Inspection Report Summary
The most recent inspection on May 20, 2025, found a deficiency related to the facility’s failure to notify a resident’s case manager upon hospital discharge. Earlier inspections showed a pattern of fire safety issues, including missing documentation, unapproved equipment, and inadequate fire drills, with multiple citations issued from 2023 through mid-2024. Other deficiencies involved administrative practices such as failure to provide refunds and improper handling of discharged residents’ belongings. Complaint investigations were mostly substantiated when conducted, with no enforcement actions like fines or license suspensions listed in the available reports. The facility’s record shows some improvement in administrative compliance by early 2025, but fire safety issues persisted through mid-2024 without full resolution.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
16.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
165% worse than Washington average
Washington average: 6.3 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 20, 2025
Visit Reason
The Department completed a complaint investigation of the Assisted Living Facility on 05/20/2025 due to complaint number 163920, which included allegations regarding a resident being unkept, a wound upon discharge to hospital, and failure to inform the case manager of discharge.
Complaint Details
Complaint investigation included allegations of resident unkept, resident had wound upon discharge to hospital, and case manager not informed of discharge. The failed practice was identified only for failure to notify the case manager of discharge.
Findings
The investigation found that the facility failed to notify the resident's case manager of the discharge to the hospital, constituting a failed practice. There was insufficient information to support failed practice regarding the resident being unkept or the wound upon discharge. A consultation was written as the facility corrected the notification issue.
Deficiencies (1)
Failed to notify the resident’s case manager when the resident was discharged to the hospital.
Report Facts
Complaint number: 163920
Compliance Determination number: 55252
Resident sample size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carol Gijima | Community Complaint Investigator (NCI) | Department staff who did the inspection and provided consultation |
| Jody Just | Field Services Administrator | Signed letter providing instructions and contact information |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Apr 9, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to licensing laws and regulations.
Complaint Details
Complaint investigation found that a discharged resident was charged fees not owed and the facility failed to issue a refund owed to the resident. The investigation concluded with a failed provider practice identified and citation(s) written.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets the Assisted Living Facility licensing requirements. A prior complaint investigation found that the facility failed to provide a refund to a discharged resident, which was corrected by the time of the follow-up.
Deficiencies (1)
Failure to provide a refund to a discharged resident within the required timeframe as per RCW 70.129.150 regarding disclosure of fees and notice requirements for deposits.
Report Facts
Compliance Determination Completion Date: Apr 9, 2025
Compliance Determination Completion Date: Feb 20, 2025
Investigation Date Range: Complaint investigation conducted from 2025-02-11 through 2025-02-20
Closed records sample size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Mason | NCI ALF Licensor | Department staff who conducted the on-site verification and complaint investigation |
| Manfay Chan | Allied Health Field Manager | Signed the follow-up inspection letter |
| Staff A | Lead Director of Resident Services | Interviewed during complaint investigation acknowledging refund owed |
| Staff B | Administrator | Provided facility policy on refunds during complaint investigation |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 7, 2025
Visit Reason
The Department completed a full inspection of the Assisted Living Facility on 01/07/2025.
Findings
The inspection found no deficiencies in the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Carmichael | Nursing Consultant Institutional | Department staff who did the inspection |
| Shirley Grew | LTC Surveyor | Department staff who did the inspection |
| Kathy Heinz | Long Term Care Surveyor | Department staff who did the inspection |
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 1
Date: Jun 11, 2024
Visit Reason
The inspection was conducted as an unannounced on-site complaint investigation due to the facility failing the 3rd Fire Safety Inspection.
Complaint Details
A complaint investigation was initiated due to the facility failing the 3rd Fire Safety Inspection. The investigation concluded with a failed provider practice identified and citations written.
Findings
The facility failed to meet all the requirements for the third fire safety inspection, placing all 110 residents at risk for harm. Numerous deficiencies from previous inspections dated 01/02/2024, 03/06/2024, and 05/28/2024 had not been corrected. The Administrator and Environmental Services Director acknowledged the outstanding issues and ongoing follow-up.
Deficiencies (1)
Failure to comply with fire and life safety inspection requirements as evidenced by failure of the 3rd Fire Safety Inspection.
