licensee: Milton Meridian LLC 08/09/2024 Based on interview and record review the Assisted Living Facility (ALF) failed to take appropriate action when one sample resident (Resident 10 [R10]) sustained an open area to their buttocks. This failure placed the resident at risk for further harm. Findings included... Review of R10's progress notes, dated 06/07/2023, showed the facility first identified R10 to have a wound to their buttocks on 06/07/2023, and the first entry of wound care by a nurse was noted on 06/23/2023, sixteen days after the wound was first identified. Review of R10's progress notes documented the following: 06/07/2023- “CS noted an open wound on residents’ buttocks. She also complained of pain.” 06/19/2023- “…Staff also charted that her bottom is getting worse.” 06/20/2023- “Staff noted the time resident was changed, that she received peri-care and barrier cream, and that her sore is getting worse.” 06/20/2023- Care staff reported that resident’s open area on her coccyx is getting bigger, notified LN [licensed nurse] who is supposed to follow up on it.” 06/23/2023- “The RN [Registered Nurse] from home health came and applied a bandage on the buttocks wound.” 08/01/2023- “The nurse had called 911 for the resident to be taken to the hospital for wound care.” In an interview on 08/09/2024 at 10:18 AM, Staff A, Executive Director, stated she had no documentation to show that R10’s wound was evaluated and treated prior to 06/23/2023. 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 Meridian at Stone 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 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 PO Box 45600, Olympia, WA 98504-5600 September 17, 2024 ELECTRONIC-FACSIMILE Administrator The Meridian at Stone Creek 1111 S 376th St Milton, WA 98354 Assisted Living Facility License # 2365 Licensee: Milton Meridian LLC IMPOSITION OF CIVIL FINE Dear Administrator: On September 4, 2024, the Department of Social and Health Services (DSHS), Residential Care Services completed a follow-up visit at your facility. This letter constitutes formal notice of a civil fine on the license for your assisted living facility, also known as The Meridian at Stone Creek, located at 1111 S 376th St, Milton, 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 September 4, 2024. Civil Fine WAC 388-78A-2610(1)(2)(c) Infection control. $400.00 The licensee failed to ensure two staff were qualified to medically evaluate staff prior to fit-testing (a test designed to verify a respirator fits a user correctly). This failure placed all residents at risk of exposure to infection during an outbreak of a communicable disease. This is an uncorrected deficiency previously cited on June 26, 2024. NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Administrator The Meridian at Stone Creek License # 2365 September 17, 2024 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: Manfay Chan, Field Manager Region 3, Unit D 9501 Lakewood Dr SW Suite E Lakewood, WA 98499 Phone: (253) 442-3013/ Fax: (253) 589-7240 rcsregion3email@dshs.wa.gov Appeal Rights: You have two appeal rights: Informal Dispute Resolution (IDR) and an Administrative Hearing. Each has a different request timeline. Informal Dispute Resolution [RCW 18.20.195] You have an opportunity to challenge the deficiencies and/or enforcement actions through the state's IDR process. All IDR requests must be in writing and include: • The deficiencies you are disputing; and • The method of review you prefer (face-to-face, telephone conference or documentation review). The written request must be received by the 10th working day from receipt of this letter. During the IDR process, you will have the opportunity to present written and/or oral evidence to dispute the deficiencies. Send your written request to: Informal Dispute Resolution Program Manager Residential Care Services PO Box 45600 Olympia, Washington 98504-5600 Administrator The Meridian at Stone Creek License # 2365 September 17, 2024 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 Meridian at Stone Creek License # 2365 September 17, 2024 Page 4 If you have any questions, please contact Manfay Chan, Field Manager, at (253) 442-3013. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 3, Unit D RCS Regional Administrator, Region 3 HCS Regional Administrator, Region 3 DDA Regional Administrator, Region 3 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW HP

Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 110510 Compliance Determination #: 37530 Region/Unit #: RCS Region 3 / Unit D Investigator: Woodetta Maulana Investigation Date(s): 12/15/2023 through 03/06/2024 Complainant Contact Date(s): Allegation(s): 1) Facility is without hot water 2) Kitchen does not have hot running water 3) Several residents have passed away 4) There is no nurse practitioner Investigation Methods: Sample: Total residents: Resident sample size: Closed records sample size: Observations: staff to resident interaction residents general observation of the facility hot water temperatures kitchen Interviews: staff residents Record Reviews: n/a Investigation Summary: 1-2) The assisted living facility (ALF) failed to report to the department when the facility’s boiler system no longer worked to keep water temperatures between 105 and 120 degrees Fahrenheit. 3) Unable to substantiate failed practice. 4) Unable to substantiate failed practice. 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. Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 120711 Compliance Determination #: 37530 Region/Unit #: RCS Region 3 / Unit D Investigator: Woodetta Maulana Investigation Date(s): 12/15/2023 through 03/06/2024 Complainant Contact Date(s): Allegation(s): 1) Facility is without hot water 2) And there are pigeon droppings at the entrance/exit of the facility Investigation Methods: Sample: Total residents: Resident sample size: Closed records sample size: Observations: staff to resident interaction residents general observation of the facility hot water temperatures Interviews: staff residents Record Reviews: n/a Investigation Summary: 1) The assisted living facility (ALF) failed to report to the department when the facility’s boiler system no longer worked to keep water temperatures between 105 and 120 degrees Fahrenheit. 2) Observed interventions of spikes and a fake owl to deter birds/pigeons. 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. Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 120593 Compliance Determination #: 37530 Region/Unit #: RCS Region 3 / Unit D Investigator: Woodetta Maulana Investigation Date(s): 12/15/2023 through 03/06/2024 Complainant Contact Date(s): Allegation(s): 1) Facility is without hot water 2) Concerned about sanitization of the kitchen Investigation Methods: Sample: Total residents: Resident sample size: Closed records sample size: Observations: staff to resident interaction residents general observation of the facility hot water temperatures kitchen Interviews: staff residents Record Reviews: n/a Investigation Summary: 1) The assisted living facility (ALF) failed to report to the department when the facility’s boiler system no longer worked to keep water temperatures between 105 and 120 degrees Fahrenheit. 2) Due to the hot water issue pots and pans are cleaned using the three sink method with sanitizer and boiling water and boiling water is used to clean kitchen and food prep areas. 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. Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 120567 Compliance Determination #: 37530 Region/Unit #: RCS Region 3 / Unit D Investigator: Woodetta Maulana Investigation Date(s): 12/15/2023 through 03/06/2024 Complainant Contact Date(s): Allegation(s): 1) Facility is without hot water 2) Concerned about sanitization of the kitchen Investigation Methods: Sample: Total residents: Resident sample size: Closed records sample size: Observations: staff to resident interaction residents general observation of the facility hot water temperatures kitchen Interviews: staff residents Record Reviews: n/a Investigation Summary: 1) The assisted living facility (ALF) failed to report to the department when the facility’s boiler system no longer worked to keep water temperatures between 105 and 120 degrees Fahrenheit. 2) Due to the hot water issue pots and pans are cleaned using the three sink method with sanitizer and boiling water and boiling water is used to clean kitchen and food prep areas. 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. Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 120787 Compliance Determination #: 37530 Region/Unit #: RCS Region 3 / Unit D Investigator: Woodetta Maulana Investigation Date(s): 12/15/2023 through 03/06/2024 Complainant Contact Date(s): Allegation(s): 1) Facility is without hot water 2) Facility has norovirus 3) Facility in general is not clean Investigation Methods: Sample: Total residents: Resident sample size: Closed records sample size: Observations: staff to resident interaction residents general observation of the facility hot water temperatures Interviews: staff residents Record Reviews: n/a Investigation Summary: 1) The assisted living facility (ALF) failed to report to the department when the facility’s boiler system no longer worked to keep water temperatures between 105 and 120 degrees Fahrenheit. 2) Interviewed ED who stated there is no outbreak of norovirus. 3) The assisted living facility (ALF) failed to ensure the exterior grounds were sanitary and kept in good repair. 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. Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 120926 Compliance Determination #: 37530 Region/Unit #: RCS Region 3 / Unit D Investigator: Woodetta Maulana Investigation Date(s): 12/15/2023 through 03/06/2024 Complainant Contact Date(s): Allegation(s): 1) Facility is without hot water Investigation Methods: Sample: Total residents: Resident sample size: Closed records sample size: Observations: staff to resident interaction residents general observation of the facility hot water temperatures Interviews: staff residents Record Reviews: n/a Investigation Summary: 1) The Assisted Living Facility failed to report to the department when the facility’s boiler system no longer worked to keep water temperatures between 105 and 120 degrees Fahrenheit. 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. Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 113054 Compliance Determination #: 37530 Region/Unit #: RCS Region 3 / Unit D Investigator: Woodetta Maulana Investigation Date(s): 12/15/2023 through 03/06/2024 Complainant Contact Date(s): Allegation(s): 1) Named resident is without hot water Investigation Methods: Sample: Total residents: Resident sample size: Closed records sample size: Observations: staff to resident interaction residents general observation of the facility hot water temperatures Interviews: staff residents Record Reviews: n/a Investigation Summary: 1) The he assisted living failed to report to the department when the facility’s boiler system no longer worked to keep water temperatures between 105 and 120 degrees Fahrenheit. 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. Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 120473 Compliance Determination #: 37530 Region/Unit #: RCS Region 3 / Unit D Investigator: Woodetta Maulana Investigation Date(s): 12/15/2023 through 03/06/2024 Complainant Contact Date(s): Allegation(s): 1) Facility is without hot water 2) Concerned about sanitization of the kitchen 3) Facility has one medication technician for three floors at night Investigation Methods: Sample: Total residents: Resident sample size: Closed records sample size: Observations: staff to resident interaction residents general observation of the facility hot water temperatures Interviews: staff residents Record Reviews: n/a Investigation Summary: 1) The assisted living facility (ALF) failed to report to the department when the facility’s boiler system no longer worked to keep water temperatures between 105 and 120 degrees Fahrenheit. 2) Due to the hot water issue pots and pans are cleaned using the three sink method with sanitizer and boiling water and boiling water is used to clean kitchen and food prep areas . 3) Assisted Living Facility's do not have minimum staffing ratios. 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. Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 120553 Compliance Determination #: 37530 Region/Unit #: RCS Region 3 / Unit D Investigator: Woodetta Maulana Investigation Date(s): 12/15/2023 through 03/06/2024 Complainant Contact Date(s): Allegation(s): 1) Facility is without hot water Investigation Methods: Sample: Total residents: Resident sample size: Closed records sample size: Observations: staff to resident interaction residents general observation of the facility hot water temperatures Interviews: staff residents Record Reviews: n/a Investigation Summary: 1) The assisted living facility (ALF) failed to report to the department when the facility’s boiler system no longer worked to keep water temperatures between 105 and 120 degrees Fahrenheit. 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. Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 120751 Compliance Determination #: 37530 Region/Unit #: RCS Region 3 / Unit D Investigator: Woodetta Maulana Investigation Date(s): 12/15/2023 through 03/06/2024 Complainant Contact Date(s): Allegation(s): 1)Facility has no hot water 2) Food prep areas are not properly sanitized and residents are using paper and plastic cups and utensils Investigation Methods: Sample: Total residents: Resident sample size: Closed records sample size: Observations: staff to resident interaction residents general observation of the facility water temperatures kitchen Interviews: staff residents Record Reviews: n/a Investigation Summary: 1) The Assisted Living Facility failed to report to the department when the facility’s boiler system no longer worked to keep water temperatures between 105 and 120 degrees Fahrenheit. 2) Resident food is served on plastic wear, and food prep areas and pots and pans are properly sanitized. 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. Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 120543 Compliance Determination #: 37530 Region/Unit #: RCS Region 3 / Unit D Investigator: Woodetta Maulana Investigation Date(s): 12/15/2023 through 03/06/2024 Complainant Contact Date(s): Allegation(s): 1) Facility is without hot water Investigation Methods: Sample: Total residents: Resident sample size: Closed records sample size: Observations: staff to resident interaction residents general observation of the facility hot water temperatures Interviews: staff residents Record Reviews: n/a Investigation Summary: 1) The assisted living facility (ALF) failed to report to the department when the facility’s boiler system no longer worked to keep water temperatures between 105 and 120 degrees Fahrenheit. 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. Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 120506 Compliance Determination #: 37530 Region/Unit #: RCS Region 3 / Unit D Investigator: Woodetta Maulana Investigation Date(s): 12/15/2023 through 03/06/2024 Complainant Contact Date(s): Allegation(s): 1) Facility is without hot water Investigation Methods: Sample: Total residents: Resident sample size: Closed records sample size: Observations: staff to resident interaction residents general observation of the facility hot water temperatures Interviews: staff residents Record Reviews: n/a Investigation Summary: 1) The assisted living facility (ALF) failed to report to the department when the facility’s boiler system no longer worked to keep water temperatures between 105 and 120 degrees Fahrenheit. 