Inspection Report
Follow-Up
Census: 23
Deficiencies: 4
Feb 26, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to medication administration and compliance with licensing laws.
Findings
The follow-up inspection found no deficiencies and confirmed that previously cited deficiencies related to medication administration errors were corrected. The facility now meets Assisted Living Facility licensing requirements.
Complaint Details
Complaint investigation triggered by allegation of neglect related to failure to administer prescribed seizure medication to a named resident. The investigation substantiated the allegation and identified failed provider practice with citations written.
Deficiencies (4)
| Description |
|---|
| Facility failed to administer prescribed seizure medication to residents, resulting in missed doses and decline in medical condition. |
| Facility failed to ensure residents received medications as ordered, including failure to follow medication reconciliation and administration policies. |
| Resident 1 missed 41 doses of seizure medication due to medication being discontinued in error, leading to hospitalization and decline. |
| Resident 2 missed 3 doses of constipation medication due to pharmacy action required and lack of follow-up. |
Report Facts
Total residents: 23
Resident sample size: 3
Closed records sample size: 2
Missed doses of levetiracetam: 41
Missed doses of levetiracetam: 13
Missed doses of Citrucel: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nikolas Jennings | Community Nurse Complaint Investigator | Conducted off-site verification during follow-up inspection |
| Regenia Coleman | ALF NCI CI | Investigator who conducted complaint investigation |
| Staff C | Registered Nurse and Health and Wellness Director | Named in investigation for failure to ensure medication administration and subsequent suspension and termination |
| Staff B | Investigator | Conducted investigation of missed seizure medication |
| Staff D | Medication Technician | Interviewed regarding missed medication and pharmacy communication |
| Staff A | Executive Director | Interviewed regarding facility policies and responsibility for medication order accuracy |
Inspection Report
Follow-Up
Census: 28
Deficiencies: 2
Dec 11, 2024
Visit Reason
The visit was a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Findings
The Department found no deficiencies during the follow-up inspection on 12/11/2024, confirming that previously cited deficiencies related to background checks and maintenance/housekeeping were corrected.
Deficiencies (2)
| Description |
|---|
| Failure to ensure a Washington State Name and Date of Birth Background Check was submitted for 1 of 6 sampled staff within one business day of hire, placing all 28 residents at risk. |
| Failure to keep 1 of 11 fire extinguisher encasements in safe and good repair, exposing residents to potential injury from cracked and sharp plexiglass edges. |
Report Facts
Residents present during inspection: 28
Staff sampled: 6
Fire extinguisher encasements inspected: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cathleen Davis | ALF Licensor | Department staff who conducted the on-site verification and inspection. |
| Cory Myers | ALF Complaint Investigator | Department staff who conducted the on-site verification and inspection. |
| Manfay Chan | Field Manager | Signed the follow-up inspection letter. |
| Angie Chaney | Administrator | Signed the Plan/Attestation Statement certifying correction of deficiencies. |
Inspection Report
Life Safety
Deficiencies: 6
Mar 13, 2023
Visit Reason
The Office of the State Fire Marshal conducted an inspection of the facility to assess compliance with fire safety and life safety code requirements.
Findings
Multiple violations were observed related to fire safety including combustible materials stored too close to sprinkler heads, lack of annual records for fire-resistance-rated construction inspections, missing documentation for fire doors and dampers maintenance, and missing escutcheon ring on a sprinkler.
Deficiencies (6)
| Description |
|---|
| Combustible material stored less than 18 inches below sprinkler head deflector in activity room closet and office. |
| Unable to provide annual records showing that fire-resistance-rated construction has been inspected/repaired in the past 12 months - pertaining to attic spaces. |
| Unable to provide annual record showing that the rolling steel fire doors at the front desk have been annually inspected, tested and maintained in accordance with NFPA 80. |
| January 2023 fire/smoke damper report indicated 1 inaccessible damper - inspection, testing, and maintenance required - access possible through Apt. 126. |
| Unable to provide documentation showing that required Heat Survey was performed to determine appropriate fusible link rating - link rating not indicated on suppression system service report. |
| Sprinkler is missing escutcheon ring in the clean linen closet by Apt. 102. |
Report Facts
Inaccessible dampers: 1
Inspection date: Mar 13, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lysandra Davis | Deputy State Fire Marshal | Conducted the inspection and signed the report |
| David Hillard | Maintenance Technician | Named as Owner's Representative signing the report |
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