Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 8, 2025
Visit Reason
The Department of Social and Health Services completed a complaint investigation at Ashley Pointe Senior Living related to infection control measures during a respiratory outbreak.
Findings
The licensee failed to implement infection control measures to prevent infectious respiratory disease during one outbreak, resulting in staff not being properly assessed for N95 respirators and placing residents, staff, and visitors at risk. This was a recurring deficiency previously cited in 2023 and 2024.
Complaint Details
Complaint investigation completed on July 8, 2025, substantiating a recurring infection control deficiency related to respiratory outbreak management.
Deficiencies (1)
| Description |
|---|
| Failure to implement infection control measures to prevent infectious respiratory disease during an outbreak, including improper assessment of staff for N95 respirators. |
Report Facts
Civil fine amount: 400
Previous deficiency citation dates: February 1, 2023 and February 22, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the imposition of civil fine letter |
| Ross Devito | Field Services Administrator | Contact person for plan of correction and inquiries |
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 1
Jul 8, 2025
Visit Reason
The inspection was conducted due to a complaint investigation related to an outbreak at the Assisted Living Facility (ALF).
Findings
The facility failed to implement infection control measures by not having staff who provided direct care fit tested for N95 respirators during a respiratory outbreak, resulting in a citation for failure of WAC 388-78a-2610 (1), Infection Prevention.
Complaint Details
There was an outbreak at the Assisted Living Facility. The investigation found a failed provider practice with citation written for failure of infection prevention requirements related to respirator fit testing.
Deficiencies (1)
| Description |
|---|
| Failure to implement infection control measures by not having staff fit tested for N95 respirators during a respiratory outbreak. |
Report Facts
Total residents: 25
Resident sample size: 3
Closed records sample size: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Devito | Field Services Administrator | Investigator and named in the report |
| Cynthia Chenot-Potter | Nursing Consultant Institutional | Department staff who did the on-site verification and investigated the facility |
Inspection Report
Life Safety
Deficiencies: 5
Jun 10, 2025
Visit Reason
The Office of the State Fire Marshal conducted an inspection at the Ashley Pointe residential care facility on 06/10/2025 to verify correction of previous violations.
Findings
All violations noted during previous related inspections have been corrected as of the 06/10/2025 inspection. The prior inspection on 05/07/2025 found multiple fire safety violations including holes in the basement ceiling fire barrier, water hoses hanging on sprinkler piping, and lack of documentation for monthly smoke alarm, carbon monoxide alarm testing, and emergency light power tests.
Deficiencies (5)
| Description |
|---|
| Two 12 inch by 36 inch holes in the ceiling of basement where a leak was repaired but ceiling fire barrier not repaired. |
| Two water hoses hanging on the sprinkler piping in the basement near the water heaters. |
| Facility unable to provide documentation for monthly single station smoke alarm testing. |
| Facility unable to provide documentation for monthly carbon monoxide alarm testing including list of all alarms tested. |
| Facility unable to provide documentation for annual 90 minute power test for emergency lights. |
Report Facts
Inspection date: Jun 10, 2025
Previous inspection date: May 7, 2025
Hole size: 12
Hole size: 36
Emergency light power test duration: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandon G. Brown | Deputy State Fire Marshal | Signed inspection reports |
| Troy Roach Jr | Maintenance Director | Named as Owner or Owner's Representative on 06/10/2025 inspection |
| Jeff Hendrickson | E.D. | Named as Owner or Authorized Representative on 05/07/2025 inspection |
Inspection Report
Follow-Up
Census: 24
Deficiencies: 5
May 16, 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 found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previous deficiencies related to food worker cards, background checks, training, water temperature, and tuberculosis testing were corrected.
