Inspection Reports for
Garden Terrace Healthcare Center at Federal Way
WA, 98003
Back to Facility Profile7 Reports
Inspection Report — Oct 30, 2025
Follow-Up
Date: Oct 30, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to medication services.
Findings
The follow-up inspection on 10/30/2025 found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies were corrected.
Deficiencies (1)
WAC 388-78A-2210-1-b - Deficiencies related to medication services were corrected as verified on-site.
Inspection Report — Oct 8, 2025
Follow-Up
Date: Oct 8, 2025
Visit Reason
Follow-up inspection to verify correction of previously cited deficiencies.
Findings
The Department completed a follow-up inspection on 10/08/2025 and found no deficiencies. Previously cited deficiencies related to preadmission assessments, service agreement planning, training, background checks, and other regulatory requirements were corrected.
Inspection Report — Aug 8, 2025
Enforcement
Date: Aug 8, 2025
Visit Reason
This document is a follow-up visit conducted on August 8, 2025, resulting in the imposition of civil fines due to uncorrected deficiencies previously cited on June 2, 2025.
Findings
The facility failed to complete required pre-admission assessments, service agreement planning, staff training, and background checks. All cited deficiencies remain uncorrected, resulting in civil fines totaling $1,600.
Deficiencies (4)
WAC 388-78A-2070 (1)(2) Timing of preadmission assessment. The licensee failed to complete two residents’ pre-admission assessments, placing residents at risk for admission to a facility unable to meet their needs.
WAC 388-78A-2130 (1)(a)(b)(c)(2)(5)(a)(b)(c)(d)(e)(6)(a)(i)(ii)(b) Service agreement planning. The licensee failed to document in two residents’ service agreements a plan to monitor and address interventions required to meet care and clinical needs.
WAC 388-78A-2474 (2)(a)(c)(d)(e) Training and home care aide certification requirements. The licensee failed to ensure four staff completed all required training, placing nine residents at risk of unmet care needs.
WAC 388-78A-2466 (1)(a)(b)(2) Background checks—Washington state name and date of birth background check—Valid for two years—National fingerprint background check—Valid indefinitely. The licensee failed to complete a national fingerprint background check for three staff, placing nine residents at risk of potential abuse or neglect.
Report Facts
Civil fines total: 1600
Residents affected: 9
Staff affected: 4
Staff affected: 3
Residents affected: 2
Inspection Report — May 2, 2025
Life Safety
Date: May 2, 2025
Visit Reason
The Office of the State Fire Marshal conducted a scheduled fire and life safety inspection at the facility to determine compliance with applicable codes.
Findings
All violations noted during previous related inspections have been corrected as of the current inspection date. The facility was approved following this inspection.
Inspection Report — May 7, 2024
Follow-Up
Date: May 7, 2024
Visit Reason
The Office of the State Fire Marshal conducted a follow-up inspection to verify correction of previously cited fire and life safety code deficiencies at the facility.
Findings
All violations noted during previous related inspections have been corrected, and the facility's approval status is now Approved.
Inspection Report — Feb 5, 2024
Follow-Up
Date: Feb 5, 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 as listed in the report.
Deficiencies (9)
WAC 388-78A-2300 Food and nutrition services. The facility failed to ensure menus included all food items offered and that menus were not repeated within a three-week timeframe, placing residents at risk of decreased quality of life and unmet dietary needs.
WAC 388-78A-2150 Signing negotiated service agreement. The facility failed to ensure 2 of 7 sampled residents or their representatives signed an annual negotiated service agreement, risking uninformed care and unmet needs.
WAC 388-78A-2730 Licensee's responsibilities. The facility failed to maintain and post the current assisted living facility license and failed to renew the Medical Test Site Waiver certificate, placing residents at risk of being uninformed about facility services.
WAC 388-78A-2570 Notification of change in administrator. The facility failed to notify the Department in writing within 10 days of a change in the assisted living facility administrator.
WAC 388-78A-2180 Activities. The facility failed to provide group activities for 7 out of 7 sampled residents, placing them at risk for decreased quality of life.
WAC 388-78A-2305 Food sanitation. The facility failed to have valid food worker cards for two food service employees as required.
WAC 388-78A-3090 Maintenance and housekeeping. The facility failed to keep ceiling tiles clean and in good repair due to water damage from the previous winter.
WAC 388-78A-2510 Specialized training for dementia. The facility failed to ensure all staff completed specialized dementia training for residents with dementia as their primary diagnosis.
WAC 388-78A-2140 Negotiated service agreement contents. The facility failed to document potential side effects and interventions for one sampled resident receiving blood thinning medication, placing the resident at risk for worsening medical condition.
Report Facts
Sampled residents: 7
Sampled residents with deficiencies: 7
Deficiencies cited: 9
Inspection Report — Mar 16, 2023
Life Safety
Date: Mar 16, 2023
Visit Reason
The Office of the State Fire Marshal conducted a scheduled inspection at the facility to assess fire safety compliance.
Findings
No violations were observed during this inspection. The facility was approved with no deficiencies noted.
8 CMS Surveys
Inspection Report — Sep 12, 2025
Complaint Investigation
Date: Sep 12, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide appropriate care and treatment for a resident with ongoing diarrhea and distress.
