Inspection Reports for Edmonds Landing Assisted Living

180 Second Avenue South, Edmonds, WA 98020, WA, 98020

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Deficiencies per Year

24 18 12 6 0
2022
2023
2024
Severe High Moderate Low Unclassified

Census Over Time

20 40 60 80 100 Nov '22 Apr '23 Feb '24 Jun '24 Sep '24
Census Capacity
Inspection Report Follow-Up Census: 37 Deficiencies: 1 Sep 3, 2024
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.
Findings
The follow-up inspection on 09/03/2024 found no deficiencies and confirmed the facility meets Assisted Living Facility licensing requirements. The prior deficiencies related to failure to implement a Respiratory Protection Program and fit testing of staff were corrected.
Complaint Details
Complaint investigation regarding positive COVID cases at the facility. The investigation found the facility did not implement the Respiratory Protection Program and not all caregivers were fit tested for N95 respirators, constituting a deficient practice.
Deficiencies (1)
Description
Failure to follow a Respiratory Protection Program by ensuring 6 of 18 caregiving staff were fit-tested for respirator masks annually, placing 37 residents at risk for COVID-19 exposure.
Report Facts
Total residents: 37 Resident sample size: 2 Caregiving staff not fit tested: 6 Total caregiving staff: 18
Employees Mentioned
NameTitleContext
Hayley PinkhamALF LicensorDepartment staff who conducted the on-site verification and complaint investigation
Jamie SingerField ManagerSigned official letters related to inspection and compliance
Inspection Report Follow-Up Census: 40 Capacity: 83 Deficiencies: 1 Aug 5, 2024
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 inspection failures.
Findings
The follow-up inspection on 08/05/2024 found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. The prior complaint investigation found the facility failed fire and life safety inspections and did not comply with required fire marshal safety codes.
Complaint Details
The complaint investigation was triggered by the facility failing their second fire and life safety inspection and receiving a State Fire Marshal's Office Letter of Noncompliance. The investigation concluded with a failed provider practice and citations written.
Deficiencies (1)
Description
Facility failed to ensure compliance with Washington State Patrol Office of State Fire Marshal (OSFM) after failing initial and follow-up fire and life safety inspections, including failure to provide documentation for the annual 90-minute power test for emergency lights.
Report Facts
Total residents: 40 Licensed beds: 83
Employees Mentioned
NameTitleContext
Hayley PinkhamALF LicensorDepartment staff who conducted the on-site verification and investigation
Jamie SingerField ManagerSigned correspondence related to compliance determinations and inspections
Inspection Report Follow-Up Census: 36 Deficiencies: 1 Jun 13, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to national fingerprint background checks and other compliance issues.
Findings
The follow-up inspection on 06/13/2024 found no deficiencies, indicating that previously cited issues, including failure to complete a national fingerprint background check for one staff member, were corrected. The prior unannounced on-site visit on 05/15/2024 found noncompliance with licensing laws, specifically regarding background checks.
Deficiencies (1)
Description
Failed to ensure a national fingerprint background check (NFBC) for 1 of 1 sampled staff (Staff A) was completed, placing 36 residents at risk.
Report Facts
Residents at risk: 36 Sample size: 5 Total current residents: 36
Employees Mentioned
NameTitleContext
Faith LeNCIDepartment staff who inspected the Assisted Living Facility
Erin SteinbrennerNursing Consultant InstitutionalDepartment staff who inspected the Assisted Living Facility
Staff AAdministratorStaff member who failed to complete national fingerprint background check
Staff BRegional Vice President of OperationsInterviewed regarding Staff A's fingerprint background check status
Jamie SingerField ManagerSigned follow-up inspection report and correspondence
Inspection Report Follow-Up Census: 36 Deficiencies: 1 May 15, 2024
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to the Edmonds Landing Assisted Living Community to verify correction of previously cited deficiencies.
Findings
The facility failed to ensure a national fingerprint background check for one staff member was completed, placing 36 residents at risk. This was an uncorrected citation previously cited on March 26, 2024, resulting in a civil fine.
Deficiencies (1)
Description
Failure to ensure a national fingerprint background check for one staff member.
Report Facts
Civil fine amount: 300 Residents at risk: 36
Employees Mentioned
NameTitleContext
Matt HauserCompliance SpecialistSigned the letter regarding the civil fine and inspection findings.
Jamie SingerField ManagerContact person for the plan of correction and appeals process.
Inspection Report Complaint Investigation Census: 39 Deficiencies: 1 Feb 26, 2024
Visit Reason
The investigation was conducted due to a complaint alleging that a named resident fell at the Assisted Living Facility and sustained a significant injury.
