Inspection Reports for Garden Terrace Healthcare Center at Federal Way
WA, 98003
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Inspection Report
Follow-Up
Deficiencies: 12
Oct 8, 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 Department found no deficiencies during the follow-up inspection and confirmed that previously cited deficiencies related to preadmission assessments, service agreement planning, training, and background checks were corrected.
Deficiencies (12)
| Description |
|---|
| Failed to complete preadmission assessments for residents prior to move-in. |
| Failed to document service agreements with plans to monitor and address resident care needs. |
| Failed to ensure staff completed required training including specialty training, CPR, first aid, and continuing education. |
| Failed to complete required background checks including Washington state and national fingerprint checks for staff. |
| Failed to notify the Department of a change in facility administrator within required timeframe. |
| Failed to provide residents with the facility's Medicaid acceptance policy and obtain signed acknowledgement. |
| Failed to ensure menus included all food and snacks served and did not repeat items within a three-week cycle. |
| Failed to maintain kitchen sanitation including dust and residue on vent fans, ceiling tiles, light fixtures, shelves, and refrigerator/freezer fan grates. |
| Failed to provide residents with a system to summon staff assistance in all resident-accessible areas. |
| Failed to develop and implement policies and procedures specific to assisted living services and operations. |
| Failed to ensure medications were properly labeled and stored separately for each resident. |
| Failed to ensure all staff had required orientation, training, and documentation of qualifications. |
Report Facts
Residents sampled for review: 7
Staff with incomplete training: 4
Staff without required background checks: 3
Days staff worked without background check: 2485
Days staff worked without background check: 2206
Days staff worked without background check: 484
Days staff worked without background check: 256
Residents in facility: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Executive Director | Named in findings for incomplete training, missing background checks, lack of orientation, and failure to notify change of administrator |
| Staff B | Director of Nursing | Named in findings for incomplete training, lack of orientation, and lack of policies |
| Staff C | Care Staff/CNA | Named in findings for missing fingerprint background check and lack of orientation |
| Staff D | Care Staff/CNA | Named in findings for missing fingerprint background check and lack of orientation |
| Staff E | Care Staff/CNA | Named in findings for missing fingerprint background check and lack of orientation |
| Staff F | Care Staff/CNA | Named in findings for missing fingerprint background check and lack of orientation |
| Staff H | Dietary Director | Named in findings for menu deficiencies and kitchen sanitation issues |
Inspection Report
Complaint Investigation
Census: 12
Deficiencies: 1
Aug 21, 2025
Visit Reason
The department conducted an unannounced on-site complaint investigation due to allegations of medication diversion and tampering at Garden Terrace Healthcare Center of Federal Way.
Findings
The investigation found unsubstantiated allegations of medication tampering, suspension of two staff members, and multiple medication spillages. A citation was issued for noncompliance with medication services regulations due to failed practices in medication management and safe handling of liquid narcotic medication for one resident.
Complaint Details
Allegations included medication diversion and tampering. The facility's internal investigation found unsubstantiated allegations but identified failed medication management practices. Two staff members were suspended and law enforcement notified.
Deficiencies (1)
| Description |
|---|
| Failed to ensure safe handling and storage of liquid narcotic medication services for 1 of 2 residents, placing Resident 1 at risk of increased pain, comfort issues, and diminished quality of life. |
Report Facts
Total residents: 12
Resident sample size: 3
Compliance Determination Completion Date: Sep 16, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kailash Sharma | ALF Licensor | Department staff who conducted the on-site verification and investigation |
| James Sherman | Field Manager | Signed correspondence and plan of correction |
Inspection Report
Follow-Up
Deficiencies: 4
Aug 8, 2025
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to Garden Terrace Healthcare Center of Federal Way to assess correction of previously cited deficiencies.
Findings
The facility was found to have multiple uncorrected deficiencies related to pre-admission assessments, service agreement planning, staff training, and background checks, resulting in civil fines totaling $1,600.
Deficiencies (4)
| Description |
|---|
| Failed to complete two residents’ pre-admission assessments. |
| Failed to document in two residents service agreements a plan to monitor and address interventions required to meet care and clinical needs. |
| Failed to ensure four staff completed all required training to perform their job duties. |
| Failed to complete a national fingerprint background check for three staff. |
Report Facts
Civil fine amount: 300
Civil fine amount: 300
Civil fine amount: 500
Civil fine amount: 500
Total civil fines: 1600
Residents affected: 2
Residents affected: 2
Staff affected: 4
Residents at risk: 9
Staff affected: 3
Residents at risk: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter |
| Laurie Anderson | Field Manager | Contact person for submission of Statement of Deficiencies and inquiries |
Inspection Report
Life Safety
Deficiencies: 4
Apr 21, 2025
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An unannounced Fire and Life Safety Code inspection was conducted at Garden Terrace Healthcare Center of Federal Way by a representative of the Washington State Patrol, State Fire Marshal's Office to determine compliance with all applicable codes.
