7 Reports
Inspection Report — Mar 26, 2026
Follow-Up
Date: Mar 26, 2026
Visit Reason
The Department of Social and Health Services conducted a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies and confirmed that all previously cited licensing law violations were corrected. The facility meets the Assisted Living Facility licensing requirements.
Report Facts
Sampled residents: 9
Total current residents: 64
Staff training compliance: 3
Staff background check compliance: 2
Staff fingerprint background check compliance: 4
Staff tuberculosis testing compliance: 3
Inspection Report — Mar 17, 2026
Life Safety
Date: Mar 17, 2026
Visit Reason
The Office of the State Fire Marshal conducted a fire protection inspection at the residential care facility to assess compliance with fire safety codes and regulations.
Findings
The inspection identified multiple fire safety deficiencies, some corrected on site and others remaining uncorrected. The facility was disapproved due to unresolved issues including lack of documentation for fire/smoke damper inspections, sprinkler system testing, fire alarm panel troubles, and incomplete fire drill records.
Deficiencies (19)
IFC 315.3.2 (2021) - Combustible materials shall not be stored in exits or enclosures for stairways and ramps. Combustible materials in the means of egress during construction, demolition, remodeling or alterations must comply with Section 3311.3.
IFC 603.5.1.1 (2021) - Relocatable power taps shall be listed and labeled in accordance with UL 1363 and UL 498A.
IFC 603.6 (2021) - Extension cords shall not be a substitute for permanent wiring and must be listed and labeled per UL 817. Extension cords marked for indoor use shall not be used outdoors.
IFC 606.4 (2021) - Gas-fired commercial cooking appliances on casters must be connected to piping systems with compliant appliance connectors and movement limited by restraining devices.
IFC 610.1.2 (2021) - Clothes dryer exhaust systems must be maintained to prevent lint accumulation that blocks exhaust of air and combustion products.
IFC 703.1 (2021) - Fire and smoke penetration openings must be maintained to resist passage of smoke and fire, securely attached or bonded with no visible openings.
IFC 705.2 (2021) - Opening protectives in fire-resistance assemblies and smoke barriers must be inspected and maintained per NFPA 80 and NFPA 105. Fusible links must be replaced promptly when damaged.
IFC 705.2.4 (2021) - Swinging fire doors shall close from the full-open position and latch automatically. Several fire doors failed to latch during testing.
IFC 706.1 (2018) - Dampers protecting ducts and air transfer openings must be inspected and maintained per NFPA 80 and NFPA 105. Facility lacks documentation of four-year fire/smoke damper inspection.
IFC 903.5 (2021) - Sprinkler systems must be tested and maintained per Section 901. Facility unable to provide documentation for fire department connection hydro test and internal pipe inspection.
IFC 907.8.1 (2021) - Fire alarm testing and maintenance schedules must be maintained with records. Fire alarm panels showed trouble status in Elm and Fir Buildings.
IFC 907.8.3 (2021) - Smoke detector sensitivity must be checked within one year and every alternate year thereafter. No documentation was provided for sensitivity testing.
IFC 915.1.4 (2021) - Carbon monoxide detection must be provided in dwelling units, sleeping units, and classrooms with fuel-burning appliances. Detection was provided as required.
IFC 915.6 (2021) WAC - Carbon monoxide alarms and detectors must be maintained and replaced if inoperable or signaling end-of-life. Maintenance was confirmed.
IFC 1023.5 (2018) - Penetrations in exit stairways and ramps must be protected per Section 714 of the International Building Code. Penetrations were properly protected.
IFC 1032.10.1 (2021) - Emergency lighting equipment must be tested monthly for at least 30 seconds. Testing was performed and equipment corrected.
IFC 1032.2 (2021) - Required exit accesses and discharges must be free from obstructions. Stairwell in Fir Building was obstructed by multiple objects and inaccessible.
IFC 5303.5.3 (2021) - Compressed gas containers must be secured to prevent falling by approved methods. Containers were properly secured.
WAC 212-12-044 - Fire drills must be held quarterly or monthly depending on occupancy group. Facility was unable to provide documentation confirming completion of required fire drills for multiple quarters and shifts.
Report Facts
Deficiencies cited: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maxi Harrell | Executive Director | Named in signature block as Owner or Authorized Representative |
Inspection Report — Jul 18, 2025
Follow-Up
Date: Jul 18, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to resident assessments and ongoing care.
Complaint Details
The complaint investigation was triggered by a fall with injury involving a resident using a knee scooter. The facility failed to update the resident's assessment after the injury, resulting in a citation for noncompliance with WAC 388-78A-2100 and WAC 388-78A-2090. The allegation was substantiated with a citation issued.
Findings
The follow-up inspection on 07/18/2025 found no deficiencies; all previously cited violations related to full and ongoing resident assessments were corrected.
Deficiencies (2)
WAC 388-78A-2090 Full assessment topics. The assisted living facility must obtain sufficient information to assess each resident's capabilities, needs, and preferences, completing a full assessment within fourteen days of move-in unless extended for good cause.
WAC 388-78A-2100 Ongoing assessments. The assisted living facility must complete a full assessment annually and a focused assessment when a resident has an injury requiring practitioner intervention.
