Inspection Reports for Cogir of Vancouver

10011 NE 118th Ave, Vancouver, WA 98682, United States, WA, 98682

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Inspection Report Life Safety Deficiencies: 3 Aug 7, 2025
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The Office of the State Fire Marshal conducted a fire protection inspection at the residential care facility located at 10011 NE 118TH AVE, Vancouver, WA.
Findings
The inspection found that all violations noted during previous related inspections have been corrected. However, prior re-inspections on 2025-05-16 and 2025-03-27 identified multiple violations related to sprinkler system testing and maintenance, commercial cooking system fire-extinguishing requirements, fire alarm system inspection and testing, and inspection/testing/maintenance procedures.
Deficiencies (3)
Description
Facility failed to provide forward flow testing of the backflow device and 10 year dry pendant fire sprinkler head testing or replacement and 20 year quick response testing or replacement.
Instructions not provided to new employees on hiring and to all employees annually on the use of portable fire extinguishers and the manual actuation of the fire-extinguishing system; records of compliance not maintained and available.
Facility failed to provide semi-annual fire alarm system inspection and testing.
Report Facts
Next inspection scheduled date: Jun 15, 2025 Next inspection scheduled date: Apr 26, 2025
Employees Mentioned
NameTitleContext
Nicholas D. WoldenDeputy State Fire MarshalSigned inspection reports and noted as Deputy State Fire Marshal
Debbie WooderyExecutive DirectorSigned as Owner or Authorized Representative and Executive Director
Jay TetlowMaintenance DirectorSigned as Owner or Owner's Representative
Inspection Report Follow-Up Census: 68 Deficiencies: 1 May 16, 2025
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The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously identified deficiencies related to mandated reporting requirements.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies related to staff education on mandated reporting were corrected.
Complaint Details
Complaint investigation regarding allegations that facility staff were not knowledgeable on mandated reporting requirements. The investigation identified a failed provider practice and citations were written.
Deficiencies (1)
Description
Facility staff failed to educate on mandatory reporting requirements, placing residents at risk of unreported abuse.
Report Facts
Total residents: 68 Resident sample size: 3 Staff members not educated: 8
Employees Mentioned
NameTitleContext
Jacob UblALF NCI CIDepartment staff who conducted on-site verification and investigation
Clinton FridleyAdult Family Home Nurse Field ManagerSigned follow-up inspection letter and statement of deficiencies
Inspection Report Re-Inspection Deficiencies: 4 May 16, 2025
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The Office of the State Fire Marshal conducted a re-inspection at the residential care facility located at 10011 NE 118TH AVE, Vancouver, WA 98661, to verify correction of previously identified fire safety violations.
Findings
The facility failed to provide required inspection reports including forward flow testing of the backflow device, 10 year dry pendant fire sprinkler head testing or replacement, and 20 year quick response testing or replacement. Additionally, the facility failed to provide semi-annual fire alarm system inspection and testing, and kitchen semi-annual hood suppression systems report identified required corrections due to changes in cooking appliances and nozzle coverage.
Deficiencies (4)
Description
Facility failed to provide forward flow testing of the backflow device.
Facility failed to provide 10 year dry pendant fire sprinkler head testing or replacement and 20 year quick response testing or replacement.
Facility failed to provide semi-annual fire alarm system inspection and testing.
Kitchen semi-annual hood suppression systems report identified required corrections due to a change in cooking appliances and nozzle coverage.
Report Facts
Next inspection scheduled date: Jun 15, 2025
Employees Mentioned
NameTitleContext
Debbie WooderyExecutive DirectorSigned as Owner or Authorized Representative on re-inspection report dated 03/27/2025
Nicholas D. WoldenDeputy State Fire MarshalSigned as Deputy State Fire Marshal on inspection reports
Inspection Report Follow-Up Census: 54 Deficiencies: 2 May 14, 2025
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The Department completed a follow-up inspection of the Assisted Living Facility on 05/14/2025 to verify correction of previously cited deficiencies related to medication services and resident records.
Findings
The follow-up inspection found no deficiencies, indicating that the facility corrected the previously cited issues regarding medication services and resident records.
Deficiencies (2)
Description
Failure to develop and implement systems that support and promote safe medication services for residents, resulting in inconsistent medication administration documentation for 8 of 10 residents.
Failure to maintain adequate resident records to effectively provide care and respond to emergencies, including inaccurate documentation of resident care needs for 4 of 10 sampled residents.
