The Meridian at Stone Creek

The facility had two violations: failure to complete required national fingerprint background checks for staff, and a staff member observed dispensing medications without proper dose verification. These represent procedural compliance failures with potential resident safety implications. The facility responded appropriately by re-educating and counseling the named staff member on proper medication administration techniques, demonstrating corrective action, though the background check issue required a citation.

The facility failed to notify the Department of a change in ownership when the original licensee entity (Milton Meridian LLC #603 476 829) was administratively dissolved in 2016, creating regulatory uncertainty about whether the operating entity was qualified to provide services to all 67 residents. The facility cooperated with the investigation, provided clarification about the correct ownership entity (Milton Meridian LLC #605 935 574), and corrected the deficiency by the completion date. A follow-up inspection on 10/15/2025 confirmed full compliance with no remaining deficiencies, demonstrating effective corrective action.

The facility had recurring fire and life safety code violations across multiple inspections (12/2024, 2/2025, 6/2025) affecting all 76 residents, including failed fire dampers, missing sprinkler system documentation, non-functional fire doors, overdue hood suppression servicing, and inadequate emergency generator maintenance. The facility showed some responsiveness by working to address deficiencies between inspections, ultimately achieving compliance by 8/2025, but the response was slow with repeated failures across three follow-up inspections. The pattern of recurring violations across critical life-safety systems (fire suppression, emergency power, fire-rated barriers) demonstrated systemic maintenance and compliance tracking failures that placed residents at significant risk during the 8-month remediation period.

A resident with a serious leg laceration requiring 13 stitches did not receive mandated follow-up care for suture removal or timely wound management, with the facility failing to coordinate home health services per policy despite documented wound deterioration over 21 days that ultimately required emergency department evaluation. The facility's response included acknowledgment and attestation of corrective measures with a plan of correction, and a follow-up inspection on 08/12/2025 confirmed deficiencies were corrected, though initial response was hampered by poor documentation practices and delayed recognition of wound complications. The event represents systemic failure in care coordination that placed the resident at significant risk for infection and complications, while the facility's corrective actions were adequate but not exceptional given the severity of the lapse.

This residential care facility had multiple severe life-safety violations including disabled fire doors that wouldn't self-close or latch (some modified with deadbolts), missing fire protection system documentation, delayed kitchen hood suppression servicing, and improperly stored oxygen cylinders in resident rooms. The facility demonstrated a moderate response through a pattern of gradual corrections over multiple re-inspections spanning 12 months (July 2024 to July 2025), ultimately achieving full compliance by July 31, 2025, though the slow pace of corrections and repeated failures to maintain documentation indicate systemic management deficiencies rather than prompt comprehensive remediation.

On May 12, 2025, a fire occurred in the outdoor smoking area at approximately 3:15 AM, burning a plastic ashtray and nearby chair. Staff noticed the fire from inside, called 911, but did not use a fire extinguisher despite having access. The facility responded appropriately by replacing the plastic ashtray with a required metal canister and providing staff retraining on fire response procedures, though no IFC violations were ultimately cited.

This residential care facility demonstrated systemic and persistent fire safety violations across multiple inspections from July 2024 through June 2025. Critical deficiencies included non-functional fire doors (modified with deadbolts, missing latches), failed fire dampers, missing sprinkler system maintenance documentation, inoperable emergency generator, and kitchen hood suppression system 14+ months overdue for servicing. The facility's response was inadequate, showing repeated failure to correct violations across four re-inspections, with multiple items remaining uncorrected for nearly a year, indicating organizational neglect of life-safety systems rather than isolated oversights.

The facility failed to maintain compliance with State Fire Marshal codes for long-term care facilities, placing 76 residents, visitors, and staff at risk in emergency situations. This is a recurring deficiency previously cited in December 2024 and uncorrected from March 2025, demonstrating a pattern of non-compliance with life-safety requirements. The facility's response has been inadequate, as evidenced by the recurrence and lack of correction over multiple inspections spanning six months, resulting in an $800 civil fine. The persistent failure to address fire safety violations indicates insufficient corrective action and weak systems to maintain regulatory compliance.

The facility had three serious violations: failure to document investigation of alleged neglect involving three residents found in prolonged urine-soaked conditions, non-functional commercial laundry equipment lacking proper sanitization for three months creating infection risk, and failure to implement required alert charting for a resident reporting inappropriate touching. The facility demonstrated a good response by correcting all deficiencies by the May 2025 follow-up inspection, though the initial lack of documentation for the abuse/neglect investigation and delayed action on the laundry equipment indicate moderate systemic gaps in compliance oversight.

