Inspection Reports for Garden Terrace Healthcare Center at Federal Way
WA, 98003
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
26.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
324% worse than Washington average
Washington average: 6.3 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
12 residents
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 12
Date: Oct 8, 2025
Visit Reason
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)
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
Deficiencies: 1
Date: Sep 12, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate treatment and care for residents, specifically related to bowel care for Resident 1.
Complaint Details
The complaint investigation found that Resident 1 experienced multiple episodes of diarrhea which were not properly assessed or addressed by nursing staff, and the physician was not notified as required. The resident's representative confirmed the resident was in distress and requested hospital transfer.
Findings
The facility failed to assess Resident 1's change in condition, address signs and symptoms of distress, and notify the physician about ongoing diarrhea episodes, placing the resident at risk for nutrition and hydration problems and decreased quality of life.
Deficiencies (1)
Failure to ensure residents received care and treatment in accordance with their assessed needs and professional standards of practice for bowel care.
Report Facts
Episodes of diarrhea: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director of Nursing | Interviewed regarding lack of documentation and facility policy on standards of care for residents with diarrhea. |
Inspection Report
Complaint Investigation
Census: 12
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
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
Date: 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)
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
Complaint Investigation
Deficiencies: 5
Date: Jun 16, 2025
Visit Reason
The inspection was conducted based on complaints regarding failure to follow physician ordered medication parameters, unclear medication orders, inadequate weight monitoring, ineffective pain management, and infection prevention and control deficiencies.
Complaint Details
The visit was complaint-related, triggered by allegations of medication errors, unclear orders, inadequate weight monitoring, ineffective pain management, and infection control failures. Substantiation status is not explicitly stated.
Findings
The facility failed to ensure physician ordered medication parameters were followed, orders were clarified as needed, weights were monitored as ordered, effective pain management was provided, and infection prevention and control protocols were followed including proper use of PPE and sanitation measures. These failures placed residents at risk for unmet needs, ineffective treatments, untreated pain, and healthcare-associated infections.
Deficiencies (5)
Failed to ensure physician ordered parameters for medications were followed for 3 of 17 sampled residents.
Failed to ensure orders were clarified as needed for 2 of 5 residents whose medication regimens were reviewed.
Failed to ensure weights were monitored as ordered for 1 of 4 residents reviewed for nutrition.
Failed to provide safe, appropriate pain management for residents requiring such services.
Failed to maintain an infection prevention and control program including failure to follow Contact Precautions signs, Enhanced Barrier Precautions, and proper use of PPE.
Report Facts
Residents sampled for medication parameter adherence: 17
Residents sampled for order clarification: 5
Residents reviewed for nutrition weight monitoring: 4
Residents affected by deficiencies: 3
Weight difference: 24.8
Pain medication doses: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director of Nursing | Interviewed regarding medication administration and pain management deficiencies |
| Staff N | Registered Nurse | Interviewed regarding unclear medication orders and pain management |
| Staff O | Unit Care Coordinator | Interviewed regarding unclear medication orders |
| Staff M | Unit Care Coordinator | Interviewed regarding weight monitoring protocol and pain management |
| Staff E | Unit Care Coordinator | Interviewed regarding infection control and edema monitoring |
| Staff S | Infection Preventionist | Interviewed regarding infection control policies and PPE use |
| Staff W | Certified Occupational Therapy Assistant | Observed and interviewed regarding failure to use PPE in Contact Precautions room |
| Staff T | Certified Nurse's Assistant | Observed entering Contact Precautions room without PPE |
| Staff U | Housekeeping Assistant | Observed cleaning without gown in Contact Precautions room |
| Staff V | Physical Therapy Assistant | Observed transferring resident without PPE despite Contact Precautions |
Inspection Report
Routine
Deficiencies: 13
Date: Jun 16, 2025
Visit Reason
Routine inspection of Garden Terrace Healthcare Center of Federal Way to assess compliance with regulatory requirements including resident care, safety, and facility conditions.
Findings
The facility was found deficient in multiple areas including failure to provide required Medicare liability notices, maintain a homelike environment, resolve resident grievances, develop comprehensive care plans, follow physician orders for medications and weight monitoring, provide adequate assistance with activities of daily living, ensure meaningful activities, manage pain effectively, maintain infection control precautions, and ensure proper medication storage and labeling.
Deficiencies (13)
Failed to provide required Notification of Medicare Non-Coverage (NOMNC) to Resident 117 before discharge.
