Inspection Reports for
The Gardens at Town Square
933 111th Ave NE, Bellevue, WA 98004, United States, WA, 98004
Back to Facility Profile11 Reports
Inspection Report — Jul 7, 2026
Follow-Up
Date: Jul 7, 2026
Visit Reason
The Department 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 deficiencies were corrected. The facility meets the Assisted Living Facility licensing requirements.
Deficiencies (5)
WAC 388-78A-2468 Background checks Employment Conditional hire Pending results of Washington state name and date of birth background check. The facility failed to submit the required background inquiry for one of two sampled contracted staff within one business day after start date, placing 64 residents at risk.
WAC 246-215-02310 Hands and arms When to wash. Food employees must clean hands and exposed arms as specified before food preparation. The facility failed to follow proper sanitation procedures in one of two kitchens, placing 64 residents at risk of foodborne illness.
WAC 388-78A-2320 Intermittent nursing services systems. The facility failed to assess and implement nurse delegation services for three of five sampled residents, placing them at risk for unsafe medication administration by non-licensed staff.
WAC 388-78A-2700 Emergency and disaster preparedness. The facility failed to have a system to ensure emergency water supply accessibility and secure hazardous areas, placing 64 residents at risk of harm.
WAC 388-78A-3040 Laundry. The facility failed to ensure the exhaust fan vent cover in the main commercial laundry room was free of debris and fully operational, restricting exhaust flow.
Report Facts
Sampled residents: 9
Residents at risk: 64
Sampled contracted staff: 2
Residents requiring nurse delegation: 3
Inspection Report — Apr 3, 2026
Follow-Up
Date: Apr 3, 2026
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to medication availability and administration.
Complaint Details
The complaint investigation (Complaint #206804) was based on delayed medication orders and administration of eye drops for a named resident. The investigation found a failed provider practice related to timely medication procurement and administration.
Findings
The follow-up inspection found no deficiencies and confirmed that the previously cited deficiency regarding delayed medication administration was corrected. The facility meets the Assisted Living Facility licensing requirements.
Deficiencies (1)
WAC 388-78A-2240 Nonavailability of medications. The Assisted Living Facility failed to obtain prescribed medication in a timely manner for one resident, resulting in delayed administration of prescribed eye drops and risk of medical complications.
Report Facts
Total residents: 43
Resident sample size: 3
Inspection Report — Jun 23, 2025
Life Safety
Date: Jun 23, 2025
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the facility on 06/23/2025.
Findings
All violations noted during previous related inspections have been corrected. The facility was approved at the time of this inspection.
Inspection Report — Apr 25, 2025
Follow-Up
Date: Apr 25, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Findings
The follow-up inspection on 04/25/2025 found no deficiencies and confirmed that all previously cited deficiencies were corrected.
Deficiencies (5)
WAC 388-78A-2450 Staff. The facility failed to ensure that all resident care and services were provided only by staff persons with the necessary training, credentials, and qualifications. This deficiency was previously cited and corrected.
WAC 388-78A-2450 Staff. The facility failed to maintain required documentation on staff orientation, training, and certification pertinent to duties during employment and for at least two years following termination. This deficiency was previously cited and corrected.
WAC 388-112A-0090 Which long-term care workers are exempt from the seventy-hour long-term care worker basic training requirement? The facility failed to ensure that a nursing assistant completed the training program and certification within required timeframes. This deficiency was previously cited and corrected.
WAC 246-980-030 Can a nonexempt long-term care worker work before obtaining certification as a home care aide? The facility allowed a long-term care worker to work beyond the allowed 200 calendar days from hire without obtaining certification. This deficiency was previously cited and corrected.
WAC 246-980-025 Individuals exempt from obtaining a home care aide certification. The facility failed to ensure that a staff member in an approved training program completed certification within required timeframes, placing residents at risk.
Report Facts
Residents at risk: 38
Residents at risk: 60
Resident sample size: 1
Days after hire: 197
Days after hire: 272
Medication administration days: 5
Inspection Report — Feb 26, 2025
Enforcement
Date: Feb 26, 2025
Visit Reason
This document is a formal notice of a civil fine imposed on THE GARDENS AT TOWN SQUARE following a follow-up visit conducted by the Department of Social and Health Services Residential Care Services on February 26, 2025.
Findings
The licensee failed to ensure that one staff member was qualified to work with vulnerable adult residents, placing all 38 residents at risk. This deficiency was uncorrected from a prior citation and resulted in a $300 civil fine.
Deficiencies (3)
WAC 246-980-030 (2) Working while obtaining certification as a home care aide. The licensee failed to ensure that one staff was qualified to work with vulnerable adult residents, placing residents at risk.
