Inspection Report
Follow-Up
Census: 67
Deficiencies: 1
Oct 15, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to licensing laws and regulations.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies related to failure to notify the Department of a change of ownership were corrected.
Complaint Details
Complaint investigation conducted from 07/17/2025 through 08/12/2025 regarding concerns about signing multiple contracts and questions about ownership of the Assisted Living Facility. Failed provider practice was identified and a citation was written under WAC 388-78A-2770 for failing to notify the Department of a change of ownership.
Deficiencies (1)
| Description |
|---|
| Failure to notify the Department of a change of ownership, resulting in the Department not knowing who owned the facility and whether the current owner was qualified. |
Report Facts
Total residents: 67
Resident sample size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Heinz | Long Term Care Surveyor | Conducted the follow-up inspection and complaint investigation |
| Staff A | Senior Vice President of Operations | Provided email interview clarifying ownership details during complaint investigation |
Inspection Report
Follow-Up
Deficiencies: 1
Aug 12, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility on 08/12/2025 to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility corrected the previously cited deficiency related to coordination of health care services.
Deficiencies (1)
| Description |
|---|
| The assisted living facility failed to coordinate services for a resident who required wound care, including failure to refer to home health services, provide timely follow-up care, and facilitate necessary external services. |
Report Facts
Compliance Determination Completion Date: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Woodetta Maulana | Investigator and Department staff who did the On Site verification | |
| Manfay Chan | Allied Health Field Manager | Signed the follow-up inspection letter |
Inspection Report
Follow-Up
Census: 76
Capacity: 76
Deficiencies: 6
Aug 5, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to compliance with licensing laws and fire safety codes.
Findings
The follow-up inspection on 08/05/2025 found no deficiencies, indicating that previously cited violations related to fire and life safety codes and other licensing laws were corrected. Prior inspections from 12/09/2024, 03/06/2025, and 06/09/2025 documented recurring deficiencies related to fire safety, sprinkler system maintenance, emergency power system maintenance, and labeling of fire dampers.
Complaint Details
Complaint investigation conducted from 12/05/2024 through 12/09/2024 regarding life safety and fire marshal regulation non-compliance. Failed provider practice identified and citations written.
Deficiencies (6)
| Description |
|---|
| Failed to maintain compliance with State Fire Marshal codes for Long Term Care facilities, placing 76 residents, visitors, and staff at risk in an emergency. |
| Dampers protecting ducts and air transfer openings failed inspection; failed to label all damper access panels with 'Fire Damper' in letters not less than 1 inch. |
| Unable to provide fire sprinkler system documentation including annual standpipe confidence report and 3-year full flow trip test report. |
| Kitchen hood suppression system out of alignment affecting system performance; no corrective report approving appliance location. |
| Unable to provide documentation of annual servicing of emergency backup generator, diesel fuel compliance, and monthly load tests for past 12 months. |
| Fire alarm circuit breaker missing required lock device; unable to provide last annual inspection of fire-resistant-rated construction assemblies; fire doors not annually inspected, tested, and repaired; fire-rated doors improperly locked with keyed deadbolt. |
Report Facts
Residents at risk: 76
Deficiency recurrence dates: Recurring deficiencies cited on 12/09/2024, 03/06/2025, and 06/09/2025.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nikolas Jennings | Community Nurse Complaint Investigator | Conducted inspections and complaint investigations. |
| Staff A | Executive Director | Interviewed regarding receipt and correction of fire marshal deficiency reports. |
| Staff B | Maintenance Director | Received non-compliance letter from fire marshal on 09/25/2024. |
| CC1 | Interviewed regarding facility non-compliance letter procedures. |
Inspection Report
Follow-Up
Census: 76
Deficiencies: 1
Jun 9, 2025
Visit Reason
The Department of Social and Health Services completed a follow-up visit to The Meridian at Stone Creek to verify correction of previously cited deficiencies.
Findings
The facility failed to maintain compliance with the State Fire Marshal codes for Long Term Care facilities, placing 76 residents, visitors, and staff at risk in an emergency. This deficiency was recurring from December 9, 2024, and remained uncorrected since March 6, 2025.
Deficiencies (1)
| Description |
|---|
| Failure to maintain compliance with the State Fire Marshal codes for Long Term Care facilities. |
Report Facts
Civil fine amount: 800
Resident count at risk: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter regarding the civil fine. |
| Manfay Chan | Field Manager | Contact person for plan of correction and inquiries. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 4, 2025
Visit Reason
The inspection was conducted in response to a complaint (#178945) regarding smoking and fire safety at the Meridian at Stone Creek facility.
Findings
A fire was discovered burning outside the building in the smoking area, caused by an ashtray. The fire was extinguished by the fire department with no injuries reported. The facility replaced the ashtray with a metal canister and provided staff training. No IFC violations were observed.
Complaint Details
Complaint #178945 involved a smoking/fire incident. The fire was caused by an ashtray outside, no sprinklers were activated, no evacuation occurred, no injuries were reported, and the fire department responded. The complaint was investigated by Deputy State Fire Marshal Cozetta Christian.
