Inspection Reports for
Mirror Lake Village Senior Living Community

IFC 907.8 (2021) - The maintenance and testing schedules and procedures for fire alarm and fire detection systems were not documented as required. Documentation of prior deficiencies was missing.

IFC 405.5 (2021) - Facility failed to provide documentation for completion of twelve planned and unannounced fire drills in the previous 12 months. Several quarterly drills were missing.

IFC 606.3.3 (2021) - Facility needs to increase cleaning service of hoods, grease-removal devices, fans, and ducts to quarterly intervals.

IFC 701.6 (2021) - Facility must maintain detailed documentation and maps of fire-rated construction locations, including annual inspection reports detailing testing dates, modifications, and repairs.

IFC 703.1 (2021) - Building A, floor 2 electrical room has penetration in the floor compromising fire resistance.

IFC 705.2 (2021) - Facility must maintain detailed documentation and maps of fire door locations including inspection reports. Multiple fire doors are held open improperly or have been removed without showing they are not needed for fire/smoke protection.

IFC 903.5 (2021) - Documentation missing for annual forward flow test, quarterly inspection reports, and painted sprinkler heads noted in prior report. Building A floor 1 hair salon storage room is missing a sprinkler.

IFC 904.13.5.2 (2021) - Second semi-annual service report for automatic fire-extinguishing systems was not provided.

IFC 906.2 (2021) - Building B, 1st floor fire extinguisher by room 112 is missing annual inspection tag.

IFC 907.8 (2021) - Building B, 3rd floor fire alarm amplifier annual testing is past due and documentation is missing.

IFC 915.1 (2021) WAC 51-54A - Facility must maintain detailed documentation and maps of carbon monoxide detector locations including monthly inspection reports. Building A, floor 1 laundry room is missing a carbon monoxide detector.

IFC 1010.2.5 (2021) - Building B, 1st floor in the path of egress doors by resident door 115 has a dead bolt, which is not permitted.

IFC 1203.4 (2021) - Facility failed to provide annual service report, log of weekly inspections, and monthly 30-minute full load test documentation for emergency and standby power systems.

IFC 5303.7 (2021) - Kitchen has a loose tank near soda machine posing hazardous condition.

WAC 388-78A-2130 (3)(a)(b)(4) Service agreement planning. The licensee failed to document in two residents' service agreements a plan to monitor and address interventions to meet current needs. This failure placed residents at risk for unmet care needs and potential harm.

WAC 388-78A-2290 (3)(a)(c)(d)(e)(4)(a)(b)(c)(d) Family assistance with medications and treatments. The licensee failed to ensure two residents had a written plan for family assistance with medication management. This failure placed residents at risk for unmet care needs.

WAC 388-78A-2140 Negotiated service agreement contents. The facility failed to document care needs and interventions for diagnoses and physician ordered medical treatments in 5 of 15 residents' Negotiated Service Agreements, placing them at risk for unmet care needs and worsening conditions.

WAC 388-78A-2170 Required assisted living facility services. The facility failed to ensure side bed rails for 2 of 4 residents were free from safety risks, placing residents at risk of harm or death from unsafe medical equipment.

WAC 388-78A-2140 Negotiated service agreement contents. The facility failed to document care needs and interventions for diagnoses and physician ordered medical treatments in 5 of 10 residents' Negotiated Service Agreements, placing them at risk for unmet care needs and worsening conditions.

WAC 388-78A-2170 Required assisted living facility services. The facility failed to ensure side bed rails for 3 of 3 residents were free of entrapment hazards, placing residents at risk of harm or death from unsafe medical equipment.

WAC 388-78A-2690 Electronic monitoring equipment Resident requested use. The facility failed to document in writing an initial agreement, duration of use, and quarterly reevaluations for electronic monitoring for 1 of 3 sampled residents, placing the resident at risk for potential violation of rights.

WAC 388-78A-2140 Negotiated service agreement contents. The facility failed to document care needs and interventions for diagnoses and physician ordered medical treatments in 5 of 10 residents' Negotiated Service Agreements, placing them at risk for unmet care needs and worsening conditions.

WAC 388-78A-2170 Required assisted living facility services. The facility failed to ensure side bed rails for 3 of 3 residents were free of entrapment hazards, placing residents at risk of harm or death from unsafe medical equipment.