Deficiencies (5)
| Description |
|---|
| Failed to ensure 4 of 6 staff obtained food worker cards within 14 days of hire, resulting in untrained staff handling food and increased risk of foodborne illness. |
| Failed to ensure 3 of 6 staff had national fingerprint background checks and 2 of 6 had valid Washington state name and date of birth background checks, placing residents at risk. |
| Failed to ensure staff completed required training including Orientation and Safety, 70-hour Basic training, Specialty Dementia training, CPR and First Aid, continuing education, and home care aide certification within required timeframes. |
| Failed to maintain water temperature in resident and common area sinks between 105°F and 120°F, with temperatures as high as 145.7°F, placing residents at risk of scalding. |
| Failed to ensure 6 of 6 staff completed two-step tuberculosis skin testing within required timeframes, placing residents at risk of exposure to communicable disease. |
Report Facts
Residents present: 24
Staff sample reviewed: 5
Staff sample size: 6
Water temperature: 145.7
Water temperature: 120.3
Days late for food worker card: 126
Days late for TB testing: 406
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Executive Director | Named in findings for missing national fingerprint background check, late TB testing, and water temperature knowledge |
| Staff B | Medication Technician | Named in findings for missing food worker card and late TB testing |
| Staff C | Resident Assistant | Named in findings for missing food worker card, background checks, training, CPR, continuing education, and TB testing |
| Staff D | Medication Technician | Named in findings for missing national fingerprint background check, training, CPR, and TB testing |
| Staff E | Medication Technician | Named in findings for missing food worker card, background checks, training, continuing education, and TB testing |
| Staff F | Resident Assistant | Named in findings for missing food worker card, background checks, training, and TB testing |
| Staff G | Business Office Manager | Provided statements confirming missing documentation and training schedules |
| Staff H | Health Services Director | Responsible for completing staff TB testing |
| Staff I | Maintenance Director | Provided statements about water temperature monitoring |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 7
May 28, 2024
Visit Reason
The inspection was a complaint investigation triggered by multiple allegations regarding quality of care, staffing issues, medication errors, housekeeping, and resident safety at Ashley Pointe Senior Living.
Findings
The investigation found multiple failed provider practices including inadequate investigation of incidents, medication errors, delayed response to call pendants, inconsistent housekeeping, unsigned negotiated service agreements, incomplete resident assessments, and lack of family assistance plans for medications. Several citations were issued for noncompliance with Washington Administrative Codes.
Complaint Details
The complaint investigation was based on multiple allegations including poor quality of care, lack of engagement by activity staff, transportation issues, food quality complaints, safety check failures, unclean resident rooms, failure to provide requested documents, inconsistent assistance with personal care, mental health decline, medication errors, staffing shortages, and billing concerns.
Deficiencies (7)
| Description |
|---|
| Failed to investigate and document investigative actions and findings for alleged incidents affecting resident health or safety. |
| Failed to provide and maintain a clean environment; housekeeping services were not provided for one week resulting in unsanitary conditions. |
| Failed to have signed negotiated service agreements for residents and their legal representatives. |
| Failed to ensure safe medication services; medication errors occurred including missed medications and incorrect application of medication patches. |
| Failed to respond within a reasonable time to residents using call pendants, resulting in delayed care. |
| Failed to obtain sufficient information in resident assessments to fully assess capabilities, needs, and preferences. |
| Failed to obtain written family assistance plans for residents managing their own medications. |
Report Facts
Total residents: 35
Resident sample size: 13
Call response time: 2221
Number of call events: 24
Number of call events: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Glover | Complaint Investigator | Department staff who did the on-site verification. |
| Wesler Dumecquias | Community Complaint Investigator | Investigator who conducted the complaint investigation. |
| Christine Banta | ALF Licensor | Department staff involved in the investigation. |
| Kimberley Ripley | Field Manager | Mentioned in relation to the inspection report. |
| Staff K | Vice President Clinical Operations | Provided statements regarding investigations and medication management. |
| Staff M | Regional Director for Health and Services | Signed some negotiated service agreements and involved in assessments. |
| Staff J | Operations Specialist | Provided information about care plans and assessments. |
| Staff L | Med Tech | Provided information about call pendant issues. |
| Staff F | Medication Technician | Provided information about laundry services. |
| Staff E | Housekeeping | Explained housekeeping staffing shortages. |
| Staff H | Medication Technician | Involved in medication error incident. |
Inspection Report
Follow-Up
Census: 38
Deficiencies: 1
Apr 19, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to infection control.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies related to failure to ensure proper N95 fit testing and use during a COVID-19 outbreak were corrected.
Complaint Details
The complaint investigation found that the facility failed to follow Department of Health infection control guidelines during a COVID-19 outbreak. Eight care staff were not properly fit tested for N95 masks while providing direct care to COVID-19 positive residents. A citation was issued for noncompliance with WAC 388-78A-2610(1)(2)(d).
