Inspection Report
Follow-Up
Census: 100
Capacity: 159
Deficiencies: 2
Apr 30, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to fire and life safety inspections.
Findings
The follow-up inspection found no deficiencies, confirming that the previously cited fire and life safety deficiencies were corrected. The prior complaint investigation found the facility failed two fire and life safety inspections and was out of compliance with multiple International Fire Code standards.
Complaint Details
Complaint investigation was conducted due to notification of facility failure to pass two fire and life safety inspections. The complaint was substantiated with failed provider practice identified and citations written.
Deficiencies (2)
| Description |
|---|
| Facility failed second Fire and Life Safety Inspection (LSI) placing residents, staff, and visitors at risk. |
| Out of compliance in 6 of 29 code requirements including Opening Protectives-Floor Openings and Shafts, Inspection and Maintenance, Door Operation, Duct and Air Transfer Openings, Testing and Maintenance, and Smoke Detector Sensitivity. |
Report Facts
Total residents: 100
Total licensed capacity: 159
Number of code requirements out of compliance: 6
Total code requirements reviewed: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Milanez | Community Complaint Investigator | Conducted on-site verification and complaint investigation |
| Laura Williams-Davis | ALF Field Manager | Signed follow-up inspection report letter |
| Staff A | Executive Director | Interviewed regarding resident census and awareness of failed fire inspections |
| Staff B | Maintenance Director | Interviewed regarding maintenance efforts to resolve fire safety issues |
| Laurel Knight | Community Complaint Investigator | Assisted in complaint investigation |
Inspection Report
Follow-Up
Census: 92
Deficiencies: 1
Apr 10, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to maintenance and housekeeping.
Findings
The follow-up inspection found no deficiencies and confirmed that previously cited deficiencies related to maintenance and housekeeping were corrected.
Complaint Details
The complaint investigation found that the carpet was dirty and difficult to operate a manual wheelchair on. Observations and interviews confirmed the facility failed to maintain a clean, sanitary environment on the 2nd and 3rd floors, with stained, bubbled, and worn carpet creating hazards and resident dissatisfaction. The facility had attempted professional cleaning but stains remained or returned. The deficiency was cited and repeated over multiple inspections.
Deficiencies (1)
| Description |
|---|
| Failure to maintain a clean, sanitary environment on 2 of 3 floors (2nd and 3rd floors), resulting in residents' dissatisfaction, risk for falls, and decreased quality of life. |
Report Facts
Resident sample size: 92
Resident sample size: 4
Total residents: 93
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laurel Knight | Community Complaint Investigator | Conducted inspections and complaint investigations |
| Staff A | Administrator | Interviewed regarding carpet condition and replacement delays |
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 3, 2025
Visit Reason
The Department of Social and Health Services completed a complaint investigation at Brookdale Richland assisted living facility due to concerns about medication administration.
Findings
The investigation found that the licensee failed to ensure medication was administered as prescribed for one resident, resulting in the resident not receiving medications as ordered and requiring hospitalization. This was a recurring deficiency previously cited multiple times.
Complaint Details
Complaint investigation conducted on April 3, 2025. The deficiency was substantiated as the licensee failed to administer medication as prescribed, causing harm to a resident.
Deficiencies (1)
| Description |
|---|
| Failure to ensure medication was administered as prescribed for one resident, resulting in hospitalization. |
Report Facts
Civil fine amount: 600
Previous citations: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the imposition of civil fine letter |
| Laura Williams-Davis | Field Manager | Contact person for plan of correction and inquiries |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 1
Feb 11, 2025
Visit Reason
The investigation was conducted due to a complaint that an identified resident did not receive their medications as prescribed.
Findings
The investigation found that the resident's medication was inadvertently discontinued, resulting in hospitalization. The facility failed to ensure medication was administered as prescribed, leading to a citation for medication services.
Complaint Details
The complaint alleged that an identified resident did not get their medications as prescribed. The complaint was substantiated with a failed provider practice identified and citation(s) written.