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. Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 120683 Compliance Determination #: 37530 Region/Unit #: RCS Region 3 / Unit D Investigator: Woodetta Maulana Investigation Date(s): 12/15/2023 through 03/06/2024 Complainant Contact Date(s): Allegation(s): 1) Facility is without hot water Investigation Methods: Sample: Total residents: Resident sample size: Closed records sample size: Observations: staff to resident interaction residents general observation of the facility hot water temperatures Interviews: staff residents Record Reviews: n/a Investigation Summary: 1) The assisted living facility (ALF) failed to report to the department when the facility’s boiler system no longer worked to keep water temperatures between 105 and 120 degrees Fahrenheit. 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. Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 120728 Compliance Determination #: 37530 Region/Unit #: RCS Region 3 / Unit D Investigator: Woodetta Maulana Investigation Date(s): 12/15/2023 through 03/06/2024 Complainant Contact Date(s): Allegation(s): 1) Facility is without hot water Investigation Methods: Sample: Total residents: Resident sample size: Closed records sample size: Observations: staff to resident interaction residents general observation of the facility hot water temperatures Interviews: staff residents Record Reviews: n/a Investigation Summary: 1) The assisted living facility (ALF) failed to report to the department when the facility’s boiler system no longer worked to keep water temperatures between 105 and 120 degrees Fahrenheit. 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. Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 120737 Compliance Determination #: 37530 Region/Unit #: RCS Region 3 / Unit D Investigator: Woodetta Maulana Investigation Date(s): 12/15/2023 through 03/06/2024 Complainant Contact Date(s): Allegation(s): 1) Facility is without hot water 2) Dishwasher not working 3) Eating on plasticware Investigation Methods: Sample: Total residents: Resident sample size: Closed records sample size: Observations: staff to resident interaction residents general observation of the facility hot water temperatures kitchen Interviews: staff residents Record Reviews: n/a Investigation Summary: 1) The assisted living facility (ALF) failed to report to the department when the facility’s boiler system no longer worked to keep water temperatures between 105 and 120 degrees Fahrenheit. 2) Dishwasher was working, but due to the hot water issue pots and pans are cleaned using the three sink method with sanitizer and boiling water 3) Residents are eating on plasticware which is not a violation of the regulation while the facility works on their boiler. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written This document was prepared by Residential Care Services for the Locator website. N/A This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 120732 Compliance Determination #: 37530 Region/Unit #: RCS Region 3 / Unit D Investigator: Woodetta Maulana Investigation Date(s): 12/15/2023 through 03/06/2024 Complainant Contact Date(s): Allegation(s): 1) Facility has no hot water 2) Residents were eating with regular plates and silverware and possible sanitization issue with no hot water 3) One of the elevators was not working Investigation Methods: Sample: Total residents: Resident sample size: Closed records sample size: Observations: staff to resident interaction residents general observation of the facility hot water temperatures kitchen Interviews: staff residents Record Reviews: n/a Investigation Summary: 1) The assisted living facility (ALF) failed to report to the department when the facility’s boiler system no longer worked to keep water temperatures between 105 and 120 degrees Fahrenheit. 2) Observation of the kitchen and interview with dietary manager showed that the kitchen area has a way to properly sanitize plates silverware and utensils with boiling water and sanitizing solution. 3) The facility has more than one elevator, and working elevator can be used until the other elevator is repaired. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written This document was prepared by Residential Care Services for the Locator website. Failed Provider Practice Not Identified / No Citation Written N/A This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 120734 Compliance Determination #: 37530 Region/Unit #: RCS Region 3 / Unit D Investigator: Woodetta Maulana Investigation Date(s): 12/15/2023 through 03/06/2024 Complainant Contact Date(s): Allegation(s): 1) Facility is without hot water 2) Dishwasher not working 3) Eating on plasticware Investigation Methods: Sample: Total residents: Resident sample size: Closed records sample size: Observations: staff to resident interaction residents general observation of the facility hot water temperatures kitchen Interviews: staff residents Record Reviews: n/a Investigation Summary: 1) The assisted living facility (ALF) failed to report to the department when the facility’s boiler system no longer worked to keep water temperatures between 105 and 120 degrees Fahrenheit. 