The facility failed to properly document investigations of abuse/neglect allegations and did not follow their own policies regarding daily alert charting for residents involved in incidents. Multiple violations across three separate intake cases involved residents left in urine for extended periods and resident-to-resident incidents. The facility's response was inadequate, with incomplete investigative documentation and failure to implement required monitoring protocols, though citations were issued for the identified deficiencies.

The facility failed to update a resident's service agreement after multiple falls occurred in May-June 2024, with the agreement still documenting 'no falls' despite five documented falls over three weeks. This represents a moderate procedural violation affecting care quality and fall prevention planning. The facility acknowledged the deficiency, completed corrective actions, and passed follow-up inspection on 05/21/2025, demonstrating a good response with appropriate remediation and system improvements to prevent recurrence.

The facility failed to maintain compliance with State Fire Marshal codes for long-term care facilities, placing 76 residents at risk in emergency situations. This is a repeat violation previously cited on December 9, 2024, demonstrating a pattern of non-compliance over a three-month period. The state imposed a $600 civil fine and conducted a follow-up visit, but the violation remained uncorrected, indicating inadequate facility response to address critical life-safety infrastructure requirements despite prior citation and sufficient time to remediate.

The facility exhibited severe and systemic fire safety violations across three inspections (July, September, December 2024), including multiple inoperable fire doors, missing fire safety system maintenance records, improper modifications to fire-rated assemblies, and failure to maintain critical life-safety equipment. The facility's response was inadequate, with most violations remaining uncorrected through two re-inspections spanning five months, demonstrating persistent non-compliance with fundamental fire protection requirements. While no immediate life-threatening conditions like active fires or blocked exits were present, the pervasive failures in fire-resistance systems, sprinkler maintenance, emergency power systems, and door assemblies create substantial risk in a residential care facility housing vulnerable populations. The facility showed minimal corrective action between inspections, with the same violations cited repeatedly and approval status remaining 'Disapproved' throughout.

The facility committed serious infection control violations during a COVID outbreak by failing to maintain adequate N-95 respirator supplies and having unqualified staff (Executive Director and LPN) conduct medical evaluations and fit testing for 23 employees, violating both state and OSHA regulations. This was an uncorrected repeat deficiency from June 2024, demonstrating a pattern of systemic non-compliance. The facility's response was inadequate: despite being cited previously, they repeated the same violations two months later, showing only minimal corrective action and failure to implement effective preventive measures. The lack of proper respiratory protection during an active outbreak placed all 69 residents and staff at significant risk of infectious disease transmission, representing a severe threat to resident safety with only superficial facility remediation efforts.

The facility had multiple environmental sanitation violations including lack of toilet paper/paper towels, unsanitary conditions from sewage backup, poor laundry management, and overflowing garbage, resulting in citations under maintenance and housekeeping standards. Additional violations were found for failing to secure hazardous items and improper medication delegation. The facility's response was inadequate, showing no awareness of resident-to-resident altercations, no investigation of missing resident items, and failure to address known environmental deficiencies, indicating poor oversight and reactive rather than proactive management.

The facility failed to ensure two staff members were qualified to medically evaluate employees prior to respirator fit-testing, placing all residents at risk of infection exposure during communicable disease outbreaks. This violation was previously cited on June 26, 2024, and remained uncorrected at the September 4, 2024 follow-up visit, demonstrating a failure to implement timely corrective action. The state imposed a $400 civil fine for this repeat infection control deficiency. The facility's inadequate response to the initial citation resulted in continued systemic risk to vulnerable residents during potential outbreak situations.

A small kitchen fire occurred within an oven at the facility and was quickly extinguished by staff without activating suppression or sprinkler systems. No evacuations, injuries, or fire department response were required. The facility's response was appropriate and timely, with staff immediately addressing the incident. The complaint investigation found no violations related to either the incident or the facility's response.

This re-inspection identified 22 uncorrected fire and life-safety violations across critical systems including fire alarm protection, suppression systems, emergency power, and egress components. Severe issues include multiple inoperable fire doors, missing fire protection system inspections (sprinkler, alarm, dampers, emergency lighting), improper extension cord use, and unsecured oxygen cylinders. The facility's response has been inadequate, as evidenced by persistent violations from the initial inspection, missing documentation spanning multiple years, and failure to schedule required testing, indicating systemic neglect of fire safety compliance rather than isolated oversights.