Deficiencies (1)
| Description |
|---|
| Failure to ensure medication was administered as prescribed, resulting in resident hospitalization. |
Report Facts
Total residents: 71
Resident sample size: 12
Closed records sample size: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laurel Knight | Community Complaint Investigator | Investigator who conducted the complaint investigation and on-site verification |
Inspection Report
Enforcement
Deficiencies: 1
Jan 16, 2025
Visit Reason
The Department of Social and Health Services completed a follow-up visit to Brookdale Richland assisted living facility to address previously cited deficiencies and impose a civil fine for failure to maintain a clean, sanitary environment.
Findings
The facility was found to have failed to maintain a clean, sanitary environment on two floors, resulting in residents' dissatisfaction, risk for falls, and decreased quality of life. This deficiency was repeated and uncorrected from prior citations.
Deficiencies (1)
| Description |
|---|
| Failure to maintain a clean, sanitary environment on two floors |
Report Facts
Civil fine amount: 400
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter |
| Laura Williams-Davis | Field Manager | Contact person for plan of correction and appeals |
Inspection Report
Life Safety
Deficiencies: 45
Jan 9, 2025
Visit Reason
The Office of the State Fire Marshal conducted an inspection at the facility to assess compliance with fire protection and life safety codes.
Findings
Multiple violations related to fire protection systems, door operations, duct and air transfer openings, smoke detector sensitivity, and testing and maintenance were observed. The facility was unable to provide documentation for several required tests and inspections, and some fire safety equipment was found to be non-functional or missing. The facility is actively working with contractors and vendors to address and correct these issues.
Deficiencies (45)
| Description |
|---|
| Facility was unable to provide documentation of correction and retesting of fire/smoke dampers that were not tested or failed testing as noted on March 20, 2022 testing report. |
| Facility was unable to provide documentation of sample testing of quick response sprinkler heads greater than 20 years old. |
| Facility was unable to provide documentation of sample testing of sprinkler heads exposed to extreme environment (exterior) that are greater than 10 years old. |
| Facility was unable to provide documentation that all single station smoke alarms are less than 10 years old. |
| Facility was unable to provide documentation of correction to failed items on April 2, 2024 fire alarm system annual service report. |
| Facility was unable to provide documentation of inspection on items contractor stated they unable to inspect on April 2, 2024 fire alarm system annual service report. |
| Facility was unable to provide documentation of annual forward flow testing of fire sprinkler system backflow within the past twelve months. |
| Facility was unable to provide documentation of second semi annual kitchen hood suppression service. Report provided was dated June 13, 2023. |
| Facility was unable to provide documentation of monthly activation testing of emergency lights and exit signs since February 28, 2024. |
| Facility was unable to provide documentation of monthly testing of single station smoke alarms. |
| Facility was unable to provide documentation that all single station smoke alarms are less than 10 years old. |
| Facility's documentation of carbon monoxide alarm testing only included devices in corridors. |
| Carbon monoxide alarms failed when tested in the following locations: Attic access by 332, Mechanical room across from 241, Corridor by Room 130. |
| Emergency lighting failed to illuminate when tested in multiple locations including Light 309, Light by 329, Light 3 in stairwell, Light 208, Light 216, Light 222, Light 4 (also marked 113) in stairwell, Light 103, Light 114, Light 107, Light 109, Light 111. |
| Mechanical room across from 241 - unsecured compressed gas cylinder. |
| Copy Room - unsecured oxygen cylinder. |
| Storage room behind laundry by Room 312 - no self closer installed. |
| Room 233 - no self closer installed. |
| Cross corridor doors by 341 - facility removed doors. |
| Room 329 - door knob removed creating a penetration in door. |
| Stairwell door by Room 201 - door handle broken and door is delaminating. |
| Stairwell door by Room 213 - door handle missing. |
| Cross corridor by resident storage - hardware broken. |
| Cross corridor door by 115 - facility removed door. |
| Dining Room by Room 130 - door splitting. |
| Emergency exit - corridor by Kitchen - door knob missing. |
| Kitchen to Dining Room - replacement door does not have a latch. |
