Inspection Reports for Covenant Living at the Shores
9150 Fortuna Dr, Mercer Island, WA 98040, United States, WA, 98040
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Follow-Up
Census: 38
Deficiencies: 7
Oct 4, 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.
Deficiencies (7)
| Description |
|---|
| Failed to ensure Washington State name and date of birth background inquiry (BGI) was renewed before expiration for staff, resulting in residents receiving services from staff with unknown criminal background history. |
| Failed to ensure staff received specialty training for dementia and mental health, placing residents at risk due to untrained care staff. |
| Failed to ensure tuberculosis screening was initiated within three days of employment for staff, placing residents at risk for contracting TB. |
| Failed to implement a Respiratory Protection Program including respirator mask fit-testing for healthcare workers, placing residents, staff, and visitors at risk for exposure to COVID-19. |
| Failed to ensure prescribed medications were available for residents requiring medication assistance, causing residents to go without prescribed medications and placing them at risk for medical complications. |
| Failed to secure toxic chemicals in an area accessible to residents, placing residents at risk for inadvertent ingestion of toxic substances. |
| Failed to develop and implement policies and procedures to ensure timely availability of prescribed medications for residents. |
Report Facts
Residents present during inspection: 38
Sample size: 5
Sample size: 8
Residents with dementia or cognitive impairment: 24
Residents with dementia or cognitive impairment: 25
Residents with mental health diagnosis: 1
Residents with behavior or psychosocial health issues: 7
Residents on assisted living floor: 28
Residents with dementia or cognitive impairment on second floor: 15
Residents at risk due to unrenewed background checks: 38
Staff with expired background checks: 2
Staff without specialty training: 1
Staff without timely tuberculosis screening: 1
Staff without two-step tuberculosis skin testing: 1
Staff without respiratory mask fit-testing: 2
Residents at risk due to unsecured toxic chemicals: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Dining Services Aide | Named in deficiency for expired background check not renewed before expiration |
| Staff H | Human Resources Manager | Interviewed regarding missed background check renewals and tuberculosis screening |
| Staff A | Licensed Practical Nurse | Named in deficiency for lack of specialty training for dementia and mental health and incomplete two-step tuberculosis skin testing |
| Staff C | Activities Coordinator | Named in deficiency for failure to initiate tuberculosis screening within three days of employment |
| Staff F | Assisted Living Director | Interviewed regarding specialty training, medication availability, and respiratory protection program |
| Staff E | Certified Nursing Assistant | Named in deficiency for expired background check not renewed before expiration and lack of respiratory mask fit-testing |
| Staff G | Nursing Supervisor | Interviewed regarding medication availability and refill procedures |
| Staff J | Housekeeper | Observed leaving housekeeping cart unlocked with toxic chemicals accessible to residents |
Inspection Report
Follow-Up
Census: 38
Deficiencies: 4
Aug 7, 2024
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to Covenant Living West to assess correction of previously cited deficiencies and to impose civil fines based on ongoing violations.
Findings
The facility failed to renew a staff member's Washington State background check, failed to provide required specialty training for dementia and mental health, did not initiate tuberculosis screening within three days of employment for one staff, and failed to implement a Respiratory Protection Program including respirator mask fit-testing. These deficiencies were uncorrected and recurring from prior citations.
Deficiencies (4)
| Description |
|---|
| Failure to renew Washington State name and date of birth background inquiry for one staff before two-year expiration. |
| Failure to ensure one staff received specialty training for dementia and mental health. |
| Failure to initiate tuberculosis screening within three days of employment for one staff. |
| Failure to implement Respiratory Protection Program including respirator mask fit-testing for healthcare workers. |
Report Facts
Residents affected: 38
Civil fines total: 1400
Civil fine: 400
Civil fine: 300
Civil fine: 300
Civil fine: 400
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Singer | Field Manager | Contact person for the Statement of Deficiencies and follow-up communication. |
| Matt Hauser | Compliance Specialist | Signed the enforcement letter regarding civil fines. |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Sep 5, 2023
Visit Reason
The inspection was conducted due to a complaint alleging that a named resident did not receive ordered medications from the Assisted Living Facility.
Findings
The investigation found that the facility staff failed to transcribe new medication orders, resulting in the resident not receiving the prescribed medications. A citation was issued for this deficiency.
Complaint Details
The complaint alleged that the Named Resident did not receive ordered medications from the Assisted Living Facility. The investigation substantiated this failure, citing WAC 388-78A-2210(1)(b)(2).
Deficiencies (1)
| Description |
|---|
| Failure to transcribe new medication orders resulting in a resident not receiving prescribed medications. |
Report Facts
Total residents: 35
Resident sample size: 2
Closed records sample size: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Hauk | Complaint Investigator | Conducted the on-site complaint investigation |
| Jamie Singer | Field Manager | Signed enforcement and follow-up correspondence |
| Debbie Gillespie | Administrator | Signed Plan of Correction and attestation statements |
Inspection Report
Life Safety
Deficiencies: 15
Jun 5, 2023
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the facility on 6/5/2023 to assess compliance with fire protection and safety codes.
Findings
The inspection found multiple deficiencies including improper storage in boiler rooms, power strip misuse, failure to provide required paperwork for fire-resistance construction inspections, malfunctioning fire doors, incomplete sprinkler system testing, missing semi-annual and annual inspection reports, lack of carbon monoxide alarms and testing, and deficiencies in emergency lighting and fire/smoke damper inspections.
Deficiencies (15)
| Description |
|---|
| Boiler room is being used also as storage |
| In the Activities room office a power strip was found plugged into another power strip |
| Annual inspection of fire-resistance-rated construction will need to be performed and completed by end of 2023 |
| Facility will need to identify and establish a schedule for inspection of Fire-Rated construction by 30 days of this inspection |
| Double doors by kitchen entrance would not latch |
| Double doors by beauty shop would not latch |
| Quarterly sprinkler system inspections will need to be tested per code |
| Semi-Annual fire-extinguishing system inspection report was not provided |
| Carbon Monoxide Alarms will need to be installed |
| Carbon Monoxide Alarms and Detectors testing and maintenance paperwork was not provided |
| 30-second monthly emergency lighting activation test had not been formed and documented |
| Annual 90 minute emergency lighting power test had not been formed and documented |
| Exit sign in the memory care living room was not working |
| Fire/smoke damper 4-year inspection paperwork was not provided |
| Fire door annual inspection will need to be performed and documented |
Report Facts
Inspection date: Jun 5, 2023
Next inspection scheduled on or after: Jul 5, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lawrence White Jr | Facilities Maint Director | Named as facility representative signing the inspection report |
| Jason Van Gorkum | Deputy State Fire Marshal | Conducted the inspection and signed the report |
Loading inspection reports...