Report Facts
Complaint number: 178945
Time of fire: 315
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cozetta Christian | Deputy State Fire Marshal | Conducted the complaint investigation and inspection |
Inspection Report
Follow-Up
Deficiencies: 0
May 21, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to service agreement planning.
Findings
The follow-up inspection found no deficiencies; the previously cited deficiencies regarding failure to update residents' negotiated service agreements following changes in condition were corrected.
Complaint Details
The complaint investigation conducted from 08/14/2024 through 08/29/2024 involved allegations that a resident on hospice did not receive routine showers and that a resident was neglected towards the end of their stay. The investigation substantiated failure to update the negotiated service agreement for one resident following a change in condition, resulting in a citation.
Report Facts
Complaint investigation dates: 08/14/2024 through 08/29/2024
Number of residents sampled: 3
Number of falls: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Woodetta Maulana | Investigator | Conducted the complaint investigation and follow-up inspection |
| Manfay Chan | Allied Health Field Manager | Signed the follow-up inspection letter |
| Staff A | Executive Director | Confirmed that the negotiated service agreement had not been updated during the complaint investigation |
Inspection Report
Follow-Up
Census: 5
Deficiencies: 0
May 21, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies, indicating that previously cited issues related to investigations, laundry, and policies and procedures were corrected.
Complaint Details
Multiple complaint investigations were conducted between 10/01/2024 and 10/28/2024 regarding allegations including residents being wet with urine for extended periods and resident-to-resident incidents. The facility failed to document investigative findings and actions, failed to follow policies for alert charting, and failed to maintain proper laundry sanitation. All complaints resulted in failed provider practices with citations written.
Report Facts
Total residents: 5
Resident sample size: 5
Closed records sample size: 2
Complaint numbers referenced: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Woodetta Maulana | Investigator | Conducted complaint investigations and follow-up inspection |
| Manfay Chan | Allied Health Field Manager | Signed follow-up inspection letter |
| Staff D | Memory Care Director | Interviewed regarding residents wet with urine |
| Staff A | Executive Director interviewed regarding incident report and investigation | |
| Staff B | Maintenance Director | Interviewed regarding laundry machines |
| Staff C | Housekeeping Staff | Interviewed regarding laundry practices |
| Staff E | Director of Nursing | Interviewed regarding alert charting and resident care |
Inspection Report
Follow-Up
Census: 5
Deficiencies: 0
May 21, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies from compliance determinations dated 10/28/2024 and 05/21/2025.
Findings
The follow-up inspection on 05/21/2025 found no deficiencies, indicating that previously cited deficiencies related to investigations, laundry sanitation, and policies and procedures were corrected.
Complaint Details
The complaint investigation conducted from 10/01/2024 through 10/28/2024 involved allegations of resident to resident abuse and neglect, including failure to document investigative findings, inadequate laundry sanitation, and failure to follow alert charting policies. The investigation found multiple deficiencies with citations written.
Report Facts
Total residents: 5
Resident sample size: 5
Closed records sample size: 2
Complaint numbers referenced: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Woodetta Maulana | Investigator | Conducted complaint investigation and follow-up inspection |
| Staff A | Executive Director | Interviewed regarding investigation of resident neglect allegations |
| Staff B | Maintenance Director | Interviewed regarding laundry washing machines and sanitation |
| Staff C | Housekeeping Staff | Interviewed regarding laundry practices |
| Staff D | Memory Care Director | Reported resident neglect incident to Executive Director |
| Staff E | Director of Nursing | Interviewed regarding alert charting and resident complaint documentation |
| Manfay Chan | Allied Health Field Manager | Signed follow-up inspection letter |
Inspection Report
Enforcement
Census: 76
Deficiencies: 1
Mar 6, 2025
Visit Reason
A follow-up visit was conducted on March 6, 2025, to assess compliance with prior deficiencies, resulting in the imposition of a civil fine due to failure to maintain compliance with State Fire Marshal codes.
Findings
The facility failed to maintain compliance with State Fire Marshal codes for Long Term Care facilities, placing 76 residents at risk in the event of an emergency. This was an uncorrected citation previously cited on December 9, 2024.
Deficiencies (1)
| Description |
|---|
| Failure to maintain compliance with the State Fire Marshal codes for Long Term Care facilities. |
Report Facts
Civil fine amount: 600
Residents at risk: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter regarding the civil fine. |
| Manfay Chan | Field Manager | Contact person for the plan of correction and appeals. |
Inspection Report
Re-Inspection
Deficiencies: 21
Feb 12, 2025
Visit Reason
The Office of the State Fire Marshal conducted a re-inspection at The Meridian at Stone Creek facility to verify correction of previous fire and life safety code violations.
Findings
The re-inspection found multiple unresolved violations including lack of documentation for fire and safety equipment inspections and maintenance, missing labels on damper access panels, deficiencies in fire door inspections and maintenance, and issues with emergency power systems and fire suppression systems.