| Doors with self closers were obstructed inhibiting closer in multiple rooms including Room 330, 326, 325, 320, 321, 316, 317, 303, Stairwell door by Room 201, Stairwell door by Room 213. |
| Doors failed to close and latch in multiple locations including Third floor elevator lobby by 341 (delay failed), Cross corridor doors by 341, Room 326, Room 320, Room 317, Second floor elevator lobby by Room 242, Cross corridor doors by 238, Storage by Room 213, Room 209, Room 201, Elevator lobby by nurses station, Dining Room by Room 130, Kitchen exit to garbage collection area, Dining Room to corridor, Arts and Crafts Room, Arts and Crafts Storage Room. |
| Facility was unable to provide documentation of corrections and retesting of fire/smoke dampers that were not tested or failed testing as noted on March 20, 2022 testing report. |
| Facility was unable to provide documentation of sample testing of quick response sprinkler heads greater than 20 years old. Note: observed heads dated 2003. |
| Facility was unable to provide documentation of sample testing of sprinkler heads exposed to extreme environment (exterior) that are greater than 10 years old. |
| Facility was unable to provide documentation of annual forward flow testing of fire sprinkler system backflow within the past twelve months. |
| Facility was unable to provide documentation of second semi annual kitchen hood suppression service. Report provided was dated June 13, 2023. |
| Copy Room - two unsecured fire extinguishers. |
| Facility was unable to provide documentation of fire alarm system detector nuisance log for the past twelve months. |
| Facility was unable to provide documentation of monthly testing of single station smoke alarms. |
| Facility was unable to provide documentation of correction to failed items on April 2, 2024 fire alarm system annual service report. |
| Facility was unable to provide documentation of inspection on items contractor stated they unable to inspect on April 2, 2024 fire alarm system annual service report. |
| Facility was unable to provide documentation of monthly activation testing of emergency lights and exit signs since February 28, 2024. |
| Facility was unable to provide documentation of annual power test of the emergency lights and exit signs within the past twelve months. |
| Facility was unable to provide documentation of carbon monoxide alarm testing only included devices in corridors. |
| Carbon monoxide alarms failed when tested in the following locations: Attic access by 332, Mechanical room across from 241, Corridor by Room 130. |
| Storage room behind laundry by Room 312 - no self closer installed. |
| Room 233 - no self closer installed. |
Report Facts
Inspection dates: 3
Next inspection scheduled: Next inspection scheduled on or after 06/28/2024 and 02/08/2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jon Connors | Executive Director | Named as Owner or Authorized Representative signing inspection documents |
| Barbara Maier | Deputy State Fire Marshal | Signed inspection documents |
| Andrea Ely | Deputy State Fire Marshal | Signed inspection documents |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 1
Dec 10, 2024
Visit Reason
The inspection was conducted as a complaint investigation regarding a broken pipe and possible mold in the dining room of the assisted living facility.
Findings
The facility had a water leak causing damage to the kitchen and dining room area, which put residents at risk for discontinuation of services and exposure to mold. The facility failed to report the incident to the department as required.
Complaint Details
Complaint investigation included allegations of a broken pipe and possible mold in the dining room. The complaint was substantiated by findings of water damage and failure to report the incident.
Deficiencies (1)
| Description |
|---|
| Failure to report a water leak incident that caused damage and potential mold growth, risking resident safety and service continuation. |
Report Facts
Total residents: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Milanez | Community Complaint Investigator | Investigator who conducted the complaint investigation |
| Laurel Knight | Community Complaint Investigator | Investigator who conducted the complaint investigation |
| Laura Williams-Davis | Field Manager | Signed the letter regarding the complaint investigation |
Inspection Report
Enforcement
Deficiencies: 1
Oct 30, 2024
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to Brookdale Richland to assess correction of previously cited deficiencies and imposed a civil fine based on uncorrected violations.
Findings
The licensee failed to maintain a clean, sanitary environment on the 2nd and 3rd floors, resulting in resident dissatisfaction, risk of falls, and decreased quality of life. This deficiency was previously cited and remained uncorrected.