Failed to maintain walls, baseboards, and privacy curtains in a clean, homelike condition in 5 of 17 resident rooms.
Failed to initiate, investigate, and resolve grievances for 2 of 17 sampled residents and 1 supplementary resident.
Failed to thoroughly investigate an allegation of drug diversion for 1 resident.
Failed to develop and implement comprehensive care plans for 3 of 17 residents reviewed.
Failed to follow physician ordered medication parameters and clarify unclear orders for several residents; failed to monitor weights as ordered for 1 resident.
Failed to provide required assistance with activities of daily living for 4 of 9 residents reviewed.
Failed to provide meaningful activity programs meeting residents' needs for 3 residents reviewed.
Failed to provide appropriate treatment and care for skin impairments and bowel care for some residents.
Failed to provide safe, appropriate pain management including non-pharmacological interventions and proper medication dosing for 2 residents.
Failed to ensure proper labeling and storage of medications and failed to maintain narcotic count signatures.
Failed to provide timely specialized rehabilitative services including Speech Language Pathology evaluation for 1 resident.
Failed to maintain infection prevention and control program including failure to follow Contact Precautions and Enhanced Barrier Precautions, improper use of PPE, and improper handling of ice scoop.
Report Facts
Deficiencies cited: 13
Weight difference: 24.8
Pain severity: 7
Pain severity: 8
Pain severity: 5
Pain severity: 6
Days without bowel movement: 7
Missing narcotic log signatures: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Social Services Director | Reviewed Resident 117's record and confirmed failure to provide NOMNC letter. |
| Staff C | Maintenance Assistant | Observed repairs needed in resident rooms and noted unpainted areas and unclean privacy curtain. |
| Staff D | Licensed Practical Nurse | Reported missing clothing for Resident 44. |
| Staff B | Director of Nursing | Discussed grievance process failures and pain medication administration issues. |
| Staff O | Unit Care Coordinator | Discussed missing dentures grievance and unclear medication orders. |
| Staff A | Administrator | Reviewed grievance logs and acknowledged missing documentation. |
| Staff E | Unit Care Coordinator | Discussed missing clothing grievance and pain medication delays. |
| Staff N | Registered Nurse | Confirmed lack of care assistance and infection control failures. |
| Staff M | Unit Care Coordinator | Reviewed care plans, weight monitoring, and medication labeling issues. |
| Staff F | Speech Language Pathologist | Conducted delayed swallowing evaluation for Resident 113. |
| Staff J | Director of Rehabilitation | Confirmed therapy referral delays. |
| Staff I | Food Service Manager - Dietary Manager | Reported sanitizer shortage and kitchen exhaust fan cleanliness issues. |
| Staff L | Registered Nurse | Noted unlabeled steroid inhaler on medication cart. |
| Staff W | Certified Occupational Therapy Assistant | Entered Contact Precautions room without PPE. |
| Staff S | Infection Preventionist | Discussed PPE use and infection control signage issues. |
| Staff T | Certified Nurse's Assistant | Entered Contact Precautions room without PPE. |
| Staff V | Physical Therapy Assistant | Failed to wear PPE when transferring resident on Contact Precautions. |
| Staff U | Housekeeping Assistant | Cleaned room without gown despite Contact Precautions. |
Inspection Report
Life Safety
Deficiencies: 4
Date: Apr 21, 2025
Visit Reason
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)
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
Complaint Investigation
Deficiencies: 1
Date: Feb 7, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide appropriate treatment and services for a resident's pressure ulcer/pressure injury (PU/PI).
Complaint Details
The complaint investigation revealed that the wound care treatment order was received late and not processed promptly, resulting in no treatment being administered as ordered. Staff interviews confirmed lack of awareness and failure to implement the wound care treatment.
Findings
The facility failed to ensure that Resident 1 received the necessary treatment for a pressure ulcer, specifically a medicated honey-based dressing as ordered by the wound care provider. This failure led to a delay in treatment and the resident being transferred to the hospital for further evaluation.
Deficiencies (1)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for Resident 1.
Report Facts
Residents reviewed for PU/PI: 3
Residents affected: 1
Wound measurement: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nursing Assistant | Interviewed regarding Resident 1's ability to use the bathroom and wound care |
| Staff C | Licensed Practical Nurse | Interviewed and stated unawareness of wound care treatment order for Resident 1 |
| Staff B | Interim Director of Nursing | Interviewed and confirmed failure to carry out wound care treatment as ordered |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 16, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to implement abuse and neglect policies and procedures, specifically related to an incident involving Resident 1's dislocated left hip prosthesis.