Report Facts
Residents sampled: 10 Current residents census: 54 Residents with medication documentation issues: 8 Residents with inaccurate care needs documentation: 4
Employees Mentioned
NameTitleContext
Clinton FridleyAdult Family Home Nurse Field ManagerSigned report and conducted follow-up inspection
Debbie WooleryAdministratorSigned acknowledgment and plan of correction
Jacob UblALF NCI CIDepartment staff who inspected the Assisted Living Facility
Jennifer SiharathALF LicensorDepartment staff who inspected the Assisted Living Facility
Kyle GehlenALF Licensor - LTCDepartment staff who inspected the Assisted Living Facility
Staff AExecutive DirectorAcknowledged department findings and failed practice in documentation
Staff BHealth and Wellness DirectorConfirmed resident receiving home health services
Staff CRegional Health Services DirectorAcknowledged failed practice in documentation and need for further training
Inspection Report Follow-Up Deficiencies: 0 Mar 5, 2025
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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 previously cited deficiencies related to resident rights and reporting abuse and neglect were corrected.
Report Facts
Total residents: 70 Resident sample size: 3 Complaint investigation dates: 2024-11-19 to 2024-12-12 Citation count: 2
Employees Mentioned
NameTitleContext
Jacob UblInvestigatorConducted complaint investigation and follow-up inspection
Clinton FridleyAdult Family Home Nurse Field ManagerSigned follow-up inspection letter
Staff AExecutive DirectorReported on facility practices regarding resident rights and abuse reporting
Staff BAnonymous reporterReported on visitation restrictions and abuse reporting practices
Staff CAnonymous reporterReported on visitation restrictions and abuse reporting practices
Staff DCaregiverReported on abuse reporting practices
Staff ECaregiverReported on abuse reporting practices and observed abuse incident
Staff FCaregiverReported on abuse reporting practices
Collateral Contact 1Ombuds for Resident 1Reported on resident rights violation and abuse allegations
Collateral Contact 2Power of Attorney for Resident 1Directed facility visitation restrictions
Inspection Report Complaint Investigation Census: 65 Deficiencies: 1 Feb 20, 2025
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The Department completed a complaint investigation of the Assisted Living Facility based on complaints alleging the facility was resistant to issuing a refund to a resident's representative and that refunds were issued late.
Findings
The investigation found that the facility failed to provide a refund timely to a resident representative within 30 days of the resident's discharge. Other resident representatives reported receiving refunds within the required timeframe. No other failed facility practices were substantiated.
Complaint Details
Complaint investigation included allegations of fraud/false billing related to delayed refunds to resident representatives. The facility was found to have failed practice regarding timely refund issuance. Other allegations were not substantiated.
Deficiencies (1)
Description
Facility failed to provide a refund timely to a resident representative within 30 days of discharge.
Report Facts
Total residents: 65 Resident sample size: 4 Days late for refund: 8
Employees Mentioned
NameTitleContext
Jacob UblALF NCI CIDepartment staff who did the inspection and provided consultation
Clinton FridleyAdult Family Home Nurse Field ManagerSigned letter regarding the complaint investigation
Inspection Report Life Safety Deficiencies: 1 Apr 25, 2024
Visit Reason
The Office of the State Fire Marshal conducted an inspection of the facility to assess compliance with fire safety regulations.
Findings
On the 04/25/2024 inspection, all violations noted during previous related inspections were corrected. However, on a prior inspection dated 03/07/2024, the facility was found to have emergency lighting inoperative throughout the building, possibly caused by the generator, resulting in a disapproval status.
Deficiencies (1)
Description
Facility emergency lights inoperable throughout building possibly caused by generator
Report Facts
Next inspection scheduled: Apr 6, 2024
Employees Mentioned
NameTitleContext
Nicholas D. WoldenDeputy State Fire MarshalSigned inspection reports and conducted inspection
Jay TetleyOwner or Authorized Representative who signed the report
Inspection Report Complaint Investigation Census: 63 Deficiencies: 1 Dec 26, 2023
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The Department completed a complaint investigation of the Assisted Living Facility due to a reported COVID outbreak and infection control concerns.
Findings
The facility failed to have its staff don and doff gowns according to Federal Centers for Disease Control recommendations during a coronavirus outbreak. Staff were reusing disposable gowns for the duration of their shifts instead of discarding them after each use.
Complaint Details
Complaint number 105725 regarding infection control during a COVID outbreak was investigated and substantiated with a failed provider practice identified and citation(s) written.
Deficiencies (1)
Description
Failure to have staff don and doff gowns properly according to CDC recommendations during a coronavirus outbreak, with staff reusing disposable gowns instead of discarding them after each use.
Report Facts
Total residents: 63 Resident sample size: 3 Closed records sample size: 0
Employees Mentioned
NameTitleContext
Jacob UblALF NCI CIDepartment staff who conducted the inspection and provided consultation
Jody JustField ManagerRegion 3, Unit I Residential Care Services, signed the letter
Inspection Report Complaint Investigation Census: 3 Deficiencies: 2 Sep 26, 2023
Visit Reason
The inspection was conducted as an unannounced on-site complaint investigation regarding allegations that the facility was not providing residents' medications as prescribed and was documenting incorrect medication delivery times.
