Inspection Reports for
Jefferson House Memory Care Community

WAC 388-78A-2100 Ongoing assessments. The facility failed to complete full and focused assessments for residents with pressure injuries and did not update care plans accordingly. This failure placed residents at risk of harm.

WAC 388-78A-2100 Ongoing assessments. The facility failed to assess and ensure the safe use of medical devices including a Hoyer lift and a tilt-in-space wheelchair with an inflatable pressure relief cushion, resulting in risk to residents.

WAC 388-78A-2130 (3)(a)(b) Service agreement planning. The licensee failed to ensure two residents’ service agreements were updated to meet current and changing needs and to include care staff instructions and interventions.

WAC 388-78A-2130 Service agreement planning. The assisted living facility failed to ensure 2 of 11 residents' service agreements were updated to meet current and changing needs and to include care staff instructions and interventions, placing residents at risk for unmet needs and decreased quality of life.

IFC 603.4 (2021) - Less than three foot working space around electrical panel in Electrical Room third floor.

IFC 0603.5.1 (2021) - Power adapter needs over current protection in Activity Director office.

IFC 606.3.3 (2021) - Facility failed to provide documentation for semi-annual hood cleaning.

IFC 606.3.3.2 (2021) - Kitchen stove grease trap full with accumulation.

IFC 606.4 (2021) - Kitchen oven appliance not tethered to the wall.

IFC 705.2 (2021) - Fire rated door from the staff lounge to the corridor was propped open with a door wedge.

IFC 705.2.4 (2021) - Fire rated cross corridor door did not close or latch from the fully open position near room 308.

IFC 903.5 (2021) - The walk-in type cooler and freezer with automatic defrost has ordinary temperature heads installed.

IFC 904.13.5.2 (2021) - Facility failed to provide documentation for kitchen suppression semi-annual servicing.

IFC 1010.2.13.1 (2021) - Missing delayed exit sign on emergency delayed egress door next to post office and emergency delayed egress door near room 307 did not have the required instructions for delayed egress.

IFC 1010.2.4 (2021) WAC 51-54A - Door code not posted within six feet in main entry.

IFC 0405.6 (2021) - Records of required emergency evacuation drills were not adequately maintained; only education on records was noted.

IFC 606.3.3.1 (2021) - Hoods, grease-removal devices, fans, ducts, and other appurtenances must be inspected at specified intervals; inspection was corrected on site.

IFC 701.6 (2021) - The facility failed to provide records of annual fire wall inspection and repairs for all fire-resistant-rated construction.

IFC 706.1 (2018) - Documentation for last fire/smoke damper testing was not provided; number and location of dampers were not indicated.

IFC 903.5 (2021) - Documentation was missing for annual sprinkler servicing and quarterly sprinkler servicing.

IFC 904.13.5.2 (2021) - Service reports for kitchen suppression system semi-annual servicing were not provided.

IFC 1032.10.1 (2021) - Emergency lighting equipment testing was corrected on site.

IFC 1031.10.2 (2021) - Documentation showing 90-minute annual testing of emergency lighting was not provided.

IFC 1203.4 (2021) - Documentation for annual servicing of emergency generator and required weekly visual inspections and monthly load tests were not provided.

IFC 5303.5.3 (2018) - Compressed gas containers were required to be secured; an unsecured oxygen cylinder was observed in the Med room on the 3rd floor.

NFPA Standard 10 Section 6.2.1 - Documentation for monthly inspection of fire extinguishers was not provided; some extinguishers were inspected monthly.

NFPA Standard 10 Section 6.2.1 - Documentation for monthly inspection of fire extinguishers was not provided.

IFC 5303.5.3 (2018) - Compressed gas containers must be secured to prevent falling; an unsecured oxygen cylinder was observed in the Med room on the 3rd floor.

NFPA Standard 10 Section 6.2.1 - Documentation showing fire extinguishers were inspected monthly was not provided.