Deficiencies (1)
| Description |
|---|
| Failure to maintain a clean, sanitary environment on two floors (2nd Floor and 3rd floor) |
Report Facts
Civil fine amount: 300
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter |
| Laura Williams-Davis | Field Manager | Contact person for plan of correction and appeals |
Inspection Report
Follow-Up
Deficiencies: 0
Jun 25, 2024
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. Previously cited deficiencies were corrected.
Complaint Details
The complaint investigation conducted from 04/09/2024 through 04/29/2024 involved allegations including residents not receiving insulin, neglect, and inadequate care. The investigation found one failed provider practice related to staff training and certification requirements, specifically that some staff were not properly trained or certified to administer insulin and provide care. Other allegations were not substantiated.
Report Facts
Total residents: 85
Resident sample size: 19
Residents who did not get insulin: 10
Staff affected by deficient practice: 3
Date by which correction will be made: Jun 12, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laurel Knight | Community Complaint Investigator | Conducted on-site verification and complaint investigation |
| Michelle Closner | Complaint Nurse Field Manager | Conducted on-site verification and authored follow-up letter |
| Robin Rainville | Assisted Living Facility Licensor | Investigated the Assisted Living Facility during complaint investigation |
| Gwin Archer | Residential Care Services | Signed Statement of Deficiencies report |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 11
Jun 19, 2024
Visit Reason
The inspection was a complaint investigation triggered by allegations including a resident injury due to improper use of a footrest during escorts and other compliance concerns.
Findings
The facility was found deficient in multiple areas including failure to investigate resident injuries, incomplete assessments, medication administration errors, delayed staff response to call lights, incomplete admission agreements, lack of respirator fit testing and medical clearance for staff, and failure to conduct timely tuberculosis screening and background checks.
Complaint Details
The complaint involved a resident injury to the left foot due to the footrest not being used during escorts. The investigation found failure to investigate and rule out abuse and neglect related to this injury.
Deficiencies (11)
| Description |
|---|
| Failed to investigate and document investigative actions for a resident injury (Resident 5). |
| Failed to complete focused assessments on safety considerations for residents with mobility devices or self-medication (Residents 7 and 8). |
| Failed to observe and evaluate residents with changes in condition and incidents (Residents 4 and 8). |
| Failed to ensure residents received medications as prescribed and document medication errors (Residents 7 and 8). |
| Failed to develop negotiated service agreements reflecting resident needs and interventions (Resident 1). |
| Failed to respond timely to resident call lights, with documented delays up to several hours (Residents 1, 4, 6, 12). |
| Failed to maintain current admission agreements reviewed within 24 months for residents (Residents 1, 8). |
| Failed to ensure staff completed respirator mask medical clearance and fit testing prior to resident care (Staff A, B, C, D, E). |
| Failed to submit valid Washington state background checks every two years for staff (Staff E, F). |
| Failed to complete Character, Competency, and Suitability (CCS) reviews for staff with non-disqualifying background checks (Staff E, F). |
| Failed to ensure tuberculosis screening within three days of hire for staff (Staff A, B). |
Report Facts
Total residents: 91
Resident sample size: 12
Closed records sample size: 0
Call light response delays: 10
Days medication missed: 15
Days late background check: 659
Days late background check: 583
Days late TB test: 42
Days late TB test: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrator | Named in findings for lack of respirator fit testing and delayed tuberculosis screening |
| Staff B | Licensed Practical Nurse/Health and Wellness Director | Named in findings for lack of respirator fit testing, delayed tuberculosis screening, and medication assessment errors |
| Staff E | Caregiver | Named in findings for expired background checks and missing CCS review |
| Staff F | Caregiver | Named in findings for expired background checks and missing CCS review |
| Staff G | Registered Nurse/Health Wellness Director | Involved in medication and injury investigation findings |
| Staff I | Business Office Coordinator | Provided information on background checks, TB testing, and admission agreements |
Inspection Report
Follow-Up
Deficiencies: 0
Apr 24, 2024
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. Previously cited deficiencies were corrected.