Report Facts
Total residents: 110
Resident sample size: 0
Closed records sample size: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Mason | NCI ALF Licensor | Investigator who conducted the on-site verification and complaint investigation |
Inspection Report
Re-Inspection
Deficiencies: 18
Date: Mar 6, 2024
Visit Reason
The Office of the State Fire Marshal conducted a re-inspection at the Cascade Park Vista facility to verify correction of previous fire safety deficiencies.
Findings
The facility was found to have multiple unresolved fire safety violations including missing fire sprinkler system documentation, uninspected fire doors, unserviced kitchen hood suppression systems, fire alarm system issues, unracked oxygen cylinders, and failure to conduct required fire drills.
Deficiencies (18)
Unable to provide fire sprinkler system documentation including quarterly inspection reports, annual confidence test, 3-year full flow trip test, 5-year inspection/test reports, and annual forward flow test for backflow control valve.
Loaded sprinkler head found in dish washing room near air supply vent.
Ordinary-rated fire sprinkler head found in walk-in cooler; replacement with high temperature head required.
Multiple unprotected penetrations found throughout building ceilings and corridor walls with no plans to identify fire-resistance rating.
Facility failed to produce an inventory of all fire-resistance-rated construction as indicated on building's as-built/life safety plans.
Unable to provide reports showing two semi-annual kitchen hood suppression system servicings and cleanings in past 12 months; kitchen hood found yellow-tagged with tag date January 2022.
Unable to provide signage on exhaust hood or system cabinet indicating type and arrangement of cooking appliances protected by hood suppression system.
Unable to provide heat survey report showing correct fusible link rating for hood suppression system.
Fire alarm system found in silence mode with unknown cause; unable to provide documentation showing correction of deficiencies noted in January 26, 2024 annual fire alarm system confidence report.
Unable to provide documentation showing annual servicing of fire alarm system and smoke detector sensitivity testing in past 5 years.
Unable to provide documentation showing monthly inspection of carbon monoxide alarms in past 12 months.
Exit sign between rooms 534/535 failed to illuminate on battery backup when tested.
Unable to provide documentation showing 30-second monthly battery testing and 90-minute annual battery testing of emergency lighting and exit signs in past 12 months.
Found 17 unracked oxygen cylinders in 4th floor oxygen storage room; staff education required.
Multiple fire doors throughout facility found with painted frame labels, missing hardware screws, door gaps exceeding allowed clearances, and unable to produce last annual fire door inspection report.
Facility failed to conduct/document twelve planned and unannounced fire drills in past 12 months; missing documentation for night shift drill 3rd quarter 2023 and day shift drill 2nd quarter 2023.
Unapproved portable space heaters found in activities office.
Hardware on fire door to main boiler/electrical room modified with self-closing hinges installed with plastic parts.
Report Facts
Unracked oxygen cylinders: 17
Fire drills missing: 2
Fire drills required annually: 12
Sprinkler system quarterly inspections missing: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lysandra Davis | Deputy State Fire Marshal | Signed inspection report |
Inspection Report
Re-Inspection
Deficiencies: 13
Date: Jan 2, 2024
Visit Reason
The Office of the State Fire Marshal conducted a re-inspection of the facility to verify correction of previously cited fire safety violations.
Findings
The facility was found to have multiple unresolved fire safety violations including lack of documentation for fire sprinkler system inspections, kitchen hood cleanings, fire alarm servicing, emergency lighting tests, and fire drills. Physical deficiencies included loaded sprinkler heads, unapproved portable heaters, unsecured oxygen cylinders, and multiple fire doors with missing hardware and excessive gaps.
Deficiencies (13)
Unable to provide fire sprinkler system documentation including quarterly inspection reports, annual confidence test, 3-year full flow trip test, 5-year inspection/test reports, and annual forward flow test for backflow control valve.
Loaded sprinkler head found in dish washing room near air supply vent.
Ordinary-rated fire sprinkler head found in walk-in cooler; replacement with high temperature head required.
Unable to provide reports showing two semi-annual kitchen hood suppression system servicings in past 12 months; kitchen hood yellow-tagged with tag date January 2022 and no documentation of correction.
Fire alarm system found in silence mode; unable to provide documentation of annual servicing and smoke detector sensitivity testing in past 5 years.