WAC 388-78A-2690 Electronic monitoring equipment Resident requested use. The facility failed to document in writing an initial agreement, duration of use, and quarterly reevaluations for electronic monitoring for 1 of 2 sampled residents, placing the resident at risk for potential violation of rights.

WAC 388-78A-2140 Negotiated service agreement contents. The facility failed to document care needs and interventions for diagnoses and physician ordered medical treatments in 5 of 10 residents' Negotiated Service Agreements, placing them at risk for unmet care needs and worsening conditions.

WAC 388-78A-2150 Signing negotiated service agreement. The facility failed to ensure 6 of 10 sampled residents or their representatives signed their Main Assessment Results and Service Plan, placing them at risk of being uninformed about their assessed care and services and having unmet care needs.

WAC 388-78A-2170 Required assisted living facility services. The facility failed to ensure 3 of 3 residents' medical devices were safe and free of entrapment hazards, placing residents at risk of potential harm or death from unsafe medical equipment.

WAC 388-78A-2320 Intermittent nursing services systems. The facility failed to ensure 2 of 3 residents received medication assistance from caregivers with proper nurse delegation training, placing them at risk of medication errors and diminished quality of life.

WAC 388-78A-2690 Electronic monitoring equipment Resident requested use. The facility failed to document in writing an initial agreement, duration of use, and quarterly reevaluations for electronic monitoring for 2 of 2 sampled residents, placing them at risk for potential violation of rights.

WAC 388-78A-2480 Tuberculosis Testing Required. The facility failed to ensure 3 of 6 staff were screened for tuberculosis within three days of employment, placing all residents at risk of exposure to TB.

WAC 388-78A-2474 Training and home care aide certification requirements. The facility failed to ensure 2 of 6 staff completed all required continuing education training, placing all residents at risk of unmet care needs from staff with incomplete training.

WAC 388-78A-2610 Infection control. The facility failed to implement infection control policies and requirements to protect all 58 residents from infectious illnesses, placing them at risk of contracting and spreading potentially life-threatening infections. The facility lacked a respiratory protection program and did not provide required N95 fit testing.

WAC 388-78A-2140 Negotiated service agreement contents. The licensee failed to document care needs and interventions in five residents’ Negotiated Service Agreements, placing residents at risk for unmet care needs and worsening conditions.

WAC 388-78A-2170 (1) Required assisted living facility services. The licensee failed to ensure two residents’ side bed rails were free from safety risks, placing residents at risk of harm or death from unsafe medical equipment.

WAC 388-78A-2140(1)(a)(i)(ii)(iii)(b)(c)(e) Negotiated service agreement contents. The licensee failed to document in five residents' Negotiated Service Agreements the care needs and interventions for diagnoses and physician ordered medical treatments. This failure placed residents at risk for unmet care needs and worsening conditions.

WAC 388-78A-2170(1) Required assisted living facility services. The licensee failed to ensure three residents' side bed rails were free of entrapment hazards, placing residents at risk of harm or death from unsafe medical equipment.

WAC 388-78A-2690(6)(a)(b)(c)(7)(a)(b)(12) Electronic monitoring equipment—Resident requested use. The licensee failed to document in writing an initial agreement, duration of use, and quarterly reevaluations of electronic surveillance for one resident, risking violation of resident rights.

WAC 388-78A-2140(1)(a)(i)(ii)(iii)(b)(c)(e) Negotiated service agreement contents. The licensee failed to document in five residents Negotiated Service Agreements the care needs and interventions for diagnoses and physician ordered medical treatments.

WAC 388-78A-2170(1) Required assisted living facility services. The licensee failed to ensure three residents’ medical devices were safe and free from entrapment hazards.

WAC 388-78A-2690(6)(a)(b)(c)(7)(a)(b)(12) Electronic monitoring equipment—Resident requested use. The licensee failed to document in writing an initial agreement to use electronic monitoring, the duration of use, and quarterly reevaluations for one resident.

WAC 388-78A-2474(2)(e) Training and home care aide certification requirements. The licensee failed to ensure one staff completed all required training to perform their job duties and responsibilities.

The electrical room in the kitchen has multiple penetrations in the fire wall.

Building A and B have open conduits on 2nd floor that need capped and/or filled.

Unprotected joints and voids in fire-resistance-rated walls, floors, smoke barriers, and exterior curtain walls.