Deficiencies (21)
| Description |
|---|
| Unable to provide documentation showing all automatic and fusible link fire/smoke dampers received inspection and testing in the past four years; facility failed to label all damper access panels with the words 'Fire Damper' in letters not less than 1 inch in height. |
| Unable to provide fire sprinkler system documentation including last annual standpipe confidence report, last 3-year full flow trip test report, last 5-year inspection/test reports, and last 5-year FDC hydro test report. |
| Kitchen hood suppression system report indicated cooking appliances were out of line with suppression system nozzles affecting system performance; no corrective Cintas report approving appliance location. |
| Unable to provide documentation showing annual servicing of emergency backup generator, diesel fuel compliance, and monthly load tests for emergency generator for the past 12 months. |
| Unable to provide last annual inspection of all fire-resistant-rated construction assemblies in the building or record of repairs. |
| Unable to provide record showing all fire doors have been annually inspected, tested, and repaired in the past 12 months; multiple fire doors failed to self-close and latch when tested. |
| Found kitchen hood suppression system past due for semi-annual servicing; last performed in May 2023. |
| Found portable fire extinguishers throughout the facility did not have the required 30-day inspections documented for April, May, or June of 2024. |
| Fire alarm circuit breaker in main electrical room missing required lock device-locking breaker in the 'ON' position. |
| Found unapproved silicone used to protect penetration inside mechanical room; unsealed penetrations observed in exterior access boiler room and exterior riser room. |
| Found extension cords used as permanent wiring in multiple locations. |
| Found exit sign with internal part blocking light bulb preventing full illumination. |
| Unable to provide documentation showing 30-second monthly battery testing of emergency lighting and exit signs performed in the last 12 months. |
| Unable to provide documentation showing 90-minute annual battery testing of emergency lighting and exit signs performed in the last 12 months. |
| Exterior lever handle on west dining room exit doors installed backwards obstructing interior right leaf from opening; facility installed strap around left leaf's interior push bar preventing proper operation. |
| Found painted fire door frame labels throughout the facility. |
| Found ordinary-rated fire sprinkler heads in walk-in cooler and freezer; require replacement with intermediate-temperature classification or higher. |
| Cover plate behind recessed sprinkler head missing; notable gap in sheetrock observed around sprinkler head. |
| Found kitchen hood suppression system report indicated cooking appliances out of line with suppression system nozzles affecting system performance. |
| Two unracked oxygen cylinders found in resident room W334—one on floor and one on table. |
| Portable fire extinguishers throughout the facility lacked required 30-day inspection documentation for April, May, and June 2024. |
Report Facts
Inspection dates missing: 3
Inspection dates missing: 4
Inspection dates missing: 12
Inspection dates missing: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lysandra Davis | Deputy State Fire Marshal | Signed inspection reports and conducted re-inspections |
| Cozetta Christian | Deputy State Fire Marshal | Signed inspection reports and conducted inspections |
| Shylah Hallam-Noel | Owner or Authorized Representative | Signed inspection reports |
Inspection Report
Re-Inspection
Deficiencies: 18
Feb 12, 2025
Visit Reason
The Office of the State Fire Marshal conducted a re-inspection at Meridian at Stone Creek to determine compliance with fire and life safety codes and to verify correction of previous deficiencies.
Findings
The re-inspection found multiple unresolved violations including lack of documentation for fire and safety system inspections and maintenance, failure to label damper access panels properly, deficiencies in fire door inspections and maintenance, and issues with emergency power systems and fire extinguishing systems.
Deficiencies (18)
| Description |
|---|
| Unable to provide documentation showing that all automatic and fusible link fire/smoke dampers in the facility have received inspection and testing in the past four years. |
| Facility shall label all damper access panels with the words 'Fire Damper' in letters not less than 1 in. (25 mm) in height. |
| Unable to provide fire sprinkler system documentation for annual standpipe confidence report, 3-year full flow trip test, 5-year inspection/test reports, and 5-year FDC hydro test report. |
| Kitchen hood suppression system report indicated cooking appliances were out of line with suppression system nozzles, affecting system performance and coverage. |
| Unable to provide documentation showing annual servicing of emergency backup generator, compliance with diesel fuel manufacturer's recommendations, and monthly load tests for emergency generator. |
| Unable to provide last annual inspection of all fire-resistant-rated construction assemblies or record of repairs. |
| Unable to provide record showing all fire doors have been annually inspected, tested, and repaired in the past 12 months; facility had only partial records. |
| Fire doors failed to self-close and latch when tested; multiple doors had latch hardware inoperable or replaced with deadbolt locks. |
| Found unapproved silicone used to protect penetration inside mechanical room and unsealed penetrations in rated ceiling and wall. |
| Found extension cords used as permanent wiring in multiple locations. |
| Found kitchen hood suppression system past due for semi-annual servicing. |
| Found portable fire extinguishers without required 30-day inspections documented for April, May, or June 2024. |
| Found fire alarm circuit breaker missing required lock device in the main electrical room. |
| Found exit sign with internal part blocking light bulb, preventing full illumination. |
| Unable to provide documentation showing 30-second monthly battery testing of emergency lighting and exit signs. |
| Unable to provide documentation showing 90-minute annual battery testing of emergency lighting and exit signs. |
| Exterior lever handle on west dining room exit doors installed backwards, obstructing interior right leaf from opening. |
| Unable to provide documentation showing monthly inspection of carbon monoxide alarms in the past 12 months. |
Report Facts
Next inspection scheduled date: Mar 17, 2025
Next inspection scheduled date: Jan 9, 2025
Next inspection scheduled date: Oct 21, 2024
Next inspection scheduled date: Aug 26, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lysandra Davis | Deputy State Fire Marshal | Signed multiple inspection reports and re-inspection documents |
| Shylah Hallam-Noel | Owner or Authorized Representative | Signed inspection documents |
Inspection Report
Life Safety
Deficiencies: 9
Dec 10, 2024
Visit Reason
The Office of the State Fire Marshal conducted a re-inspection at the Meridian at Stone Creek facility to verify correction of previous fire safety violations.