2) Dishwasher was working, but due to the hot water issue pots and pans are cleaned using the three sink method with sanitizer and boiling water. 3) Residents are eating on plasticware which is not a violation of the regulation while the facility works on their boiler. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written This document was prepared by Residential Care Services for the Locator website. N/A This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 120725 Compliance Determination #: 37530 Region/Unit #: RCS Region 3 / Unit D Investigator: Woodetta Maulana Investigation Date(s): 12/15/2023 through 03/06/2024 Complainant Contact Date(s): Allegation(s): 1) Facility is without hot water 2) Dishwasher not working 3) Eating on plasticware Investigation Methods: Sample: Total residents: Resident sample size: Closed records sample size: Observations: staff to resident interaction residents general observation of the facility hot water temperatures kitchen Interviews: staff residents Record Reviews: n/a Investigation Summary: 1) The assisted living facility (ALF) failed to report to the department when the facility’s boiler system no longer worked to keep water temperatures between 105 and 120 degrees Fahrenheit. 2) Dishwasher was working, but due to the hot water issue pots and pans are cleaned using the three sink method with sanitizer and boiling water. 3) Residents are eating on plasticware which is not a violation of the regulation while the facility works on their boiler. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written This document was prepared by Residential Care Services for the Locator website. N/A This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 120738 Compliance Determination #: 37530 Region/Unit #: RCS Region 3 / Unit D Investigator: Woodetta Maulana Investigation Date(s): 12/15/2023 through 03/06/2024 Complainant Contact Date(s): Allegation(s): 1) Facility is without hot water 2) Kitchen has black sewer worms 3) Facility has mice 4) Parking lot has old furnishings on facility grounds Investigation Methods: Sample: Total residents: Resident sample size: Closed records sample size: Observations: staff to resident interaction residents general observation of the facility hot water temperatures kitchen outside environment Interviews: staff residents Record Reviews: n/a Investigation Summary: 1) The assisted living facility (ALF) failed to report to the department when the facility’s boiler system no longer worked to keep water temperatures between 105 and 120 degrees Fahrenheit. 2) Observed kitchen and did not observe sewer worms. 3) Observation of the facility and kitchen did not show mice or mice droppings. 4) The assisted living facility (ALF) failed to ensure the exterior grounds were sanitary and kept in good repair. This failure placed all residents at risk for harm. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written This document was prepared by Residential Care Services for the Locator website. Failed Provider Practice Not Identified / No Citation Written N/A This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: The Meridian at Stone CreekProvider Type: Assisted Living Facility License/Cert.#: 2365 Intake ID: 120529 Compliance Determination #: 37530 Region/Unit #: RCS Region 3 / Unit D Investigator: Woodetta Maulana Investigation Date(s): 12/15/2023 through 03/06/2024 Complainant Contact Date(s): Allegation(s): 1) Residents have no hot water since 2/23/24. This is not the first time in the last year that the residents have not had hot water for an extended period of time. 2) Maintenance has not been kept up on the facility with the residents not having working washers and dryers for extended periods. 3 )January there was a shortage of food for the residents and the food has been giving many of them diarrhea. The safe handling of food is in question as well as the shortage of food. Investigation Methods: Sample: Total residents: Resident sample size: Closed records sample size: Observations: staff to resident interaction residents general observation of the facility hot water temperatures kitchen Interviews: staff residents Record Reviews: n/a Investigation Summary: 1) The assisted living facility (ALF) failed to report to the department when the facility’s boiler system no longer worked to keep water temperatures between 105 and 120 degrees Fahrenheit. 2) Unable to substantiate failed practice 3) Unable to substantiate failed practice Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written This document was prepared by Residential Care Services for the Locator website. Failed Provider Practice Not Identified / No Citation Written N/A This document was prepared by Residential Care Services for the Locator website.

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

—: WA DSHS report: Inspections (08/2023) —: WA DSHS report: Investigations (08/2023) —: WA DSHS report: Investigations (08/2023)