WAC 388-112A-0090 (4) Which long-term care workers are exempt from the 70-hour long-term care worker basic training requirement? The licensee failed to ensure that one staff was qualified to work with vulnerable adult residents, placing residents at risk.
WAC 388-78A-2450 (2)(e)(3)(d)(i)(A)(B) Staff. The licensee failed to ensure that one staff was qualified to work with vulnerable adult residents, placing residents at risk.
Report Facts
Civil fine amount: 300
Residents at risk: 38
Inspection Report — Jan 3, 2025
Plan of Correction
Date: Jan 3, 2025
Visit Reason
This document reports the results of an Informal Dispute Resolution (IDR) process regarding a prior Statement of Deficiencies (SOD) report dated October 31, 2024, for The Gardens at Town Square assisted living facility.
Findings
The IDR process resulted in the deletion of the cited deficiency WAC 388-78A-2700 from the prior SOD. No other changes or findings are noted in this report.
Deficiencies (1)
WAC 388-78A-2700 - The cited deficiency was deleted following the Informal Dispute Resolution process.
Notice — Dec 23, 2024
Date: Dec 23, 2024
Visit Reason
The letter confirms the scheduling of an Informal Dispute Resolution meeting requested by the facility to dispute a citation dated October 31, 2024.
Findings
The document does not contain inspection findings but serves to schedule a review meeting for disputed citations.
Inspection Report — Jul 8, 2024
Life Safety
Date: Jul 8, 2024
Visit Reason
The Office of the State Fire Marshal conducted a scheduled fire safety inspection at the residential care facility Gardens At Town Square.
Findings
All violations noted during previous related inspections have been corrected. The facility was approved following this inspection.
Inspection Report — May 1, 2023
Routine
Date: May 1, 2023
Visit Reason
The Department completed a full inspection of the Assisted Living Facility on 05/01/2023 to assess compliance with regulatory requirements.
Findings
The inspection found no deficiencies in the facility.
Inspection Report — Apr 20, 2023
Life Safety
Date: Apr 20, 2023
Visit Reason
The Office of the State Fire Marshal conducted a scheduled fire and life safety inspection at the facility.
Findings
The inspection identified multiple fire and life safety code violations including blocked electrical panel access, missing documentation for required inspections and maintenance, malfunctioning fire doors, missing fire/smoke dampers, and inadequate fire drill records. The facility was disapproved due to these outstanding violations.
Deficiencies (14)
IFC 604.3 (2018) - Combustible storage was found blocking access to the electrical panel in the life enrichment supply room.
IFC 604.4.2 (2018) - A power strip was plugged into another power strip in the copy room on the ground floor.
IFC 607.3.3 (2018) - Facility was unable to provide documentation for the semi-annual hood cleaning report.
IFC 701.6 (2018) - Facility failed to provide an inventory of all fire-resistance-rated construction and had multiple unprotected penetrations without plans to identify wall ratings.
IFC 705.2 (2018) - Facility was unable to provide documentation showing that an annual fire door inspection was completed in the past 12 months.
IFC 705.2.4 (2018) - Fire door to memory care kitchen storage failed to latch when tested; fire door not latching in main kitchen next to bussing station.
IFC 706.2 (2018) - Air flow vent in the fourth floor residents laundry room's fire-resistance-rated corridor wall is missing the required fire/smoke damper control system.
IFC 903.5 (2009, 2012, 2015, 2018) - Multiple loaded sprinkler heads observed in the kitchen and unprotected gap around sprinkler escutcheon ring next to Apt. 532.
IFC 906.2 (2015, 2018) - Facility unable to provide documentation that the annual fire extinguishers inspection has been completed.
IFC 907.8 (2018) - Life enrichment storage room is missing a smoke detector; multiple pull stations missing replacement glass rods on all floors.
IFC 915.6 (2018) - Facility unable to provide documentation for the monthly check of all carbon monoxide detectors.
IFC 1203.4 (2018) - Facility unable to provide records of the monthly 30-minute full load testing of emergency and standby power systems in the past 12 months.
NFPA 72 10.6.5.2 - Fire alarm circuit breaker in the main electrical room is missing the required lock device, locking breaker in the "ON" position.
Fire Drills - Facility cannot provide documentation for completion of twelve planned and unannounced fire drills in the previous 12 months; multiple shifts and quarters missing drills.
Report Facts
Number of planned fire drills required annually: 12
Missing fire drills: 5
Inspection Report — Nov 16, 2022
Life Safety
Date: Nov 16, 2022
Visit Reason
The Office of the State Fire Marshal conducted a scheduled fire safety inspection at the facility.
Findings
All violations noted during previous related inspections have been corrected. The facility was approved at this inspection.
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