Inspection Reports for
Madison House Assisted Living Community

IFC 603.2 (2021) - The overhead light in the activity office storeroom is missing the cover exposing electrical wiring, creating an electrical shock and fire hazard.

IFC 603.6 (2021) - An extension cord was used as permanent wiring in room 202, which is prohibited as extension cords must not substitute permanent wiring.

IFC 603.9.2 (2021) - A portable electric heater in the activity office was plugged into a power strip instead of directly into an approved receptacle.

IFC 606.3.2 (2021) - There are two 2 inch gaps in the grease filters in the kitchen, which must be properly operated when commercial cooking equipment is used.

IFC 705.2 (2021) - Multiple resident room fire doors (rooms 437, 445, 459, 351, 324, 307) were blocked open, preventing proper closing and latching as required.

IFC 705.2.4 (2021) - The fire rated cross corridor door near room 226 would not close and latch from the fully open position as required.

IFC 903.5 (2021) - The facility could not provide documentation for the annual sprinkler system inspection and forward flow test, and mixed standard and quick response sprinkler heads were found in multiple areas.

WAC 388-78A-2483 Tuberculosis One test. The assisted living facility is only required to have a staff person take one test if the staff person has any of the following: (1) A documented history of a negative result from a previous two step skin test done no more than one to three weeks apart; or (2) A documented negative result from one skin or blood test in the previous twelve months. The facility failed to ensure 1 of 2 sampled staff was tested for tuberculosis, placing residents at risk of exposure to tuberculosis.

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 assisted living facility must ensure that each staff person has the following two-step skin testing: (1) An initial skin test within three days of employment; and (2) A second test done one to three weeks after the first test. The facility failed to test 5 of 5 sampled staff for tuberculosis as required, placing residents at risk of exposure.

WAC 388-78A-2468 Background checks Employment Conditional hire Pending results of Washington state name and date of birth background check. The assisted living facility may conditionally hire an administrator, caregiver, or staff person directly or by contract, pending the result of the Washington state name and date of birth background check, provided that the assisted living facility submits the background authorization form no later than one business day after start. The facility failed to submit background checks for 3 of 26 sampled staff and 1 contracted staff within one business day after start date, placing residents at risk of abuse and neglect.

WAC 388-78A-2466 Background checks Washington state name and date of birth background check Valid for two years National fingerprint background check Valid indefinitely. The facility failed to complete a Washington State background check every two years for 9 of 26 sampled staff, placing residents at risk of abuse, neglect, or exploitation.

WAC 388-78A-2485 Tuberculosis Positive test result. When there is a positive result to tuberculosis skin or blood testing the assisted living facility must ensure chest X-ray within seven days, evaluate for signs and symptoms, and follow healthcare provider recommendations. The facility failed to ensure 1 of 1 sampled staff with a positive TB test was evaluated and followed up appropriately, placing residents at risk of exposure.

WAC 388-78A-2450 Staff. The assisted living facility must maintain documentation on premises during employment and two years after termination including orientation and training pertinent to duties. The facility failed to maintain continuing education training records for 2 of 2 sampled staff, placing residents at risk for decreased quality of care.

WAC 388-78A-2100 Ongoing assessments. The assisted living facility must complete assessments focused on resident's identified problems consistent with change of condition. The facility failed to assess 3 of 3 sampled residents for their ability to use medical devices such as bedrails and transfer poles, placing residents at risk of entrapment and injury.

WAC 388-78A-2290 Family assistance with medications and treatments. The assisted living facility must have a written plan for family medication assistance including responsible persons and backup plans. The facility failed to complete written family medication assistance plans for 4 of 4 sampled residents and failed to keep one resident's significant medications on-site, placing residents at risk for not receiving medications as prescribed.

WAC 388-78A-2210 Medication services. The assisted living facility must ensure residents receive medications as prescribed and develop systems to support safe medication service. The facility failed to ensure 1 of 1 sampled resident received medications as prescribed in a safe manner, including improper measurement of topical medication by unlicensed staff, placing the resident at risk for compromised health.

WAC 388-78A-2320 Intermittent nursing services systems. The assisted living facility must develop systems to support safe nursing practice and ensure compliance with applicable laws. The facility failed to obtain written consent for nurse delegation and failed to assess and implement nurse delegation services for 1 of 1 sampled resident, placing the resident at risk for medication errors and health decline.

WAC 388-78A-2483(1)(2) Tuberculosis—One test. The licensee failed to ensure one staff member was tested for tuberculosis, placing residents at risk of exposure. This deficiency was uncorrected from a prior citation.

WAC 388-78A-2484(1)(2) Tuberculosis—Two step skin testing. The licensee failed to test one staff member for tuberculosis as required, placing residents at risk of exposure. This deficiency was uncorrected from a prior citation.

Unapproved portable heaters found in 4th floor Sun Room and hallway

Open junction boxes and open-wiring splices without approved covers in multiple locations including Library 3rd floor storage closet and Elevator room

Facility unable to provide record of annual fire wall inspection and repairs for all fire-resistant-rated construction

Fire doors on 4th floor stairwell and cable room did not close or latch properly

Dirty sprinkler head in 1st floor Resident Laundry room

Missing escutcheon rings in multiple locations including hall by room 436, 3rd floor Library, stairwell between floors 2 and 1, 1st floor hallway by Elevator room/Fitness, and Pool room

Facility unable to provide documentation showing carbon monoxide detector testing performed in past 12 months

Trash chute on 4th floor does not latch properly