Findings
The re-inspection found multiple unresolved fire safety violations including lack of annual inspection records for fire-resistant construction assemblies, fire doors, sprinkler systems, extinguishing systems, and emergency power systems. Several fire doors had hardware replaced with deadbolt locks, and deficiencies were noted in fire alarm circuit breaker locks and fire damper maintenance.
Deficiencies (9)
| Description |
|---|
| Unable to provide last annual inspection of all fire-resistant-rated construction assemblies in the building, or record of repairs. |
| Unable to provide record showing that all fire doors have been annually inspected, tested and repaired in the past 12 months. |
| Unable to provide documentation showing that all automatic and fusible link fire/smoke dampers have received inspection and testing in the past four years; service scheduling required. |
| Facility shall label all damper access panels with the words 'Fire Damper' in letters not less than 1 inch (25 mm) in height. |
| Unable to provide fire sprinkler system documentation for multiple required tests and reports including last annual forward flow test, standpipe confidence report, full flow trip test, 5-year inspection/test reports, and 5-year FDC hydro test report. |
| Kitchen hood suppression system report indicated cooking appliances were out of line with suppression system nozzles; facility to work with DOH Construction Review Services for correct coverage. |
| Unable to provide documentation showing annual servicing of emergency backup generator, diesel fuel compliance, and monthly load tests for emergency generator in past 12 months. |
| Fire alarm circuit breaker in main electrical room missing required lock device locking breaker in 'ON' position. |
| Both 'in' and 'out' fire-rated doors between kitchen and dining room had lever/latch hardware removed and replaced with keyed deadbolt locks; doors no longer latch. |
Report Facts
Next inspection scheduled date: Jan 9, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lysandra Davis | Deputy State Fire Marshal | Signed as Deputy State Fire Marshal on inspection report. |
Inspection Report
Follow-Up
Deficiencies: 0
Nov 5, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to infection control.
Findings
The follow-up inspection on 11/05/2024 found no deficiencies, indicating that the previously cited infection control issues were corrected.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Carmichael | Nursing Consultant Institutional | Department staff who did the On Site verification during the follow-up inspection. |
| Kathy Heinz | Long Term Care Surveyor | Department staff who did the On Site verification during the follow-up inspection. |
Inspection Report
Follow-Up
Census: 60
Capacity: 59
Deficiencies: 13
Oct 24, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to address deficiencies from previous compliance determinations and complaint investigations.
Findings
The facility was found to have multiple deficiencies including failure to screen staff for tuberculosis, lack of CPR and first-aid training, incomplete background checks, inadequate specialized training for mental illness and dementia, failure to maintain a safe and sanitary environment including food sanitation issues, incomplete negotiated service agreements, failure to develop initial resident service plans timely, and failure to monitor residents' well-being adequately. Some deficiencies were recurring from prior inspections.
