Inspection Reports for
Sherwood Assisted Living

WAC 388-78A-2703 Safety of the built environment. The assisted living facility failed to ensure staff positioned the resident’s bed to a safe height for 1 of 3 sampled residents, resulting in a fall and subdural hematoma. This placed the resident at risk for avoidable injuries and harm.

IFC 405.2 2021 - Required emergency drills shall be held at specified intervals to familiarize all occupants with the drill procedure.

IFC 603.2 2021 - Abatement of unsafe electrical conditions that constitute shock or fire hazards shall be completed.

IFC 606.3.3 2021 - Hoods, grease-removal devices, fans, ducts and other appurtenances shall be cleaned at required intervals.

IFC 701.6 2021 - Owner shall maintain an inventory of required fire-resistance-rated construction and inspect and repair annually.

IFC 706.1 2018 - Dampers protecting ducts and air transfer openings shall be inspected, maintained, and repaired or replaced as needed.

IFC 903.5 2021 - Sprinkler systems shall be tested and maintained in accordance with Section 901.

IFC 904.13.5.2 2021 - Automatic fire-extinguishing systems shall be serviced at least every six months and after activation.

IFC 906.2 2021 - Portable fire extinguishers shall be selected, installed, and maintained per NFPA 10 requirements.

IFC 907.8 2021 - Maintenance and testing schedules for fire alarm and detection systems shall be maintained with records.

IFC 1031.10.2 2021 - Battery-powered emergency lighting equipment shall be tested annually for not less than 90 minutes.

NFPA 80 - Fire door assemblies shall be inspected and tested annually with records maintained, including verification of labels and operation.

WAC 388-78A-2660 Resident Rights - The facility was cited for a violation related to resident rights which was upheld after the Informal Dispute Resolution process.

WAC 388-78A-2660 (1) Resident rights. The licensee failed to ensure residents were able to receive visitors of their choice for three residents reviewed for visitation. This failure placed residents at risk for psychosocial harm.

WAC 388-78A-2660 Resident rights. The assisted living facility must comply with chapter 70.129 RCW, Long-term care resident rights. The facility failed to ensure residents were able to receive visitors of their choosing for 3 of 3 residents reviewed, resulting in denied visitation and psychosocial harm.

WAC 388-78A-2660 Resident rights. The assisted living facility failed to allow a resident to participate in planning care, direct their own service plan, and refused service by moving the resident into the locked memory care unit against their wishes. This caused distress and risk of decreased quality of life for the resident.

IFC 405.2 (2021) - Required emergency drills shall be held at specified intervals to familiarize occupants with the drill procedure.

IFC 603.2 (2021) - Abatement of unsafe electrical conditions and hazards including electrical shock or fire hazards shall be performed.

IFC 606.3.3.1 (2021) - Kitchen hood vent grease filters have heavy grease accumulation requiring cleaning.

IFC 701.6 (2021) - The owner shall maintain an inventory of required fire-resistance-rated construction and inspect it annually.

IFC 706.1 (2018) - Dampers protecting ducts and air transfer openings shall be inspected and maintained; facility failed to provide the required 4-year fire/smoke damper inspection report.

IFC 903.5 (2021) - Sprinkler systems shall be tested and maintained; facility failed to provide documentation including annual forward flow test and fire department hydrostatic test.

IFC 904.13.5.2 (2021) - Automatic fire-extinguishing systems shall be serviced at least every six months and inspection certificates forwarded to the fire code official.

IFC 906.2 (2021) - Portable fire extinguishers shall be selected, installed, and maintained according to NFPA 10.

IFC 907.8 (2021) - Maintenance and testing schedules for fire alarm and detection systems shall be followed and records maintained.

IFC 915.6 (2021) WAC - Carbon monoxide alarms and detection systems shall be maintained and replaced when inoperable.

IFC 1031.10.2 (2021) - Battery-powered emergency lighting equipment shall be tested annually for not less than 90 minutes.

NFPA 80 5.2.1 - Fire doors, shutters, and window assemblies shall be inspected and tested upon installation and periodically thereafter; all listed inspection criteria must be met.

WAC 388-78A-2240 Nonavailability of medications. The licensee failed to obtain medications in a timely manner for one resident, resulting in the resident not receiving medications as prescribed and placing the resident at risk for decreased quality of life.