Unable to provide documentation of monthly inspection of carbon monoxide alarms in past 12 months.
Exit sign between rooms 534/535 failed to illuminate on battery backup when tested.
Unable to provide documentation of monthly 30-second battery testing and annual 90-minute battery testing of emergency lighting and exit signs.
Unapproved portable electric space heaters found in activities office.
Facility failed to conduct/document twelve planned and unannounced fire drills in past 12 months; missing night shift drill for 3rd quarter 2023 and day shift drill for 2nd quarter 2023.
Multiple fire doors throughout facility had painted frame labels, missing hardware screws, and door gaps exceeding allowed clearances.
Hardware on fire door to main boiler/electrical room modified with plastic parts on self-closing hinges.
Seventeen unracked oxygen cylinders found in 4th floor oxygen storage room; staff education required.
Report Facts
Unracked oxygen cylinders: 17
Fire drills missing: 2
Fire drills required annually: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lysandra Davis | Deputy State Fire Marshal | Signed the inspection report |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 9, 2023
Visit Reason
The Department completed a complaint investigation of the Assisted Living Facility related to allegations that deceased resident belongings were discarded by the facility.
Complaint Details
Complaint investigation included complaint numbers 92935, 95912, 98032, 99625, 99706. The allegation was that deceased resident belongings were discarded by the facility. The complaint was substantiated with failed provider practice identified and citations written.
Findings
The investigation found that facility staff removed personal belongings from a discharged resident's apartment before the resident representative completed sorting them. The facility added a new policy for discharged residents' belongings and made monetary restitution to the resident representative. A failed provider practice was identified and citations were written.
Deficiencies (1)
Facility staff removed personal belongings from a discharged resident's apartment before the resident representative completed sorting them.
Report Facts
Resident sample size: 2
Closed records sample size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Mason | NCI ALF Licensor | Investigator who conducted the inspection and provided consultation |
| Manfay Chan | Field Manager | Signed the letter regarding the complaint investigation |
Inspection Report
Life Safety
Deficiencies: 15
Date: Feb 16, 2023
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the Cascade Park Vista residential care facility on 02/16/2023.
Findings
Multiple fire safety violations were observed including storage of combustible materials in prohibited areas, use of non-approved electric heaters, improper power strip usage, lack of required cleaning and maintenance records, unsealed penetrations in fire-resistance-rated construction, failure of fire doors to self-close, exit signs not illuminated on battery backup, and missing documentation for emergency lighting and fire drills.
Deficiencies (15)
Multiple large furniture pieces stored in the 2nd floor mechanical/boiler room - storage of combustible material prohibited in mechanical/boiler rooms.
Non-approved space heater, without tip-over safety shut-off, found in the activities office.
Found power strip plugged into another power strip in the nurse's office–behind desk.
Unable to provide reports showing that two semi-annual kitchen hood cleanings were performed in the past 12 months.
Unable to provide annual inventory records showing that all fire-resistance-rated construction has been inspected/repaired in the past 12 months.
Unsealed penetration in wall above door to third floor storage room, near ceiling.
Unsealed penetration inside third floor storage room on corridor wall.
Unable to provide record showing that fire doors have been annually inspected, tested and repaired in the past 12 months.
Third floor, south exit stairwell door failed to be self-closing.
Second floor dish room door failed to be self-closing.
Cinema room double doors failed to be self-closing.
Exit light above the second floor south exit door failed to illuminate on battery backup when tested.
Unable to provide documentation showing that 30-second monthly battery testing of the facility's emergency lighting and exit signs has been performed in the last 12 months.
Unable to provide documentation showing that 90-minute annual battery testing of the emergency lighting and exit signs has been performed in the past 12 months.
Unable to provide records showing that twelve planned and unannounced fire drills have been conducted in the past 12 months; must be performed quarterly for each shift.
Report Facts
Fire drills required: 12
Fire drills frequency: 4
Emergency lighting test duration: 30
Emergency lighting battery test duration: 90
Next inspection scheduled on or after: Mar 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lysandra Davis | Deputy State Fire Marshal | Conducted the inspection and signed the report. |
| Harry Pickham | Director EVS | Owner or Authorized Representative who signed the report. |
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