Deficiencies (13)
| Description |
|---|
| Failure to ensure 3 of 4 sampled staff were screened for tuberculosis within three days of hire. |
| Failure to ensure 3 of 3 sampled staff obtained CPR and first-aid certification within thirty days of hire. |
| Failure to ensure 1 of 4 sampled staff completed Washington state name and date of birth criminal background check. |
| Failure to ensure 1 of 4 sampled staff completed national fingerprint criminal background check within 120 days of hire. |
| Failure to ensure 1 of 4 sampled staff completed specialized training for mental illness within 120 days of hire. |
| Failure to ensure 1 of 4 sampled staff completed specialized training for dementia within 120 days of hire. |
| Failure to ensure 2 of 2 sampled staff completed required continuing education classes. |
| Failure to verify 1 of 4 sampled staff had required licenses and credentials in good standing. |
| Failure to ensure 3 of 3 sampled staff completed facility orientation training. |
| Failure to maintain food sanitation in two kitchen areas including improper food storage, unclean surfaces, presence of insects, and failure to date mark food properly. |
| Failure to ensure negotiated service agreements were signed annually by residents or representatives and facility representatives for 4 of 8 sampled residents. |
| Failure to develop an initial resident service plan timely for 1 of 1 newly admitted sampled residents. |
| Failure to take appropriate action in response to a resident's changing needs, specifically delayed wound care for Resident 10. |
Report Facts
Residents present: 60
Total licensed capacity: 59
Sample size: 12
Closed records sample size: 1
Number of deficiencies cited: 13
Days delayed for initial care plan: 29
Days delayed for care plan signature: 125
Days delayed wound care: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Executive Director | Named in findings related to tuberculosis screening, CPR training, background checks, orientation, and wound care delay |
| Staff B | Medication Technician | Named in findings related to CPR training, continuing education, and facility orientation |
| Staff C | Memory Care Director | Named in findings related to tuberculosis screening, CPR training, continuing education, and facility orientation |
| Staff D | Resident Services Coordinator | Named in findings related to tuberculosis screening, CPR training, background checks, specialized training, credential verification, and facility orientation |
| Staff E | Food Services Director | Named in findings related to food sanitation and pest control |
| Staff F | Resident Care Director | Named in findings related to unsigned negotiated service agreements |
| Staff G | Server | Named in food sanitation observations |
| Kathy Heinz | Investigator | Conducted multiple complaint investigations and inspections |
Inspection Report
Re-Inspection
Deficiencies: 19
Sep 25, 2024
Visit Reason
The Office of the State Fire Marshal conducted a re-inspection at the facility to verify correction of previously cited fire safety and maintenance violations.
Findings
The re-inspection found multiple unresolved violations including missing lock devices on fire alarm circuit breakers, lack of documentation for annual inspections and maintenance of fire-resistant construction, fire doors, fire sprinkler systems, extinguishing systems, emergency power systems, and emergency lighting. Additional issues included unsecured oxygen cylinders, missing electrical cover plates, improper use of extension cords, and missing monthly inspections of fire extinguishers.
Deficiencies (19)
| Description |
|---|
| Fire alarm circuit breaker in the main electrical room missing required lock device locking breaker in the ON position. |
| Unable to provide last annual inspection of all fire-resistant-rated construction assemblies or record of repairs. |
| Unable to provide record showing fire doors have been annually inspected, tested, and repaired in the past 12 months. |
| Swinging fire doors failed to self-close and latch; latch hardware inoperable or disabled on multiple doors. |
| Unable to provide documentation showing all automatic and fusible link fire/smoke dampers have received inspection/testing in past four years; damper access panels not properly labeled. |
| Unable to provide fire sprinkler system documentation for multiple required tests and inspections; ordinary-rated sprinkler heads found in walk-in cooler and freezer. |
| Kitchen hood suppression system past due for semi-annual servicing; last performed May 2023. |
| Unable to provide documentation showing annual servicing of fire alarm system in past 12 months. |
| Unable to provide documentation showing monthly inspection of carbon monoxide alarms in past 12 months. |
| Emergency lighting and exit signs not tested monthly for 30 seconds; unable to provide documentation of testing in past 12 months. |
| Unable to provide documentation showing 90-minute annual battery testing of emergency lighting and exit signs in past 12 months. |
| Exterior lever handle on west dining room exit doors installed backwards obstructing door operation. |
| Unable to provide documentation showing annual servicing of emergency backup generator, diesel fuel compliance, and monthly load tests for past 12 months. |
| Two unracked oxygen cylinders found in resident room W334, one on floor and one on table. |
| Portable fire extinguishers lacked required 30-day inspection documentation for April, May, and June 2024. |
| Painted fire door frame labels throughout facility; multiple fire doors and frames had open holes due to hardware changes. |
| Light switch in kitchen pantry missing required cover plate. |
| Facility failed to maintain required workspace clearance in front of electrical panels in mechanical rooms. |
| Extension cords used as permanent wiring in multiple locations and concealed above ceiling tiles. |
Report Facts
Quarterly kitchen hood cleanings: 4
Fire extinguisher inspections missed: 3
Oxygen cylinders found unracked: 2
Fire doors with issues: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lysandra Davis | Deputy State Fire Marshal | Signed the inspection report. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 4, 2024
Visit Reason
A complaint investigation was conducted regarding a small kitchen fire that occurred within the oven located in the facility's kitchen.
Findings
Staff witnessed a small fire within the oven which was quickly extinguished. No kitchen suppression system or fire sprinkler system activation occurred. No resident evacuations or injuries were reported, and no fire department response was required. No violations or IFC violations were detected related to the incident.
Complaint Details
Complaint #143353 involved a kitchen fire. The complaint was investigated and found no violations or need for fire department response.
Report Facts
Complaint ID: 143353
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| George B. Gaul | Maintenance Director | Interviewed regarding the kitchen fire incident |
| Lysandra Davis | Deputy State Fire Marshal | Signed the inspection report |
Inspection Report
Enforcement
Deficiencies: 1
Sep 4, 2024
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to The Meridian at Stone Creek to assess compliance and enforce a civil fine related to infection control violations.
Findings
The facility failed to ensure that two staff members were qualified to medically evaluate staff prior to fit-testing respirators, placing residents at risk of infection during a communicable disease outbreak. This deficiency was previously cited and remains uncorrected.