Report Facts
Compliance Determination Completion Dates: 40270 completed on 2024-04-24 and 37432 completed on 2024-03-13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laurel Knight | Community Complaint Investigator | Department staff who did the on-site verification |
| Gwin Kaercher | Field Manager | Signed the follow-up inspection letter |
Inspection Report
Follow-Up
Census: 105
Deficiencies: 0
Apr 24, 2024
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 04/24/2024 found no deficiencies and confirmed that previously cited deficiencies related to quality of life and resident rights were corrected.
Report Facts
Total residents: 105
Resident sample size: 9
Deficiencies cited: 1
Medication unavailability duration: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laurel Knight | Community Complaint Investigator | Investigator conducting complaint investigations and follow-up inspections |
| Gwin Kaercher | Field Manager | Signed compliance determination and follow-up letters |
| Heather Steiling | Administrator | Signed plan of correction documents |
| Staff A | Executive Director | Signed Plan/Attestation Statement and conducted facility investigation regarding medication reorder deficiency |
| Staff B | Business Office Manager | Reported on carpet cleaning efforts during deficiency investigation |
Inspection Report
Enforcement
Deficiencies: 1
Feb 2, 2024
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to Brookdale Richland to address previously cited deficiencies and to impose a civil fine for uncorrected violations related to resident rights and quality of life.
Findings
The licensee failed to maintain a clean, sanitary environment on three floors of the facility, resulting in resident complaints about the condition and smell of the carpet, contributing to an unsanitary environment and risk to residents' dignity. This deficiency was previously cited and remains uncorrected.
Deficiencies (1)
| Description |
|---|
| Failure to maintain a clean, sanitary environment on three floors of the facility, resulting in resident complaints about carpet condition and smell. |
Report Facts
Civil fine amount: 300
Days to return Statement of Deficiencies: 10
Days for informal dispute resolution request: 10
Days for formal administrative hearing request: 28
Days for payment of civil fine: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter |
| Gwin Kaercher | Field Manager | Contact person for plan of correction and enforcement communication |
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 18, 2023
Visit Reason
This document reports the results of the Informal Dispute Resolution (IDR) process regarding disputed deficiencies identified in the Statement of Deficiencies (SOD) report dated October 19, 2023.
Findings
After review of all materials, oral statements, and records, the decision was made not to change the original SOD report dated October 19, 2023. The facility is instructed to begin correcting the disputed deficiencies immediately and submit a Plan/Attestation Statement within 10 calendar days.
Report Facts
Correction timeframe: 45
Plan/Attestation Statement submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Fueston | IDR Program Manager | Author of the IDR results letter |
| Gwin Kaercher | Field Manager | Recipient of Plan/Attestation Statement |
Notice
Deficiencies: 0
Oct 19, 2023
Visit Reason
The document confirms the scheduling of an Informal Dispute Resolution (IDR) meeting requested by the facility administrator to dispute a citation from a Statement of Deficiencies dated October 19, 2023.
Findings
The letter does not contain inspection findings but addresses the dispute process for a specific citation (WAC 388-78A-2660) and provides details about the scheduled IDR meeting.
Report Facts
Citation date: Oct 19, 2023
Scheduled IDR date: Dec 13, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heather Steiling | Administrator | Facility representative participating in the IDR process |
| Shannon Wiseman | District Director of Operations | Facility representative participating in the IDR process |
| Dahna Gates | District Director of Clinical Services | Facility representative participating in the IDR process |
| Rebecca Fueston | IDR Program Manager | Sender of the scheduling letter |
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 2
Oct 17, 2023
Visit Reason
The inspection was conducted as an unannounced on-site complaint investigation regarding allegations of missing money at the Assisted Living Facility.
Findings
The investigation found that the facility failed to protect residents' rights by requiring residents to sign waivers of liability for lost money and personal property for 3 residents, and failed to provide lockable storage space for residents' valuables. The facility had an increase in cases of residents missing cash, with no conclusive findings on the perpetrator. The follow-up inspection found no deficiencies and confirmed correction of previous issues.