The facility experienced a prolonged boiler failure preventing proper hot water temperatures (105-120°F) and failed to report this critical infrastructure breakdown to the department, generating multiple complaints. Additional violations included unsanitary exterior grounds with furniture debris and pigeon droppings. The facility implemented interim measures including three-sink sanitization with boiling water and temporary plasticware use, demonstrating some problem-solving, but the extended duration without reporting the boiler failure and delayed corrective action reflect inadequate emergency response protocols and regulatory compliance.

The facility failed to provide prescribed medications to residents for extended periods (up to 14 consecutive days), including critical medications for diabetes, blood pressure, and infections, affecting 3 of 8 sampled residents. The systemic failure included no backup medication supply system, lack of monitoring when medications were missed, and confusion among staff about medication administration approval processes. The facility conducted an investigation and submitted corrective action plans with completion dates, but the response was delayed and the follow-up inspection occurred four months after the initial citation, indicating a slow correction process for serious medication management failures that placed residents at risk of medical decline.

The facility failed to complete a required assessment when a resident experienced a change in condition related to wound care, despite taking some measures to manage the wound itself. This represents a moderate violation of care standards with documentation and assessment protocol failures. The facility's response was adequate but incomplete, as they took some wound management measures but did not fulfill all required assessment protocols, resulting in a citation issued on 07/27/2023.

The facility failed to ensure 2 of 5 staff members completed required tuberculosis testing documentation for new hires, placing 74 residents at potential health risk. This was an uncorrected repeat deficiency previously cited in February 2023. The administrator acknowledged awareness of the issue and stated efforts were underway to obtain compliance, but the violation persisted, demonstrating inadequate follow-through on corrective actions despite prior citations.

The facility failed its third consecutive fire and life safety inspection on 06/05/23, indicating a pattern of non-compliance with critical safety requirements that presents ongoing risk to 97 residents. The facility's response was inadequate, as demonstrated by repeated failures to remediate identified fire safety deficiencies after multiple opportunities. While no immediate life-threatening conditions are documented in this summary report, the persistence of fire safety violations across three inspections represents a moderate severity event with a poor facility response.

The facility exhibited a pattern of serious life-safety violations including failure to conduct required fire drills for nearly a year (staff stopped because residents were bothered by alarm noise), multiple fire doors propped open or failing to latch, obstructed fire alarm pull stations and extinguishers, missing fire sprinkler system inspections, and inadequate emergency generator testing. The facility's response was moderate but incomplete: they acknowledged violations and signed inspection reports, but required multiple re-inspections (February, April, June) before achieving final compliance in August 2023, indicating slow corrective action. While the facility eventually corrected all issues, the six-month timeline and need for repeated enforcement demonstrates an initially insufficient response to systemic fire safety deficiencies that created actual risk to residents in a population requiring containment and protective oversight.

This residential care facility exhibited severe and systemic fire safety violations across three inspections (Feb 2023, April 2023, June 2023), including failure to maintain fire sprinkler systems, multiple fire doors propped open or non-functional, 11+ breaches in fire-rated construction, blocked emergency equipment, and critically—abandonment of required fire drills because 'residents were bothered by the noise.' The facility's response was inadequate: most violations persisted through two re-inspections, documentation remained missing, and staff lacked proper certifications for required testing. While no actual fires or injuries occurred, the combination of compromised life-safety systems, absence of emergency preparedness training, and minimal corrective action created substantial risk to vulnerable residents in a setting where evacuation capabilities are already limited.

The facility failed to ensure two staff members completed required tuberculosis testing for new employees, placing all 74 residents at risk of communicable disease exposure. This was a repeat violation previously cited on February 6, 2023, resulting in a $300 civil fine. The facility's inadequate response to the initial citation demonstrates a pattern of non-compliance with basic infection control requirements, with no evidence of effective corrective action despite prior warning.

The facility failed to conduct required tuberculosis testing for four staff members within three days of employment, exposing all 74 residents to potential TB infection risk. This represents a severe violation as it is a recurring deficiency previously cited twice (February and September 2022), demonstrating a systemic failure in the facility's TB screening system. The facility's response has been inadequate, as evidenced by repeated citations for the same violation without effective corrective action implementation, resulting in a $300 civil fine and escalating enforcement action.