Deficiencies (1)
| Description |
|---|
| Failure to ensure two staff were qualified to medically evaluate staff prior to fit-testing respirators. |
Report Facts
Civil fine amount: 400
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter |
| Manfay Chan | Field Manager | Contact person for plan of correction and appeals |
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 3
Jun 18, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on multiple allegations including lack of staff, insufficient toilet paper and paper towels, sewage backup without sanitization, unclean environment, unmanaged laundry, unemptied garbage, lack of hot water, and staff disrespect towards residents.
Findings
The investigation found multiple deficiencies related to maintenance and housekeeping, including lack of toilet paper and paper towels, unsanitary environment, and unclean laundry. Several citations were written under WAC 388-78A-3090. Some allegations were not substantiated due to insufficient evidence or previous investigations. Unrelated citations were issued for failing to secure hazardous items and improper medication delegation.
Complaint Details
The complaint investigation was based on allegations including lack of staff, lack of toilet paper and paper towels, sewage backup without sanitization, unclean environment, unmanaged laundry, unemptied garbage, lack of hot water, and staff disrespect. Some allegations were substantiated with citations, others were not due to insufficient evidence or prior investigations.
Deficiencies (3)
| Description |
|---|
| Lack of toilet paper and paper towels in bathrooms |
| Environment not kept sanitary |
| Laundry not managed and unclean |
Report Facts
Total residents: 22
Resident sample size: 6
Compliance Determination Completion Dates: Completion dates for compliance determinations 49385 (10/24/2024) and 42907 (08/07/2024)
Investigation Date Range: Investigation conducted from 06/18/2024 through 08/07/2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Heinz | Long Term Care Surveyor | Investigator conducting the complaint investigation |
| Shirley Grew | LTC Surveyor | Investigator conducting the complaint investigation |
Inspection Report
Follow-Up
Census: 2
Deficiencies: 2
Apr 26, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to medication administration and resident care.
Findings
The follow-up inspection on 04/26/2024 found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. The prior deficiencies related to medication nonavailability and failure to monitor residents' well-being were corrected.
Complaint Details
The complaint investigation was triggered by a public complaint of care and services. The investigation found systemic problems with medication administration and monitoring residents' well-being. Failed provider practices were identified and citations were written.
Deficiencies (2)
| Description |
|---|
| Failure to implement a system to ensure medications were available to 3 of 8 sampled residents, placing them at risk for medical decline. |
| Failure to monitor and chart changes in condition for 2 of 8 sampled residents when medications were not provided, placing them at risk for medical decline. |
Report Facts
Total residents: 2
Sampled residents with medication issues: 3
Sampled residents with monitoring failures: 2
Medication non-administration dates: 19
Medication non-administration days: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cathleen Davis | ALF Licensor | Conducted the on-site verification and complaint investigation |
| Manfay Chan | Field Manager | Signed the follow-up inspection letter |
Inspection Report
Complaint Investigation
Deficiencies: 2
Mar 6, 2024
Visit Reason
The inspection was conducted as a complaint investigation regarding multiple allegations including lack of hot water, kitchen sanitation concerns, presence of pests, and facility maintenance issues at The Meridian at Stone Creek Assisted Living Facility.
Findings
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. Additional findings included failure to maintain exterior grounds in a safe and sanitary condition, and issues with kitchen sanitation and facility maintenance. Some allegations such as norovirus outbreak and food shortage were unable to be substantiated.
Complaint Details
The complaint investigation included allegations of no hot water, kitchen sanitation issues, presence of pigeon droppings, norovirus outbreak, facility cleanliness, staffing concerns, dishwasher not working, use of plasticware, presence of black sewer worms and mice, old furnishings on grounds, and food shortage. Some allegations were substantiated with citations, while others were not substantiated.
Deficiencies (2)
| Description |
|---|
| 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. |
| Failed to ensure the exterior grounds were safe, sanitary and kept in good repair, placing residents at risk for harm. |
Report Facts
Investigation Date Range: From 2023-12-15 through 2024-03-06
Number of complaint investigations referenced: 20
Resident room temperature range: 93.6
Resident room temperature range: 105
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Woodetta Maulana | Investigator | Investigator conducting complaint investigations |
| Staff A | Executive Director | Interviewed regarding boiler issues and maintenance |
| Staff B | Maintenance Director | Interviewed regarding boiler issues, maintenance, and observations of facility conditions |
| Staff C | Maintenance Director | Interviewed regarding resident room water temperatures |
| Shirley Grew | LTC Surveyor | On-site verification staff for follow-up inspection |
| Kathy Heinz | Long Term Care Surveyor | On-site verification staff for follow-up inspection |
| Manfay Chan | Field Manager | Signed follow-up inspection letter |
Inspection Report
Follow-Up
Census: 74
Deficiencies: 1
Aug 4, 2023
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to tuberculosis testing for staff.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previous deficiencies related to incomplete tuberculosis testing for staff were corrected.