Complaint Details
The complaint investigation was triggered by allegations of missing money. The facility was found to have failed provider practices with citations written. The complaint was substantiated with findings related to resident rights violations and lack of secure storage.
Deficiencies (2)
| Description |
|---|
| Failed to protect residents’ rights by requiring residents to sign waivers of liability for lost money and personal property for 3 residents. |
| Failed to provide a lockable drawer or cabinet for 3 residents, placing them at risk of personal property loss. |
Report Facts
Total residents: 103
Resident sample size: 3
Former residents sample size: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Cairns | ALF Long Term Care Surveyor | Investigator who conducted the complaint investigation |
| Jessica Clapp | Assisted Living Facility Licensor | Department staff who investigated the facility |
| Tracy Ramirez | Assisted Living Facility Licensor | Department staff who did on-site verification during follow-up inspection |
| Gwin Kaercher | Field Manager | Signed follow-up inspection letter |
| Staff A | Executive Director / Administrator | Facility staff who provided statements during investigation and follow-up |
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 1
Sep 5, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding an allegation that an identified resident did not receive diabetic medications as ordered.
Findings
The investigation confirmed that the identified resident received incorrect insulin doses twice due to transcription and administration errors, resulting in the resident requiring medical intervention and evaluation. Deficient practice was identified and citations were written related to medication services.
Complaint Details
The complaint alleged that an identified resident did not receive diabetic medications as ordered. The investigation substantiated this allegation, confirming transcription and insulin administration errors that caused the resident to receive extra insulin doses twice, requiring emergency medical evaluation.
Deficiencies (1)
| Description |
|---|
| Failure to ensure safe medication systems for residents, resulting in incorrect insulin administration to Resident 1. |
Report Facts
Total residents: 95
Resident sample size: 5
Incorrect insulin doses: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laurel Knight | Community Complaint Investigator | Conducted the on-site complaint investigation |
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 2
May 30, 2023
Visit Reason
The inspection was conducted as a complaint investigation following allegations that a named resident missed several doses of medications and that a narcotic pain medication went missing from the Assisted Living Facility.
Findings
The investigation found that the facility failed to ensure residents had updated physician orders and did not follow policies for medication administration and controlled medication tracking. Two failed provider practices were identified under WAC 388-78A-2210, resulting in citations.
Complaint Details
The complaint involved a named resident missing several doses of mood stabilizer and sleeping medications, and a separate allegation that a named resident's narcotic pain medication went missing. Both complaints were substantiated with failed provider practices identified and citations written.
Deficiencies (2)
| Description |
|---|
| Failure to ensure residents had updated physician orders and received all medications as prescribed. |
| Failure to properly log and store controlled narcotic medications, resulting in missing medication. |
Report Facts
Total residents: 104
Resident sample size: 4
Medication missed days: 3
Medication missed days: 4
Controlled substance tablets: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robin Rainville | Assisted Living Facility Licensor | Investigator who conducted the complaint investigation |
| Tracy Ramirez | Assisted Living Facility Licensor | Department staff who did the on-site verification during follow-up inspection |
| Gwin Kaercher | Field Manager | Signed follow-up inspection letter |
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 1
Apr 18, 2023
Visit Reason
The inspection was conducted as an unannounced on-site complaint investigation regarding allegations that medications were not stored securely and in a clean manner.
Findings
The investigation found that medications were stored unlocked and in an unclean area, failing to follow the facility's medication storage policy. This failure placed residents at risk and was documented as a failed provider practice with citations issued.
Complaint Details
The complaint alleged that medications were not stored securely and in a clean manner. The complaint was substantiated with failed provider practice identified and citations written.
Deficiencies (1)
| Description |
|---|
| Medications were stored unlocked and in an unclean area, failing to follow the facility's policy for secure and clean medication storage. |
Report Facts
Total residents: 97
Resident sample size: 3
Closed records sample size: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Mullins | Investigator | Investigator who conducted the complaint investigation |
| Laurel Knight | Community Complaint Investigator | Department staff who did the on-site verification during follow-up inspection |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jan 18, 2023
Visit Reason
The inspection was conducted in response to a complaint (#65541) regarding flooding and fire watch at the facility.