Findings
The investigation identified failed practices where the facility did not provide medication as prescribed for a resident and documented incorrect medication administration times. The facility was found not in compliance with Assisted Living Facility requirements.
Complaint Details
The complaint investigation was based on allegations of poor quality of care/treatment related to medication administration and falsification of records regarding medication delivery times. The investigation substantiated these allegations with failed practices identified.
Deficiencies (2)
Description
The facility failed to implement safe medication services for 1 of 3 residents reviewed, placing the resident at risk due to not receiving prescribed medication as ordered by the prescribing Primary Care Provider.
The facility was not documenting the correct times that medications were provided, with medications frequently documented several hours later than the prescribed times.
Report Facts
Total residents: 3 Resident sample size: 3 Closed records sample size: 0
Employees Mentioned
NameTitleContext
Jacob UblInvestigatorConducted the complaint investigation
Debbie WooleryAdministratorSigned the Plan of Correction attesting to corrective actions
Debra ComptonResponsible Person for CorrectionNamed in the Plan of Correction for medication services
Staff AHealth and Wellness DirectorReported changing medication prescription without proper authorization
Staff BExecutive DirectorReported regulatory violation regarding prescription order changes
Staff CMedication TechnicianDocumented medication administration and faxed notes
Inspection Report Follow-Up Census: 61 Deficiencies: 3 Jun 22, 2023
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, indicating that the facility meets the Assisted Living Facility licensing requirements. The prior deficiencies related to nursing services, signing negotiated service agreements, and training/certification requirements were corrected.
Deficiencies (3)
Description
Failure to ensure documentation of nurse delegation training for staff prior to delegation.
Failure to ensure negotiated service agreements were signed annually by responsible parties for sampled residents.
Failure to ensure staff had updated first aid and CPR training certifications.
Report Facts
Residents sampled for review: 11 Residents total census: 61 Sampled staff with missing nurse delegation documentation: 2 Sampled residents with unsigned negotiated service agreements: 4 Sampled staff without updated CPR/first aid training: 2
Employees Mentioned
NameTitleContext
Jennifer SiharathALF LicensorDepartment staff who did the off-site verification
Kyle GehlenALF Licensor - LTCDepartment staff who did the off-site verification and inspected the facility
Jacob UblALF NCI CIDepartment staff who inspected the facility
Debbie WooleryAdministratorSigned Plan/Attestation Statements and responsible for correction plans
Inspection Report Life Safety Deficiencies: 28 Mar 13, 2023
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the facility to assess compliance with fire protection and life safety codes.
Findings
The facility was found to have multiple deficiencies including failure to provide required annual fire-resistance inspections, missing or non-functional fire safety devices, lack of documentation for fire and safety system testing and maintenance, blocked egress paths, unsecured compressed gas tanks, and failure to provide required fire drill reports.
Deficiencies (28)
Description
Sprinkler riser room in kitchen lien within 3 feet of wall heater
Power strip plugged into power strip in Activities office
Facility failed to provide annual fire-resistance-rated construction inspection report
Drywall peeling on ceiling in storage room across from nursing office
Drywall peeling in private dining room on the ground floor
Facility failed to provide fire door annual inspection report
FACP room on ground floor has greater than 5% non-approved material covering a fire door
No approved auxiliary device restricting fire door to close properly in care station 2
Fire hatch open in maintenance storage area in ceiling
Fire door blocked and not able to close
Self closer removed on health & wellness office door
Facility failed to provide 4-year damper inspection report
Facility failed to provide verification that all dry sprinkler heads on outside decks have been inspected in last 10 years
Facility failed to provide 5 year fire sprinkler inspection report
Facility failed to provide annual fire sprinkler inspection report
Facility failed to provide annual forward flow test report
Facility failed to provide first and second semi-annual servicing of hood suppression system
Facility failed to provide annual fire alarm inspection report
Facility failed to provide 5-year FDC hydro testing report
Facility failed to provide documentation of monthly carbon monoxide testing
Emergency egress door in memory care had required signage covered
Exit and emergency lights battery testing and 30 second monthly activation test not provided; exit sign marked 18 not illuminating
Facility failed to provide annual 90 minute power test report
Blocked exit door with chair in memory care TV room
Facility failed to provide annual generator servicing and log of weekly inspection and monthly 30 minute full load test
CO2 tanks in kitchen failed to be properly secured
Life safety panel found with no locking device on breakers for fire alarm system
Facility failed to provide fire drill reports as required
Report Facts
Next inspection scheduled date: Apr 12, 2023
Employees Mentioned
NameTitleContext
Jay TetleyMaintenanceSigned as Owner or Authorized Representative
Nicholas WoldenDeputy State Fire MarshalConducted the inspection and signed the report

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