Deficiencies (1)
| Description |
|---|
| Failure to ensure 2 of 5 staff completed the required tuberculosis testing for new employees, placing all 74 residents at health risk of TB. |
Report Facts
Residents present: 74
Staff with incomplete TB testing: 2
Total residents: 74
Resident sample size: 0
Closed records sample size: 0
Staff to be screened: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Mason | NCI ALF Licensor | Department staff who inspected the Assisted Living Facility and investigator for complaint |
| Cathleen Davis | ALF Licensor | Department staff who did on-site verification |
| Melisa Moran | Assisted Living Facility Nursing Consultant Institutional | Department staff who did on-site verification |
| Shirley Grew | LTC Surveyor | Department staff who did on-site verification |
| Staff E | Administrator | Interviewed regarding TB testing compliance and efforts to complete testing |
Inspection Report
Follow-Up
Census: 74
Capacity: 74
Deficiencies: 1
Aug 4, 2023
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previous deficiencies related to tuberculosis testing of staff were corrected.
Deficiencies (1)
| Description |
|---|
| The Assisted Living Facility failed to develop and implement a system to ensure each staff person is screened for tuberculosis within three days of employment, placing all 74 residents at risk of TB infection. |
Report Facts
Residents at risk: 74
Sampled staff members: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Resident Care Coordinator | Did not complete TB testing within three days of employment. |
| Staff B | Caregiver | Did not complete TB testing within three days of employment. |
| Staff C | Caregiver | Did not complete TB testing within three days of employment. |
| Staff E | Maintenance | Did not complete TB testing within three days of employment. |
| Staff F | Medication Technician | Failed to reveal results from a TB skin test done within three days of employment. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 14, 2023
Visit Reason
The investigation was conducted due to a complaint alleging that a resident's wound dressing was not changed as scheduled.
Findings
The facility took measures to manage the wound but failed to complete the assessment of the sampled resident when there was a change of condition, resulting in a failed provider practice and citation.
Complaint Details
Complaint allegation: AV's wound dressing was not changed as scheduled. The complaint was substantiated with a failed provider practice identified and citation written.
Deficiencies (1)
| Description |
|---|
| Failed to complete the assessment of 1 of 1 sampled resident when there was a change of condition, placing the resident at risk for potential negative health outcomes. |
Report Facts
Resident sample size: 1
Compliance Determination Completion Date: Completion dates mentioned are 07/27/2023 and 01/22/2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nareet Bajwa | Investigator / Complaint Investigator | Conducted the complaint investigation |
| Cathleen Davis | ALF Licensor | Performed on-site verification during follow-up inspection |
| Manfay Chan | Field Manager | Signed the follow-up inspection letter |
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 10
Jun 16, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation following the facility's failure of their 3rd fire and life safety inspection on 06/05/2023.
Findings
The facility failed the fire and life safety inspection due to multiple deficiencies including failure to conduct quarterly fire sprinkler inspections, propped open fire doors, blocked fire alarm pull stations, and lack of documentation for emergency generator load testing. A plan of correction was submitted with actions to address these issues.
Complaint Details
The complaint investigation was based on the facility's failure of their 3rd fire and life safety inspection on 06/05/2023. The investigation included record reviews, interviews with staff including the Executive Director and Maintenance Director, and observations. Deficiencies were substantiated and citations were written.
Deficiencies (10)
| Description |
|---|
| Facility failed to conduct quarterly inspections of the fire sprinkler system. |
| Smoking debris observed outside the main entrance. |
| Unable to provide cleaning reports for semi-annual cleanings performed in the past 12 months. |
| Unable to provide documentation showing that annual fire-resistance-rated construction inspection was re-conducted after initial inspection. |
| Facility failed to have all fire-resistive-rated construction inventoried for the required annual inspection. |
| Unable to provide list of fire stop materials used by staff to repair each through-penetration. |
| Fire doors found propped open, including fire door to room E318 and fire door that opens to Legaciesm. |
| Fire doors failed to close and latch at multiple locations including West Med Room second floor, door to kitchen from dining room, and outdoor door to dining room from kitchen. |
| Fire alarm pull station by Stairwell 4 was blocked by lounge furniture on second and third floors. |
| Facility failed to document monthly load testing of the emergency generator. |
Report Facts
Total residents: 97
Days to fix issues: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nareet Bajwa | NCI-ALF Complaint Investigator | Investigator who conducted the complaint investigation and off-site verification |
| Manfay Chan | Field Manager | Signed follow-up inspection letter |
Inspection Report
Re-Inspection
Deficiencies: 10
Jun 5, 2023
Visit Reason
The Office of the State Fire Marshal conducted a re-inspection at the facility to verify correction of previously cited fire safety violations.
Findings
The facility was found to have multiple uncorrected fire safety violations including failure to conduct quarterly fire sprinkler inspections, smoking debris outside the entrance, missing cleaning reports for semi-annual cleanings, failure to maintain fire-resistance-rated construction inventory, fire doors propped open or failing to latch, blocked fire alarm pull stations, and failure to document monthly load testing of the emergency generator.