Findings
On 12/21/2022, a sprinkler pipe in the attic broke and flooded multiple floors, triggering the fire alarm system and fire watch until the system was restored on 01/17/2023. Six residents were relocated within the building, no injuries occurred, and facility staff responded according to the emergency plan.
Complaint Details
Complaint #65541 regarding flooding and fire watch due to sprinkler pipe failure. No injuries reported. Fire watch was maintained until system restoration.
Deficiencies (1)
| Description |
|---|
| Sprinkler pipe failure causing flooding on multiple floors and activation of fire alarm system. |
Report Facts
Number of residents relocated: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Doug DeGraff | Deputy State Fire Marshal | Named as the Deputy State Fire Marshal conducting the inspection. |
| Heather Stilling | Executive Director | Owner or Authorized Representative who signed the document. |
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 3
Sep 12, 2022
Visit Reason
The complaint investigation was conducted due to allegations that a named resident's bedding and clothing were soiled with urine, the room was dirty and smelled bad, and that the resident was not repositioned during end-of-life care.
Findings
The investigation found deficient practices in maintenance and housekeeping related to dirty rooms, unpleasant smells, and uncovered food trays left in hallways. The facility failed to follow safe medication administration policies for two residents, placing them at risk. One resident developed a 5x5 cm skin breakdown and was receiving wound care. Facility staff had not informed the resident's representative about the wounds or reports to the department hotline.
Complaint Details
The complaint investigation was substantiated with failed provider practices identified and citations written. Allegations included soiled bedding and clothing, dirty and smelly room, and failure to reposition a resident during end-of-life care. The investigation confirmed these issues and found additional medication administration deficiencies.
Deficiencies (3)
| Description |
|---|
| Failure to follow policies on safe medication administration for two residents, including leaving medications unattended and not observing ingestion. |
| Deficient maintenance and housekeeping practices resulting in dirty rooms, unpleasant smells, and uncovered food trays left in hallways. |
| Failure to reposition a resident frequently, resulting in a 5x5 cm area of skin breakdown. |
Report Facts
Total residents: 109
Resident sample size: 5
Skin breakdown size: 25
Correction timeframe: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laurel Knight | Community Complaint Investigator | Investigator who conducted the complaint investigation |
| Felicia Cantu | Community Complaint Investigator | Investigator who conducted the complaint investigation |
| Robin Rainville | Assisted Living Facility Licensor | Staff who conducted follow-up inspection |
| Michelle Closner | Field Manager | Field Manager who issued enforcement letter |
| Staff B | Medication Technician | Named in medication administration deficiency for leaving medications unattended |
| Staff A | Administrator | Commented on medication technician's experience and policy knowledge |
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 2
Aug 18, 2022
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations that a named resident was found requiring medical attention and soaked in urine.
Findings
The investigation found failed provider practices related to monitoring residents' well-being, including failure to identify and respond to significant weight loss and skin breakdown in residents. The facility failed to provide adequate assistance with toileting and care, contributing to delays in treatment and placing residents at risk.
Complaint Details
The complaint alleged that a named resident was found requiring medical attention and soaked in urine. The investigation substantiated failed provider practices and citations were written.
Deficiencies (2)
| Description |
|---|
| Failure to monitor, identify changes in residents' conditions, and take appropriate action for two of five residents reviewed, contributing to delays in treatment and risk to residents. |
| Failure to ensure staff followed policies and procedures for care and services for Resident 5, contributing to delays in addressing weight loss and skin breakdown. |
Report Facts
Total residents: 109
Resident sample size: 5
Weight loss percentage: 18
Wound size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Ramirez | Assisted Living Facility Licensor | Investigator who conducted the complaint investigation |
| Michelle Closner | Complaint Nurse Field Manager | Department staff who did on-site verification and signed report |
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