Deficiencies (1)
| Description |
|---|
| Failure to ensure that care staff providing direct resident care were properly fit tested and using appropriate N95 respirators during a COVID-19 outbreak. |
Report Facts
Total residents: 38
Care staff not fit tested: 8
Care staff fit tested after investigation: 4
Compliance Determination Completion Date: Feb 22, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wesler Dumecquias | Community Complaint Investigator | Investigator who conducted complaint investigation |
| Jodi Condyles | ALF Licensor | Department staff who conducted follow-up inspection |
| Staff A | Interim Health Services Director | Interviewed staff who confirmed lack of proper N95 fit testing |
| Staff B | Caregiver | Interviewed staff who confirmed lack of proper N95 fit testing |
| Staff C | Med Tech | Interviewed staff who confirmed lack of proper N95 fit testing |
| Staff D | Med Tech | Interviewed staff who confirmed lack of proper N95 fit testing |
| Staff E | Business Office Manager | Provided information on staff fit testing status after investigation |
Inspection Report
Re-Inspection
Deficiencies: 16
Aug 17, 2023
Visit Reason
The Office of the State Fire Marshal conducted a reinspection of Ashley Pointe on August 17, 2023, to verify correction of violations identified during a prior inspection.
Findings
All violations noted during previous related inspections have been corrected, and the facility was approved at the time of this inspection.
Deficiencies (16)
| Description |
|---|
| Facility is unable to provide documentation that the annual fire resistance rated construction material inspection has been completed. |
| Facility is unable to provide documentation for the 3 year dry system full flow trip test. |
| Facility is unable to provide documentation for the annual fire alarm system testing. |
| Facility is unable to provide documentation for the monthly single station smoke alarm testing. |
| Facility is unable to provide documentation for the annual sprinkler system inspection. |
| Facility is unable to provide documentation for the 5 year internal piping inspection. |
| Facility is unable to provide documentation for the quarterly sprinkler system inspections. |
| Facility is unable to provide documentation for the semi-annual kitchen suppression system servicing. |
| The required annual maintenance for the fire extinguisher throughout the facility has not been completed in accordance with NFPA 10. |
| Facility is unable to provide documentation for the required smoke detector sensitivity testing. |
| Facility is unable to provide documentation for the monthly carbon monoxide detector testing. |
| The internally illuminated exit signs would not illuminate when the activation test button was pushed above the exit near room 23. |
| Facility cannot provide documentation for the completion of twelve planned and unannounced fire drills in the previous 12 months. Several drills are missing for various shifts and quarters. |
| There is a power strip plugged into another power strip in the main lobby. |
| Facility is unable to provide documentation for the semi-annual hood cleaning. |
| The power breaker for fire alarm is missing locking device. |
Report Facts
Number of fire drills missing: 12
Inspection dates: Jul 5, 2023
Next inspection date: Aug 4, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Aldrich | Executive Director | Named as facility representative signing inspection documents and involved in inspection process. |
| Brandon G. Brown | Deputy State Fire Marshal | Conducted inspection and signed inspection documents. |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 4
Feb 1, 2023
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations that the facility had residents who tested positive for COVID-19 and lacked proper COVID-19 protocols, safety protocols, and nursing staff onsite.
Findings
The facility failed to follow infection control practices including placing COVID-19 outbreak signs, ensuring staff wore appropriate N95 masks, cleaning rooms of COVID-19 positive residents, and reporting the outbreak to the department. Multiple failed practices were identified and citations were written.
Complaint Details
The complaint investigation was substantiated with findings that the facility did not meet infection control requirements and failed to report a COVID-19 outbreak. The investigation referenced complaint numbers 64913, 65863, and 65740.
Deficiencies (4)
| Description |
|---|
| Failed to place COVID-19 outbreak signs at the entrance and isolation carts at doors of residents who tested positive. |
| Failed to ensure staff were fit tested and wearing appropriate N95 masks for residents' care. |
| Facility was not cleaning rooms of residents who tested positive for COVID-19. |
| Failed to report a COVID-19 outbreak to the department. |
Report Facts
Total residents: 34
Resident sample size: 9
Completion Date: Apr 4, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wesler Dumecquias | Community Complaint Investigator | Conducted the on-site verification and investigation |
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