Findings
The investigation found that the facility failed to implement the Negotiated Service Agreement for one resident, resulting in the resident being transferred without the correct equipment and sustaining a significant injury. Deficient practice was identified related to staff not using a transfer belt as required.
Complaint Details
The complaint was substantiated as the facility failed to follow the resident's negotiated service agreement, contributing to a fall and injury.
Deficiencies (1)
Description
Failure to implement the Negotiated Service Agreement for one resident, resulting in transfer without correct equipment and causing injury.
Report Facts
Total residents: 39 Resident sample size: 2 Closed records sample size: 0 Complaint numbers referenced: 2
Employees Mentioned
NameTitleContext
Hayley PinkhamALF LicensorInvestigator and off-site verification staff
Jamie SingerField ManagerSigned enforcement and compliance letters
Inspection Report Complaint Investigation Census: 39 Deficiencies: 1 Feb 26, 2024
Visit Reason
The inspection was conducted as an unannounced on-site complaint investigation following allegations that a named resident fell at the Assisted Living Facility and sustained a significant injury.
Findings
The investigation found that the facility failed to implement the resident's Negotiated Service Agreement by not using the required transfer belt during transfers, which may have contributed to the resident's fall and significant injury. The facility was cited for deficient practice related to this failure.
Complaint Details
The complaint alleged that a named resident fell and sustained a significant injury. The investigation substantiated the complaint, identifying deficient practice related to failure to use the transfer belt as required by the resident's negotiated service agreement.
Deficiencies (1)
Description
Failure to implement the Negotiated Service Agreement for 1 of 2 residents when transferred without the correct equipment, contributing to a fall and significant injury.
Report Facts
Total residents: 39 Resident sample size: 2
Employees Mentioned
NameTitleContext
Hayley PinkhamALF LicensorDepartment staff who conducted the investigation and off-site verification
Jamie SingerField ManagerSigned the follow-up inspection letter
Staff AExecutive DirectorInterviewed regarding expectation for staff to follow the negotiated service agreement
Inspection Report Life Safety Deficiencies: 23 Aug 17, 2023
Visit Reason
The Office of the State Fire Marshal conducted an inspection at Edmonds Landing Assisted Living to evaluate compliance with fire safety and emergency preparedness regulations.
Findings
The facility was found to be unable to provide documentation for multiple required fire safety inspections, tests, and maintenance activities including fire drills, fire wall inspections, fire door operations, sprinkler system inspections, fire extinguisher inspections, smoke alarm testing, carbon monoxide detector testing, emergency power system maintenance, and emergency plan documentation.
Deficiencies (23)
Description
Facility cannot provide documentation for the completion of twelve planned and unannounced fire drills in the previous 12 months.
Facility is unable to provide documentation that the annual fire wall inspection has been completed.
Facility is unable to provide documentation that the annual fire door inspection has been completed.
Private dining/living room fire door did not close and latch properly.
Facility is unable to provide documentation for the 3 year dry system full flow trip test.
Facility is unable to provide documentation for the quarterly sprinkler system inspections.
Kitchen sprinkler heads have loose or missing escutcheon rings.
Signage shall be provided on the exhaust hood or system cabinet indicating the type and arrangement of cooking appliances protected by the automatic fire-extinguishing system.
Facility is unable to provide documentation for annual fire extinguisher inspections.
Facility is unable to provide documentation for the monthly single station smoke alarm testing.
Facility is unable to provide documentation for the monthly carbon monoxide detector testing.
Carbon monoxide detector in hallway by room 153 failed push button test.
Facility is unable to provide documentation for the monthly 30 second activation test for the emergency lights.
Facility is unable to provide documentation for the annual 90 minute power test for the emergency lights.
Facility is unable to provide documentation for the annual servicing of the emergency generator.
Facility is unable to provide documentation for the weekly inspections and monthly 30 minute full load testing of the emergency generator.
Facility cannot provide a documented emergency plan in accordance with WAC 212-12-040.
Most of the mechanical, equipment and electrical rooms in the building contain flammable storage and need to be cleaned out in accordance with code.
Bistro has loose electrical wiring under the counter.
The dryer in the laundry room by 276 is not properly connected to the vent.
Facility is unable to provide documentation for the semi-annual hood cleaning.