WAC 388-78A-2130 Service agreement planning. The assisted living facility must develop an initial resident service plan based on discussions with the resident and their representative, integrating assessment information and identifying immediate needs and preferences.

WAC 388-78A-2160 Implementation of negotiated service agreement. The assisted living facility must provide the care and services as agreed upon in the negotiated service agreement to each resident unless a deviation from the negotiated service agreement is mutually agreed upon between the assisted living facility and the resident or the resident's representative at the time the care or services are scheduled. The facility failed to implement the negotiated service agreement when assisting a resident to transfer, placing residents at risk for avoidable injuries.

WAC 388-78A-2160 Implementation of negotiated service agreement. The assisted living facility must provide the care and services as agreed upon in the negotiated service agreement to each resident unless a deviation from the negotiated service agreement is mutually agreed upon between the assisted living facility and the resident or the resident's representative at the time the care or services are scheduled. The facility failed to ensure staff provided care and services in accordance with residents' negotiated service agreements for two residents, placing them at risk for decreased quality of life and dignity not maintained.

WAC 388-78A-2160 Implementation of negotiated service agreement. The assisted living facility must provide the care and services as agreed upon in the negotiated service agreement to each resident unless a deviation from the negotiated service agreement is mutually agreed upon between the assisted living facility and the resident or the resident's representative at the time the care or services are scheduled. The facility failed to implement and provide care as documented on the service plan for one resident, contributing to a fall and injury, placing all residents at risk for harm and unmet care needs.

WAC 388-78A-2160 Implementation of negotiated service agreement. The licensee failed to implement the negotiated service agreement when assisting a resident to transfer, placing residents at risk for avoidable injuries.

WAC 388-78A-2240 Nonavailability of medications. The licensee failed to obtain medications in a timely manner for one resident, resulting in the resident not receiving medications as prescribed and placing them at risk for decreased quality of life.

WAC 388-78A-3100 (1)(2)(3)(4) Safe storage of supplies and equipment. The licensee failed to secure potentially hazardous supplies accessible to memory care residents in four locations within the locked Memory Care Unit, placing 19 residents at risk for ingesting toxic materials.

WAC 388-78A-2610 Infection control. The facility failed to implement proper infection control practices during a norovirus outbreak, including lack of necessary supplies, improper hand hygiene, and failure to timely report and cooperate with the Local Health Jurisdiction. These failures placed all 63 residents at risk for spread of infectious disease.

WAC 388-78A-2160 Implementation of negotiated service agreement. The licensee failed to ensure staff members provided care and services in accordance with the residents’ negotiated service agreements for two residents. This failure placed the residents at risk for decreased quality of life and their dignity not maintained.

WAC 388-78A-2140 (1)(a)(i)(ii)(b)(c)d)(2)(a)(b)(4) Negotiated service agreement contents. The licensee failed to document in the resident's service plan the plan to provide necessary care and services for three residents.

WAC 388-78A-2260 (1)(2)(d) Storing, securing, and accounting for medications. The licensee failed to ensure all medications were stored and locked securely in one resident room, placing 18 memory care residents at risk.

WAC 388-78A-2240 Nonavailability of medications. The licensee failed to obtain and administer medications timely for one resident, risking decreased quality of life.

WAC 388-78A-2210 (1)(b)(2)(a) Medication services. The licensee failed to ensure one resident received medications as prescribed, risking health complications.

WAC 388-78A-2484 (1)(2) Tuberculosis—Two step skin testing. The licensee failed to ensure one staff received required TB testing within time frames, placing 66 residents and staff at risk.

WAC 388-78A-2665 (3)(5) Resident rights—Notice—Policy on accepting medicaid as a payment source. The licensee failed to provide Medicaid Policy to two residents, risking uninformed decisions.

WAC 388-78A-3100 (1)(2)(3)(4) Safe storage of supplies and equipment. The licensee failed to secure hazardous supplies accessible to memory care residents, placing 18 residents at risk.

WAC 388-78A-2305 (1) Food sanitation. The licensee failed to follow safe food handling and storing practices in four areas, placing 66 residents at risk.

WAC 388-78A-2930 (1)(a)(i)(ii)(b)(i)(c) Communication system. The licensee failed to ensure one area had means to summon on duty staff, placing 18 memory care residents, visitors, and staff at risk.

WAC 388-78A-2474 (2)(e) Training and home care aide certification requirements. The licensee failed to ensure one staff completed required continuing education, placing 66 residents at risk.

