Inspection Reports for
Deer Ridge Memory Care Community

WAC 388-78A-2371 Investigations. The assisted living facility failed to investigate a resident-to-resident incident for 3 sampled residents and did not implement measures to prevent recurrence, placing residents at risk of harm and decreased quality of life.

WAC 388-78A-2440 Resident register. The facility failed to maintain a current resident register, placing all 53 residents at risk for delays in care and services in emergencies.

WAC 388-78A-3140 Responsibilities during inspections. The facility failed to provide incident reports and investigations to the department during an investigation, placing all 53 residents at risk for delayed care concerns and impeding the department’s investigation.

WAC 388-78A-2371 Investigations. The assisted living facility failed to conduct investigations to determine the circumstances of accidents and incidents, implement interventions to prevent recurrence, and protect residents for 5 sampled residents, placing them at risk from continued incidents without preventive measures.

WAC 388-78A-2060 Preadmission assessment. The assisted living facility failed to conduct a preadmission assessment for 1 sampled resident, resulting in the resident not receiving appropriate services and a decline in health.

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? The facility failed to ensure 4 of 4 sampled staff completed 12 hours of continuing education, placing all 46 residents at risk from unqualified caregivers.

WAC 388-112A-0105 Who is required to obtain home care aide certification and by when? The facility failed to ensure 1 of 4 sampled staff obtained home care aide certification within 200 days of hire, potentially resulting in all 46 residents receiving care from an unqualified staff.

WAC 388-112A-0200 What is orientation training, who should complete it, and when should it be completed? The facility failed to ensure 2 of 2 sampled staff completed facility orientation training, placing all 46 residents at risk of harm due to lack of emergency response knowledge.

WAC 388-78A-2474 Training and home care aide certification requirements. The facility failed to ensure 2 of 3 sampled staff completed 12 hours of continuing education, placing all 46 residents at risk from receiving care from unqualified caregivers.

WAC 388-112A-0611 (1)(a)(i) 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? The licensee failed to ensure four staff completed 12 hours of continuing education as required.

WAC 388-78A-2474 (2)(e) Training and home care aide certification requirements. The licensee failed to ensure four staff completed 12 hours of continuing education as required.

WAC 388-78A-2371 (1)(2)(3)(4) Investigations. The licensee failed to conduct investigations to determine the circumstances of accidents and incidents, implement interventions to prevent recurrence, and protect residents for five residents.

WAC 388-78A-2371 Investigations. The assisted living facility must investigate and document investigative actions and findings for any alleged or suspected abuse, neglect, or accident affecting a resident's health or life. The facility failed to conduct thorough investigations of resident falls and injuries of unknown source for 3 of 4 sampled residents, contributing to harm and risk of harm.

WAC 388-78A-2150-1 - The facility failed to ensure that residents’ negotiated service agreements were agreed to and signed by resident representatives for 3 of 3 sample residents. This placed residents at risk for not receiving appropriate care timely.

WAC 388-78A-2430 - The facility failed to provide resident records timely to a resident’s representative, with records provided weeks to months after request. No harm was noted.

RCW 70.129.030(4) - The facility failed to notify a resident’s representative in advance of an increase in service charges. The facility reimbursed the resident’s account.

WAC 388-78A-2160 Implementation of negotiated service agreement. The assisted living facility failed to provide care and services as agreed upon in the negotiated service agreement for 6 of 8 sampled residents, placing them at risk for wounds, infections, and decreased skin integrity.

RCW 70.129.140 Quality of life -- Rights. The facility failed to promote care that maintains or enhances residents' dignity and respect for 7 of 8 sampled residents, resulting in decreased dignity and quality of life.

WAC 388-78A-2660 Resident rights. The assisted living facility failed to provide care and services consistent with resident rights for 7 of 8 sampled residents, resulting in decreased dignity and quality of life.

WAC 388-78A-2371(1)(2)(3) Investigations. The licensee failed to conduct an investigation that determined the circumstances of events and institute measures to prevent future incidents when residents sustained falls and injuries of unknown source for three residents. This failure contributed to one resident sustaining two falls with fractures requiring surgery and hospitalization, another resident lacking preventative measures, and a third resident at risk for abuse and continued harm.

WAC 388-78A-2160 Implementation of negotiated service agreement. The licensee failed to ensure residents received care and services as agreed upon in the negotiated service agreement for six residents, placing them at risk for wounds, infections, and decreased skin integrity.

RCW 70.129.140 (1) Quality of life -- Rights and WAC 388-78A-2660 (2) Resident rights. The licensee failed to ensure residents received care and services that enhance dignity and quality of life for seven residents, resulting in seven residents not receiving showers and being at risk for wounds, infections, and decreased dignity.

WAC 388-78A-2160 Implementation of negotiated service agreement. The licensee failed to provide showers for ten residents, resulting in risk of skin infections and decreased skin integrity.