Deficiencies (10)
| Description |
|---|
| Facility failed to conduct quarterly inspections of the fire sprinkler system. |
| Smoking debris observed outside the main entrance. |
| Unable to provide cleaning reports for both semi-annual cleanings performed in the past 12 months. |
| Unable to provide documentation showing that annual fire-resistance-rated construction inspection was re-conducted. |
| Facility failed to have all fire-resistive-rated construction inventoried for annual inspection. |
| Unable to provide list of fire stop materials used by staff to repair each through-penetration. |
| Fire doors found propped open with unapproved hardware and missing signage. |
| Fire doors failed to close and latch automatically in multiple locations. |
| Fire alarm pull station by Stairwell 4 blocked by lounge furniture on second and third floors. |
| Facility failed to document monthly load testing of the emergency generator. |
Report Facts
Next inspection scheduled date: Jul 5, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lysandra Davis | Deputy State Fire Marshal | Signed the re-inspection report. |
Inspection Report
Re-Inspection
Deficiencies: 10
Jun 5, 2023
Visit Reason
The Office of the State Fire Marshal conducted a re-inspection at the facility to verify correction of previously noted violations.
Findings
Multiple fire safety violations were found during the re-inspection, including failure to conduct quarterly sprinkler inspections, smoking debris outside the entrance, fire doors propped open, blocked fire alarm pull station, and failure to document monthly load testing of the emergency generator. Additional violations included missing documentation for fire-resistant construction inspections, unapproved conditions, and failure to conduct required fire drills.
Deficiencies (10)
| Description |
|---|
| Facility failed to conduct quarterly inspections of the fire sprinkler system; sprinkler contractor has no contract to perform inspections. |
| Smoking debris observed outside the main entrance. |
| Unable to provide cleaning reports for semi-annual cleanings; service company does not provide reports. |
| Unable to provide documentation showing annual fire-resistance-rated construction inspection was re-conducted. |
| Facility failed to have all fire-resistance-rated construction inventory for annual inspection. |
| Unable to provide list of fire stop materials used to repair through-penetrations. |
| Fire doors found propped open: fire door to room E318 with unapproved mag holder; fire door to Legacies with missing signage. |
| Fire doors failed to close and latch at multiple locations including West Med Room second floor, kitchen dining room doors, and dining room exit door. |
| Fire alarm pull station by Stairwell 4 blocked by lounge furniture on second and third floors. |
| Facility failed to document monthly load testing of the emergency generator. |
Report Facts
Next inspection scheduled: Jul 5, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lysandra Davis | Deputy State Fire Marshal | Conducted the inspection and signed the report |
| Cindy Schafer | Executive Director | Facility representative who signed the report |
Inspection Report
Follow-Up
Census: 74
Deficiencies: 1
May 10, 2023
Visit Reason
The Department of Social and Health Services completed a follow-up visit to The Meridian at Stone Creek to verify correction of previously cited deficiencies.
Findings
The facility failed to ensure that two staff members completed the required Tuberculosis testing for new employees, resulting in an uncorrected deficiency that placed all 74 residents at risk of TB. This deficiency was previously cited on February 6, 2023, and resulted in a civil fine.
Deficiencies (1)
| Description |
|---|
| Failure to ensure two staff completed the required Tuberculosis (TB) testing for new employees. |
Report Facts
Civil fine amount: 300
Resident census: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Manfay Chan | Field Manager | Contact person for plan of correction and appeals. |
| Matt Hauser | Compliance Specialist | Signed the enforcement letter. |
Inspection Report
Enforcement
Census: 74
Deficiencies: 1
May 10, 2023
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to impose a civil fine on the assisted living facility for recurring deficiencies related to tuberculosis testing of staff.
Findings
The facility failed to develop and implement a system to ensure four staff members were screened for Tuberculosis within three days of employment, placing all 74 residents at risk. This deficiency was recurring and previously cited on February 6, 2023, and September 8, 2022.
Deficiencies (1)
| Description |
|---|
| Failure to develop and implement a system to ensure four staff members were screened for Tuberculosis within three days of employment. |
Report Facts
Civil fine amount: 300
Residents at risk: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter |
| Manfay Chan | Field Manager | Contact person for plan of correction and inquiries |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jan 27, 2023
Visit Reason
The Department completed a complaint investigation of the Assisted Living Facility on 01/27/2023 due to complaints regarding the facility operating without a license.
Findings
The facility was found to have been operating without a license since July 1, 2016, per the Secretary of State's office. As of 12/23/2022, this issue was resolved with the facility obtaining a current business license.
Complaint Details
Complaint numbers 57811 and 58681 were investigated. The complaint was substantiated as the facility was operating without a license until recently obtaining one.
Deficiencies (1)
| Description |
|---|
| Facility does not have an active business license. |
Report Facts
Complaint numbers: 2
Investigation Date Range: 8
Resident sample size: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nareet Bajwa | NCI-ALF Complaint Investigator | Conducted the complaint investigation and provided consultation. |
| Manfay Chan | Field Manager | Signed the letter and provided contact information for questions. |
Loading inspection reports...