WAC 388-78A-2710 (1)(3)(b) Disclosure of services. The licensee failed to provide updated Disclosure of Services after decreasing scope of care for two residents, impacting 66 residents and visitors.

WAC 388-78A-2371 (1)(2)(3)(4) Investigations. The licensee failed to investigate and document actions after a resident developed a new skin impairment, placing the resident at risk for complications.

WAC 388-78A-2120 Monitoring residents' well-being. The assisted living facility must evaluate changes in residents and take appropriate action in response to each resident's changing needs. The facility failed to implement safety interventions for one resident, placing them at risk of harm from falls and decreased quality of life.

WAC 388-78A-2600 Policies and procedures. The assisted living facility must develop and implement policies and procedures in support of services that are provided and are necessary to maintain or enhance the quality of life for residents including resident decision-making rights and provide necessary care and services for residents including those with special needs. The facility failed to implement their Alert Charting Policy for one resident after a change in condition, placing the resident at risk. This deficiency was corrected.

WAC 388-78A-2140 Negotiated service agreement contents. The facility failed to document in residents' service plans the care and services necessary to support residents, placing them at risk for unmet care needs and untrained staff.

WAC 388-78A-2260 Storing, securing, and accounting for medications. The facility failed to ensure medications were stored securely in locked compartments accessible only to designated staff, risking resident access to harmful substances.

WAC 388-78A-2240 Nonavailability of medications. The facility failed to obtain and administer medications timely for a resident, placing them at risk for decreased quality of life.

WAC 388-78A-2210 Medication services. The facility failed to ensure a resident received medications as prescribed, risking health complications due to failure to follow physician orders and monitor patient status.

WAC 388-78A-2484 Tuberculosis Two step skin testing. The facility failed to ensure a staff member received required two-step TB skin testing within required timeframes, risking exposure to tuberculosis.

WAC 388-78A-2665 Resident rights Notice Policy on accepting medicaid as a payment source. The facility failed to provide Medicaid payment policy to 2 sampled residents or their representatives prior to move-in, risking uninformed financial decisions.

WAC 388-78A-3100 Safe storage of supplies and equipment. The facility failed to secure hazardous supplies accessible to memory care residents, placing them at risk of ingesting toxic materials.

WAC 388-78A-2305 Food sanitation. The facility failed to follow safe food handling and storage practices in multiple areas, risking foodborne illness for all residents.

WAC 388-78A-2930 Communication system. The facility failed to provide means for residents and staff to summon on-duty staff in common areas and failed to provide reliable wireless communication devices, risking delayed assistance.

WAC 388-78A-2474 Training and home care aide certification requirements. The facility failed to ensure a sampled staff member completed required continuing education, risking care by unqualified staff.

WAC 388-78A-2710 Disclosure of services. The facility failed to provide completed or updated disclosure of services to several residents, impacting informed consent and knowledge of services provided.

WAC 388-78A-2371 Investigations. The facility failed to investigate and document findings for a resident's new skin impairment, risking further skin breakdown and complications.

WAC 388-78A-3090 Maintenance and housekeeping. The facility failed to maintain a safe, sanitary, and well-maintained environment including water-damaged walls and uneven parking lot surfaces, risking resident safety and quality of life.

WAC 388-78A-2300 Food and nutrition services. The facility failed to post current menus in resident accessible areas, risking diminished quality of life.

WAC 388-78A-2610(1)(2)(c)(d)(f) Infection control. The licensee failed to implement proper infection control practices during an outbreak, did not provide necessary supplies, failed to perform proper hand hygiene, and failed to report and cooperate timely with the Local Health Jurisdiction.

WAC 388-78A-2732 - This deficiency was deleted following the Informal Dispute Resolution process.

WAC 388-78A-2450 Staff. The facility failed to ensure staff were trained to provide necessary care and services for 1 of 2 residents, resulting in a medication error with insulin administration.

WAC 388-78A-2610 Infection control. The facility failed to implement appropriate infection control practices, placing 77 residents and 83 staff at risk of infectious disease spread.

WAC 388-78A-2150 Signing negotiated service agreement. The assisted living facility must ensure that the negotiated service agreement is agreed to and signed at least annually by the resident or representative, facility representative, and case manager. The facility failed to obtain signatures for 2 of 3 residents, placing them at risk of unmet care needs.