Report Facts
Total residents: 47
Resident sample size: 3
Inspection Report — Jul 7, 2025
Complaint Investigation
Date: Jul 7, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on allegations including unclean conditions, untimely staff response to call lights, poor food quality, inadequate bathing, extra laundry charges, and unsafe conditions for a named resident.
Complaint Details
The complaint investigation involved allegations of uncleanliness, poor staff response, food quality issues, bathing concerns, extra laundry charges, and unsafe conditions for a named resident. Only the deficiency regarding the diet manual was substantiated and cited; all other allegations were not substantiated.
Findings
The investigation found one deficiency related to the facility's diet manual not being approved, dated, or signed by a registered dietitian as required. All other allegations were not substantiated and no failed practices were identified. A citation was issued for non-compliance with WAC 388-78A-2300 (2) (a) (i,ii,iii).
Deficiencies (1)
WAC 388-78A-2300 Food and nutrition services. The assisted living facility failed to ensure the diet manual was approved by a dietitian and reviewed and updated at least every five years, placing residents at risk for health complications.
Report Facts
Total residents: 51
Resident sample size: 4
Laundry charge: 100
Inspection Report — Apr 23, 2025
Complaint Investigation
Date: Apr 23, 2025
Visit Reason
The Department completed a complaint investigation of the Assisted Living Facility based on multiple complaint numbers alleging failure to respond to resident call buttons and lack of supervision of a named resident.
Complaint Details
The complaint investigation included multiple complaint numbers alleging failure to respond to call buttons and lack of supervision of a named resident. The investigation confirmed failed practices related to call pendant response and documentation. Staffing improvements were noted in the Memory Care Unit with no failed practices identified there.
Findings
The investigation found failed practices including staff not responding to call pendants promptly and inconsistent documentation of care tasks. Staffing was increased in the Memory Care Unit and no failed practices were identified there. Citations were written for the identified deficiencies.
Deficiencies (2)
WAC 388-78A-2930 Communication system. The Assisted Living Facility failed to ensure that pendants were responded to within a reasonable time and that care staff had pagers in their possession while working.
WAC 388-78A-2410 Content of resident records. The facility did not consistently document showers and care observations in the ADL task, but corrected documentation after in-service training.
Report Facts
Total residents: 46
Resident sample size: 8
Closed records sample size: 1
Inspection Report — Mar 7, 2025
Complaint Investigation
Date: Mar 7, 2025
Visit Reason
The inspection was a complaint investigation triggered by multiple allegations including medication errors, staffing issues, resident care concerns, and safety issues at the Assisted Living Facility.
Complaint Details
The complaint investigation included multiple allegations such as residents not receiving medications, unexpected death, understaffing, improper handling of DNR orders, and inadequate food service. The investigation substantiated medication errors and nurse delegation failures, resulting in citations. Other allegations such as infection care and resident supervision had no failed practices identified.
Findings
The investigation found multiple deficiencies including failure to ensure residents received medications as prescribed, unlicensed staff administering medications without nurse delegation, and unsafe staffing ratios. Several citations were issued for noncompliance with medication services and intermittent nursing services regulations. The facility increased staffing and implemented corrective actions but failed practices were identified.
Deficiencies (2)
WAC 388-78A-2210 Medication services. The facility failed to implement a safe medication system and ensure three residents received their medications as prescribed, resulting in missed doses and late administration.
WAC 388-78A-2320 Intermittent nursing services systems. The facility failed to ensure nurse delegation for two staff before allowing them to check blood sugar and administer insulin, placing residents at risk.
Report Facts
Total residents: 46
Resident sample size: 8
Closed records sample size: 1
Licensed beds: 84
Late insulin administrations: 100
Inspection Report — Dec 19, 2024
Complaint Investigation
Date: Dec 19, 2024
Visit Reason
The inspection was conducted as an unannounced on-site complaint investigation regarding allegations that the Assisted Living Facility failed to provide housekeeping and laundry services, lost a medication, did not assist with coordination of care, lacked a nurse on duty 40 hours a week, and failed to notify family/POA when a resident fell.
Complaint Details
The complaint investigation involved five allegations: failure to provide housekeeping and laundry services, lost medication, failure to assist with coordination of care, lack of nurse on duty 40 hours weekly, and failure to notify family/POA after a fall. Only the failure to assist with coordination of care was substantiated and cited. Other allegations were found unsubstantiated with no failed practice identified.
Findings
The investigation found one failed practice: the facility did not assist a resident with coordination of care for a telehealth appointment, resulting in a citation under WAC 388-78A-2350 (1). All other allegations were not substantiated. The facility was cited for the coordination of care deficiency.
Deficiencies (1)
WAC 388-78A-2350 Coordination of health care services. The assisted living facility failed to coordinate services with external health care providers for one resident needing assistance with a telehealth appointment, placing the resident at risk of not receiving medical care.
Report Facts
Total residents: 47
Resident sample size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Chenot-Potter | Nursing Consultant Institutional | Named as the investigator who conducted the complaint investigation |
Viewing
Loading inspection reports...



