Fieldstone Memory Care of Silverdale.

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Home and Community Living Administration PO Box 45600, Olympia, WA 98504-5600 September 26, 2025 ELECTRONIC-FACSIMILE Administrator Fieldstone Memory Care of Silverdale 11313 Clear Creek Rd NW Silverdale, WA 98383 Assisted Living Facility License #2583 Licensee: BFG Silverdale Propco V LLC IMPOSITION OF CIVIL FINE Dear Administrator: On September 16, 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 Fieldstone Memory Care of Silverdale, located at 11313 Clear Creek Rd NW, Silverdale, 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 16, 2025. Civil Fine WAC 388-78A-3100 (1)(2)(3)(4) Safe storage of supplies $500.00 and equipment. The licensee failed to secure hazardous supplies for four residents. This failure placed all 48 residents at risk of potential poisoning or other adverse effects if the hazardous materials were accessed and ingested. This is an uncorrected deficiency previously cited on July 17, 2025, for subsections (1), (2), (3), and (4). NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Administrator Fieldstone Memory Care of Silverdale License # 2583 September 26, 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: Laurie Anderson, Field Manager Region 3, Unit D 9501 Lakewood Drive 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 Fieldstone Memory Care of Silverdale License # 2583 September 26, 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 $500.00 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 Fieldstone Memory Care of Silverdale License # 2583 September 26, 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 Laurie Anderson, 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

This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: Fieldstone Memory Care of Provider Type: Assisted Living Facility Silverdale License/Cert.#: 2583 Intake ID: 91909 Compliance Determination #: 29357 Region/Unit #: RCS Region 3 / Unit D Investigator: Cathleen Davis Investigation Date(s): 09/11/2023 through 09/25/2023 Complainant Contact Date(s): Allegation(s): On 7-28-2023 methadone was left in resident room for another resident. Investigation Methods: Sample: Total residents: 140 Resident sample size: 3 Closed records sample size: 3 Observations: Identified resident Residents Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Identified resident Identified staff Nursing staff Residents Family members Business office manager Record Reviews: Medical records State reporting log Facility policies Incident investigation Investigation Summary: Interview and record review determined the facility did not secure the scheduled II medication, methadone. This medication was delivered to the wrong resident. Record Review of the incident report showed the unsecured medication was found in the wrong resident's room. Record review of the facility policy showed the scheduled II medication was left in the Assisted Living Facility resident room. This was a failed facility practice cited under WAC 388-78A- 2260. Conclusion / Action: This document was prepared by Residential Care Services for the Locator website. Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A This document was prepared by Residential Care Services for the Locator website.