Fire doors for the library did not close and latch properly.
Fire doors leading from main dining room to private dining room did not close and latch properly.
Report Facts
Fire drills documentation missing: 12 Sprinkler system inspections missing: 5 Fire extinguisher inspection frequency: 3 Emergency generator testing frequency: 30 Emergency lights testing duration: 90 Emergency lights activation test duration: 30
Employees Mentioned
NameTitleContext
Wendy MartinExecutive DirectorSigned as Owner or Authorized Representative on inspection reports
Arthur Jesse WardDeputy State Fire MarshalConducted the inspection and signed the report
Inspection Report Complaint Investigation Census: 39 Deficiencies: 1 Apr 21, 2023
Visit Reason
The investigation was conducted due to complaints alleging residents were left for 8 hours without care, a named resident was screaming for two hours without staff checking on him, and an unnamed resident was in tears due to long call light waits.
Findings
The investigation found that residents experienced very long wait times for care and call lights were not responded to in a timely manner, indicating failure to provide agreed care and services per negotiated service agreements. However, the named resident denied needing to call out for care and the unnamed resident was found to be independent.
Complaint Details
Complaints included residents being left for 8 hours without care, a named resident screaming for two hours without staff response, and an unnamed resident in tears due to long call light waits. The complaint investigation was substantiated with findings of long call light wait times and failure to implement negotiated service agreements.
Deficiencies (1)
Description
The assisted living facility failed to provide the agreed upon care and services and implement the Negotiated Service Agreement (NSA) for 5 of 5 sampled residents when staff did not respond to call lights in a timely manner, placing residents at risk of harm and reducing their quality of life.
Report Facts
Total residents: 39 Resident sample size: 7 Call light wait times over 20 minutes: 126 Call light wait times over 20 minutes: 73 Call light wait times over 20 minutes: 24 Call light wait times over 20 minutes: 23 Call light wait times over 20 minutes: 32
Employees Mentioned
NameTitleContext
Hayley PinkhamALF LicensorInvestigator who conducted the complaint investigation and on-site verification
Inspection Report Follow-Up Census: 36 Deficiencies: 0 Mar 16, 2023
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility on 03/16/2023 to verify correction of previously cited deficiencies related to compliance determinations 21041 and 18418.
Findings
The follow-up inspection found no deficiencies, confirming that the facility meets the Assisted Living Facility licensing requirements. The prior deficiencies related to failure to maintain a Respiratory Protection Program (RPP) were corrected.
Complaint Details
The department conducted an unannounced on-site complaint investigation on 01/12/2023 referencing complaint numbers 64273, 66053, and 66236. The investigation found the facility was not in compliance due to failure to maintain a Respiratory Protection Program (RPP), placing 36 residents at risk of COVID-19 exposure. The complaint was substantiated.
Report Facts
Residents at risk: 36 Sample size: 5 Complaint numbers: 64273, 66053, 66236
Employees Mentioned
NameTitleContext
Erin SteinbrennerNursing Consultant InstitutionalDepartment staff who did the on-site verification during follow-up inspection
Hayley PinkhamALF LicensorDepartment staff who investigated the Assisted Living Facility during complaint investigation
Inspection Report Complaint Investigation Census: 40 Deficiencies: 1 Nov 29, 2022
Visit Reason
The inspection was conducted as a complaint investigation regarding a named resident receiving extra doses of medication.
Findings
The facility failed to administer medications according to physician's orders, resulting in a resident receiving 27 extra doses of Abiraterone due to incorrect transcription of the medication order onto the Medication Administration Record.
Complaint Details
The complaint investigation found that the named resident received 27 extra doses of medication due to transcription errors. The facility failed to administer medications according to physician's orders. The medication error was confirmed by the facility and discovered by the pharmacy.
Deficiencies (1)
Description
Failed to ensure a resident received medication as prescribed, resulting in multiple extra doses of Abiraterone due to transcription error on the Medication Administration Record.
Report Facts
Total residents: 40 Extra medication doses administered: 27 Resident sample size: 2
Employees Mentioned
NameTitleContext
Cathy PrenticeComplaint InvestigatorConducted the complaint investigation and on-site verification
Jamie SingerField ManagerSigned correspondence related to the investigation and follow-up
Staff AMedication TechnicianInterviewed regarding medication administration procedures
Health Services DirectorHealth Services DirectorInterviewed regarding transcription error of medication order

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