Complaint Details
The complaint investigation found that the facility did not investigate or rule out abuse and/or neglect related to Resident 1's dislocated left hip prosthesis. Staff admitted to not asking how the injury occurred, and administration acknowledged no investigation was conducted to rule out abuse or neglect.
Findings
The facility failed to thoroughly investigate an allegation of physical abuse for Resident 1, who suffered a dislocated left hip prosthesis during a brief change. Staff did not follow hip precautions, failed to notify administration, and did not include hospital orders in the care plan, placing residents at risk of abuse, neglect, and unnecessary pain.
Deficiencies (1)
Failure to develop and implement policies and procedures to prevent abuse, neglect, and theft, including failure to thoroughly investigate an incident and allegation of physical abuse for Resident 1.
Report Facts
Residents affected: 1
Date of survey completed: Jan 16, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Resident Care Manager | Stated they should have asked Resident 1 how the injury occurred and should have identified or ruled out abuse or neglect |
| Staff B | Director of Nursing | Not aware Resident 1 was sent to hospital; expected nursing staff to notify for investigation |
| Staff C | Administrator-In-Training | Reviewed medical records and stated nursing staff should have included hospital orders in care plan |
| Staff A | Administrator | Stated an investigation should have been conducted but was not |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 3, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide timely written transfer/discharge notices to residents and/or their representatives, and concerns about fall prevention and accident hazards.
Complaint Details
The complaint investigation found that the facility did not provide written transfer/discharge notices for Residents 1, 6, and 7, and failed to provide adequate fall prevention measures for Resident 1, including lack of safety assessment for bed positioning and absence of frequent visual checks while isolated for COVID-19.
Findings
The facility failed to provide written transfer/discharge notices as required for 3 residents discharged to the hospital, placing them at risk for discharge not aligned with their care goals. Additionally, the facility failed to ensure a safe environment free from accident hazards and adequate supervision to prevent falls for a high-fall risk resident, including lack of safety assessment for bed positioning and absence of frequent visual checks.
Deficiencies (2)
Failure to provide timely written notification to residents and/or their representatives before transfer or discharge for 3 residents.
Failure to provide an environment free from accident hazards and ensure adequate supervision to prevent falls for 1 resident.
Report Facts
Residents affected: 3
Residents affected: 1
Resident body temperature: 100.5
Resident pulse rate: 105
Survey completion date: Dec 3, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Executive Director | Confirmed Social Services Director did not complete required Notice of Transfer or Discharge forms and acknowledged importance of notification process. |
| Staff B | Director of Nursing | Confirmed lack of completion of Notice of Transfer or Discharge forms and reviewed Resident 1's medical records regarding fall prevention. |
| Staff F | Registered Nurse | Provided information on fall risk interventions for Resident 1 and room door closure due to COVID-19. |
| Staff E | Infection Preventionist | Explained room assignments for COVID-19 positive residents and fall prevention monitoring. |
| Staff D | Resident Care Manager | Reviewed Resident 1's care plan and treatment administration record regarding fall prevention interventions. |
Inspection Report
Routine
Deficiencies: 16
Date: Apr 16, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, infection control, medication management, nutrition, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to provide written bed hold notices, timely transmission of resident assessment data, accurate resident assessments, comprehensive care plans, assistance with activities of daily living, anticoagulation monitoring, nutrition care, respiratory care, pain management, psychotropic medication use, food safety and sanitation, infection prevention and control, and vaccination administration.
Deficiencies (16)
Failed to provide residents and/or their representatives written notice of the facility's bed hold policy at the time of hospital transfer or within 24 hours.
Failed to encode and transmit resident assessment data to CMS within required timeframe for 1 of 1 resident reviewed.
Failed to ensure Minimum Data Set assessments were completed accurately to reflect residents' condition, including dental status and dementia diagnosis.
Failed to develop and implement comprehensive care plans that addressed residents' individualized needs, including nutrition, skin care, and use of side rails.
Failed to provide assistance with activities of daily living including eating and personal grooming for residents assessed as dependent.
Failed to provide appropriate anticoagulation monitoring and care, including identification and tracking of skin changes indicating bleeding.
Failed to provide care consistent with tube feeding orders including documenting rate, amount of nutrition and water infused.