Findings
Multiple deficiencies were cited including the facility's inability to provide an annual forward flow report for sprinkler systems, the need for a heat survey for the commercial hood fusible link rating, an obstructed exit door due to a bush impeding egress, and failure to provide a fuel sample report for the generator.
Deficiencies (4)
| Description |
|---|
| Facility was unable to provide an annual forward flow report for sprinkler systems. |
| Facility needs a heat survey for the commercial hood to determine fusible link rating; current report shows 7 fusible links at 450 degrees. |
| Exit door outside has a bush that impedes the egress path and door operation. |
| Facility was unable to provide a fuel sample report for their generator. |
Report Facts
Fusible links: 7
Next inspection scheduled date: Next inspection scheduled on or after 2025-05-21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cozetta Christian | Deputy State Fire Marshal | Conducted the inspection and signed the report. |
| Gary Harwood | Director of Maintenance | Named as Owner's Representative on the report. |
Inspection Report
Life Safety
Deficiencies: 3
Mar 21, 2024
Visit Reason
An unannounced Fire and Life Safety Code inspection was conducted at Garden Terrace Healthcare Center of Federal Way by the Washington State Patrol, State Fire Marshal's Office to determine compliance with applicable codes.
Findings
Several deficiencies were cited including loaded sprinkler heads in the kitchen and laundry room, yellow tagged hood suppression reports, and a fire extinguisher in the Riser room not properly mounted.
Deficiencies (3)
| Description |
|---|
| The following locations have loaded sprinkler heads: Kitchen and Laundry room |
| The facilities hood suppression report shows it is yellow tagged |
| The fire extinguisher in the Riser room is not properly mounted |
Report Facts
Next inspection scheduled: Apr 20, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gary Harwood | Director of Maintenance | Named as Owner or Authorized Representative signing the inspection documents |
| Cozetta Christian | Deputy State Fire Marshal | Conducted the inspection and signed the report |
Inspection Report
Follow-Up
Census: 8
Deficiencies: 9
Feb 5, 2024
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The Department completed a follow-up inspection of the Assisted Living Facility on 02/05/2024 to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies, and the facility meets the Assisted Living Facility licensing requirements. Previously cited deficiencies were corrected as listed in the report.
Deficiencies (9)
| Description |
|---|
| Menus did not include all food items offered and repeated within a three-week timeframe, placing residents at risk of decreased quality of life. |
| Failure to ensure 2 out of 7 sampled residents or their representatives signed an annual negotiated service agreement, risking uninformed care. |
| Failure to maintain and post the most recent assisted living facility license and to renew the Medical Test Site Waiver certificate. |
| Failure to notify the Department of a change in the assisted living facility administrator within 10 days of hire. |
| Failure to provide group activities for 7 out of 7 sampled residents, placing residents at risk for decreased quality of life. |
| Failure to ensure all staff completed specialized training for dementia for residents with dementia as their primary diagnosis. |
| Failure to document potential side effects and interventions for a resident receiving blood thinning medication, placing the resident at risk. |
| Failure to have valid food worker cards for two food service employees with expired food handler cards. |
| Failure to keep ceiling tiles clean and in good repair due to water damage. |
Report Facts
Residents sampled: 7
Deficiencies cited: 9
Plan of Correction completion date: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jane Hermano | NCI | Department staff who did the on-site verification and inspection. |
| Angelica Rios | ALF Licensor | Department staff who inspected the Assisted Living Facility. |
| Laurie Anderson | Field Manager | Signed the compliance determination letter and correspondence. |
| Megan Lavon | Administrator | Signed multiple Plan/Attestation Statements related to deficiencies. |
| Staff G | Food Service Director | Interviewed regarding food service deficiencies. |
| Staff L | Unit Nurse | Interviewed regarding signing of negotiated service agreements. |
| Staff A | Executive Director | Interviewed regarding license posting and inspection report availability. |
| Staff H | Interim Director of Nursing | Interviewed regarding medication administration and documentation. |
| Staff J | Maintenance Director | Interviewed regarding facility maintenance and ceiling tile damage. |
Inspection Report
Life Safety
Deficiencies: 0
Mar 16, 2023
Visit Reason
The Office of the State Fire Marshal conducted an inspection at the facility on 03/16/2023.
Findings
No violations were observed during this inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cozetta Christian | Deputy State Fire Marshal | Conducted the inspection |
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