NFPA 80 Fire Door Inspection and Testing - Inventory record of annual inspection and repairs for fire-resistant-rated doors was not provided; multiple doors did not close or latch properly.

WAC 212-12-044 Fire Drills - Documentation for completion of twelve planned and unannounced fire drills in the previous 12 months was not provided.

WAC 388-78A-2350 Coordination of health care services. The facility failed to notify the physician and resident's representative of a significant change in condition involving weight loss for one resident, placing the resident at risk of medical decline and diminished quality of life.

WAC 388-78A-2040 Other requirements. The facility failed to ensure 36 of 36 residents resided in a safe environment approved by the State Fire Marshal, placing residents at risk of harm and fire hazards due to unsafe environmental conditions. Multiple fire safety violations were documented in a report dated 08/20/2024.

WAC 388-78A-2420 Record retention. The facility failed to retain medication administration records for 16 residents, placing them at risk for health complications due to unknown medication management history.

WAC 388-78A-3000 Ventilation. The facility failed to ensure ventilation in 9 rooms, including resident apartments and utility closets, placing residents at risk for diminished quality of life and respiratory illness.

WAC 388-78A-2150 Signing negotiated service agreement. The facility failed to ensure 2 of 3 residents or their representatives signed the current service plan, risking uninformed care and unmet needs.

WAC 388-78A-2474 Training and home care aide certification requirements. Three of six staff failed to complete required training including orientation, safety, basic training, CPR, and continuing education, risking unmet resident care needs.

WAC 388-78A-2484 Tuberculosis Two step skin testing. Two of six staff were not screened for tuberculosis within three days of hire as required, placing residents at risk of exposure to tuberculosis.

WAC 388-78A-2140 Negotiated service agreement contents. The facility failed to document in 3 of 7 sampled residents' records the agreed upon plan addressing care needs and interventions, risking unmet care and worsening conditions.

WAC 388-78A-2610 Infection control. The facility failed to implement infection control policies and procedures to protect 39 residents from potential spread of infectious diseases, placing all residents at risk.

WAC 388-78A-2481 Tuberculosis Testing method Required. The assisted living facility must ensure that all tuberculosis testing is done through either intradermal (Mantoux) administration with test results read within forty-eight to seventy-two hours of the test. The facility failed to read the Tuberculosis test results for 2 of 2 sampled staff within 48 to 72 hours after administration, placing residents at risk.

WAC 388-78A-2570 Notification of change in administrator. The licensee must notify the department in writing within ten calendar days of the effective date of a change in the assisted living facility administrator. The facility failed to notify the Department within 10 days of hire for 2 of 2 sampled staff, placing residents at risk of receiving care from unqualified staff.

WAC 388-78A-2484 Tuberculosis Two step skin testing. Unless the staff person meets the requirement for having no skin testing or only one test, the facility must ensure each staff person has the following two-step skin testing: an initial skin test within three days of employment. The facility failed to do an initial TB skin test within three days of hire for 3 of 5 sampled staff, placing residents at risk.

WAC 388-78A-2481 Tuberculosis Testing method Required. The facility must ensure test results are read within 48 to 72 hours after administration. The facility failed to read the TB skin test results within 48 to 72 hours for 1 of 5 sampled staff, placing residents at risk.

WAC 388-78A-2485 Tuberculosis Positive test result. When there is a positive result to tuberculosis skin or blood testing, the facility must ensure the staff person has a chest X-ray within seven days and that each resident or staff with a positive test is evaluated for signs and symptoms of tuberculosis. The facility failed to determine if 1 of 4 sampled staff with a positive TB test was evaluated for signs and symptoms, placing residents at risk.

WAC 388-78A-2481 (1)(a) Tuberculosis Testing method Required. The licensee failed to read the Tuberculosis test results for two staff within 48 to 72 hours after administration, risking resident exposure to Tuberculosis.