Failed to provide respiratory care including deep breathing treatments as ordered and obtain physician orders for supplemental oxygen.
Failed to provide pain management consistent with professional standards including offering nonpharmacological interventions, identifying pain location, and specifying parameters for PRN pain medications.
Failed to implement gradual dose reductions and non-pharmacological interventions prior to initiating or continuing psychotropic medications and failed to obtain consent and identify target behaviors.
Failed to ensure food was procured, stored, prepared, and served under sanitary conditions including labeling, dating, discarding spoiled food, and maintaining cleanliness of kitchen and nourishment refrigerators.
Failed to properly dispose of garbage and refuse, maintain covered dumpsters, and keep surrounding areas clean to prevent pest infestations.
Failed to provide specialized rehabilitative services as assessed and scheduled for residents requiring skilled therapy services.
Failed to maintain accurate and consistent resident medical records including correct active diagnoses and advance directive status.
Failed to maintain an infection prevention and control program including proper implementation of isolation precautions and consistent hand hygiene during meal service.
Failed to administer pneumococcal vaccine and follow up with re-offering when resident was unavailable.
Report Facts
Weight loss: 9.4
Weight loss: 6
Therapy sessions: 3
Feeding tube rate: 60
Feeding tube flush volume: 100
Feeding tube flush volume: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Resident Care Manager | Named in bed hold policy failure and eating assistance failure |
| Staff B | Director of Nursing | Named in multiple interviews regarding care plan, nutrition, pain management, and infection control |
| Staff A | Executive Director | Named in interviews regarding bed hold policy and nutrition |
| Staff C | MDS Nurse | Named in interviews regarding MDS assessment accuracy |
| Staff G | Registered Dietician | Named in interviews regarding nutrition assessment and feeding tube care |
| Staff D | Dietary Manager | Named in interviews regarding food safety and kitchen sanitation |
| Staff E | Infection Control Preventionist | Named in interviews regarding isolation precautions and infection control |
| Staff J | Rehabilitation Director | Named in interviews regarding therapy scheduling and care |
Inspection Report
Life Safety
Deficiencies: 3
Date: 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)
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
Date: Feb 5, 2024
Visit Reason
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)
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
Routine
Deficiencies: 8
Date: Mar 21, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident rights, care planning, nursing services, food safety, and medical record maintenance.
Findings
The facility was found deficient in multiple areas including failure to maintain and update advance directives, failure to provide required Medicare notices, inadequate discharge notifications to the Long-Term Care Ombudsman, incomplete and non-comprehensive care plans, nursing services not meeting professional standards, improper food safety practices, and incomplete or inaccurate resident medical records.
Deficiencies (8)
Failure to develop and implement a system to ensure advance directives were obtained and accessible for residents.
Failure to provide Skilled Nursing Facility Advance Beneficiary Notices (ABN) to residents as required.
Failure to notify the State Long-Term Care Ombudsman of resident transfers or discharges to hospital.
Failure to develop comprehensive care plans with measurable goals and interventions for residents' current conditions.
Failure to maintain, revise, and update care plans as required by residents' changing conditions.
Failure to provide nursing services within professional standards including medication administration errors, incomplete physician orders, and untimely dressing changes.
Failure to ensure food was stored and prepared in a sanitary manner, including unlabeled food, unsecured hair of kitchen staff, and contamination of food trays.
Failure to maintain complete and accurate medical records including documentation of resident refusals and accurate catheter status.
Report Facts
Residents reviewed for care plans: 15
Residents affected by care plan deficiencies: 5
Residents affected by care plan maintenance deficiencies: 5
Residents affected by nursing service deficiencies: 3
Residents affected by food safety deficiencies: Some
Residents affected by medical record deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director of Nursing | Confirmed lack of advance directive copies, medication administration errors, and care plan deficiencies |
| Staff I | Social Services Director | Acknowledged failure to follow up with family/representatives for advance directives |
| Staff L | Unit Care Coordinator | Confirmed missing advance directives and resident refusals not documented |
| Staff C | Food Services Director | Acknowledged food labeling and hairnet deficiencies in kitchen |
| Staff O | Resident Care Manager | Discussed care plan deficiencies and incomplete physician orders |
| Staff H | Unit Care Coordinator | Discussed care plan and medication monitoring deficiencies |
| Staff G | Licensed Practical Nurse | Admitted to untimely dressing change and signing MAR without completing task |
Inspection Report
Life Safety
Deficiencies: 0
Date: 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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