WAC 388-78A-2660(2) Resident rights. The licensee failed to ensure residents received care and services that enhance dignity and quality of life for ten residents, contributing to decreased dignity and quality of life.

WAC 388-78A-2371 Investigations. The assisted living facility failed to investigate circumstances surrounding resident falls, including a fall resulting in a clavicle fracture, contributing to recurring falls and hospitalization.

WAC 388-78A-2120 Monitoring residents' well-being. The assisted living facility failed to assess, evaluate, or monitor a resident’s change in physical function after falls, contributing to continued falls and health decline.

WAC 388-78A-2600 Policies and procedures. The assisted living facility failed to train staff on policies for investigating incidents of abuse and neglect, resulting in inadequate response to a resident fall causing injury.

WAC 388-78A-2040 Other requirements. The assisted living facility failed to maintain compliance with fire and safety codes, placing all 44 residents at risk for not receiving timely assistance in case of an emergency. The facility failed its annual fire and life safety inspection on 05/16/2023 and a second follow-up inspection on 08/02/2023.

IFC 903.5 2009, 2012, 2015, 2018 - Facility was unable to provide fire sprinkler system documentation showing that annual forward flow testing has been performed per NFPA 25, 13.7.2.

NFPA 80 Fire Door Inspection and Testing - Unable to provide record showing that fire doors have been annually inspected, tested and repaired in the past 12 months.

IFC 701.6 2018 WAC 51-54A - Facility shall provide an inventory of all fire-resistance-rated construction and conduct annual inspections with records maintained.

IFC 706.1 2018 - Unable to provide test documentation showing that fire/smoke damper 1-year, post install, inspection and testing has been performed per NFPA 80, 19.5.3.

IFC 1013.1 2018 - Unable to provide documentation showing the emergency generator has received monthly load tests for the past 12 months.

IFC 607.3.3 2018 - Unable to provide reports showing that two semi-annual kitchen hood cleanings were performed in the past 12 months.

IFC 705.2 2018 - Fire door to main boiler room has been made inoperable; door handle removed and tape found on latch.

IFC 705.2.4 2018 - Ivy dining room fire door failed to close and latch when tested.

IFC 904.12.5.2 2018 - Unable to provide reports showing that two semi-annual suppression system servicings were performed in the past 12 months.

IFC 907.4.2.6 2018 - Furniture found blocking manual pull-station next to north hall exit door.

IFC 915.6 2018 - Unable to provide documentation showing that monthly inspection of the facility's carbon monoxide alarms has been performed in the past 12 months.

IFC 1013.1 2018 - Exit signs required in multiple locations including Rose activity room and exterior overhang; exit sign near north exit door must be rotated to point to exit door.

IFC 1203.4 2018 - Unable to provide documentation showing that annual servicing of the emergency backup generator has been performed in the past 12 months.

NFPA 80 Fire Door Inspection and Testing - Unable to provide record showing that fire doors have been annually inspected, tested and repaired in the past 12 months.

IFC 1013.1 2018 - Unable to provide fire drill documentation for multiple shifts and quarters from 2022 and 2023.

WAC 388-78A-2371 (1)(2) Investigations. The licensee failed to investigate circumstances surrounding a resident’s falls, including one resulting in a left clavicle fracture. This failure contributed to recurring falls and harm to the resident.

WAC 388-78A-2210 Medication services. The facility failed to receive and administer prescribed medications as ordered for one resident, placing the resident at risk by not receiving glaucoma medication Latanoprost as prescribed.

WAC 388-78A-2371 Investigations. The assisted living facility must investigate and document investigative actions and findings for any alleged or suspected abuse, neglect, or financial exploitation; or accident or incident jeopardizing or affecting a resident health or life. The facility failed to investigate and document circumstances surrounding allegations of neglect for 4 of 6 sample residents, placing them at risk of continued abuse and physical harm.

WAC 388-78A-2462 Background checks. The assisted living facility must ensure that the administrator and all caregivers employed directly or by contract have required background checks. The facility failed to obtain background checks prior to staff working with vulnerable residents for 4 of 6 sample staff, placing all residents at risk for abuse or neglect from employees with potentially disqualifying crimes.

WAC 388-78A-2630 Reporting abuse and neglect. The assisted living facility must ensure each staff person makes a report to the department's Aging and Disability Services Administration Complaint Resolution Unit hotline consistent with state law when there is reasonable cause to believe that abuse, neglect, or exploitation of a vulnerable adult has occurred. The facility failed to report an allegation of neglect for 1 of 3 sample residents, leaving the department unaware and unable to investigate potential resident neglect.

WAC 388-78A-2210 Medication services. The facility failed to develop and implement a safe medication system ensuring medications were given as prescribed for one resident, placing the resident at risk for medical and physical decline.

WAC 388-78A-2371 Investigations. The facility failed to investigate, document, and institute measures to prevent recurrence of a medication error for one resident, placing the resident at risk for physical and psychological harm.