Complaint Details
The complaint involved Resident 1 who experienced multiple episodes of diarrhea from 08/20/2025 to 08/29/2025. The facility did not assess the resident's condition, provide interventions, or notify the physician as required. The complaint was substantiated based on documentation and interviews.
Findings
The facility failed to assess and address Resident 1's ongoing diarrhea, did not notify the physician as required, and lacked a policy for managing residents with diarrhea. These failures placed the resident at risk for nutrition and hydration problems and decreased quality of life.
Deficiencies (1)
WAC 388-97-1060 (1) Provide appropriate treatment and care according to orders, resident's preferences and goals. The facility failed to ensure care and treatment met professional standards for 1 of 5 residents reviewed for bowel care, including failure to assess, intervene, and notify the physician about ongoing diarrhea.
Report Facts
Residents reviewed: 5
Diarrhea episodes: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director of Nursing | Interviewed regarding lack of documentation and facility policy on diarrhea care |
Inspection Report — Jun 16, 2025
Routine
Date: Jun 16, 2025
Visit Reason
The inspection was a routine survey of Garden Terrace Healthcare Center of Federal Way to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found to have multiple deficiencies including failure to provide required liability notices, maintain a homelike environment, investigate grievances, develop comprehensive care plans, follow medication orders, provide adequate ADL assistance, meet activity needs, manage pain effectively, maintain infection control precautions, and ensure proper medication storage and labeling. Most deficiencies were cited with minimal harm and residents affected were few. Some issues such as pain management and infection control posed risks for diminished quality of life.
Deficiencies (13)
WAC 388-97-0300(1)(e),(5),(6) - The facility failed to provide a Notification of Medicare Non-Coverage (NOMNC) letter to Resident 117 before discharge, risking lack of understanding of Medicare benefits and appeal rights.
WAC 388-97-0880 - The facility failed to maintain walls, baseboards, and privacy curtains in a homelike and sanitary condition in 5 of 17 sampled rooms, risking diminished quality of life.
WAC 388-97-0460 - The facility failed to initiate, investigate, and resolve grievances for 2 of 17 sampled residents and 1 supplementary resident, risking emotional distress and unresolved issues.
WAC 388-97-0640 (6)(c) - The facility failed to thoroughly investigate an allegation of drug diversion for Resident 55, lacking interviews and documentation, risking uncontrolled pain and diminished quality of life.
WAC 388-97-1020(1), (2)(a)(b) - The facility failed to develop and implement comprehensive care plans for 3 residents, including respiratory, swelling, and bruising care needs, risking unmet care needs and negative health outcomes.
WAC 388-97-1060 - The facility failed to follow physician ordered medication parameters, clarify orders, and monitor weights for multiple residents, risking unmet needs and ineffective treatments.
WAC 388-97-1060(2)(c) - The facility failed to provide required assistance with activities of daily living for 4 residents, resulting in poor hygiene and diminished self-worth.
WAC 388-97-0940 (1) - The facility failed to provide meaningful activities meeting the needs of 3 residents, resulting in boredom and diminished quality of life.
WAC 388-97-1060 (1) - The facility failed to provide appropriate skin care and bowel care for residents with skin impairments and constipation, risking discomfort, skin breakdown, and infection.
WAC 388-97-1060 (1) - The facility failed to provide effective pain management for residents, including failure to follow pain medication parameters and provide non-pharmacological interventions.
WAC 388-97-1280 (1)(a-b), (3)(a-b) - The facility failed to ensure timely specialized rehabilitative services, delaying speech language pathology evaluation for Resident 113, risking unnecessary diet restrictions and weight loss.
WAC 388-97-1300(2), -2340 - The facility failed to ensure proper medication storage and labeling, including unlabeled steroid inhalers and missing narcotic log signatures, risking expired medications and medication errors.
WAC 388-97-1320 (1)(a), (2)(b) - The facility failed to maintain infection prevention and control, including failure to follow Contact and Enhanced Barrier Precautions for multiple residents and improper use of ice scoop, risking healthcare-associated infections.
Report Facts
Residents sampled for grievances: 17
Residents sampled for care plans: 17
Residents sampled for medication review: 17
Residents sampled for ADL assistance: 9
Residents sampled for activities: 3
Residents sampled for infection control: 5
Missing narcotic log signatures: 5
Inspection Report — Jun 16, 2025
Complaint Investigation
Date: Jun 16, 2025
Visit Reason
The inspection was conducted based on complaints and concerns regarding medication administration, pain management, weight monitoring, and infection control practices at the nursing facility.
Complaint Details
The investigation was complaint-driven, focusing on medication administration errors, unclear physician orders, inadequate pain management, inconsistent weight monitoring, and infection control breaches. Multiple residents were involved, and the findings confirmed failures in these areas.
Findings
The facility failed to follow physician-ordered medication parameters, clarify unclear medication orders, and consistently monitor resident weights as ordered. Pain management was inadequate for some residents, with incorrect dosing and lack of non-pharmacological interventions. Infection prevention and control practices were deficient, including failure to follow Contact and Enhanced Barrier Precautions, improper use of PPE by staff, and poor handling of contaminated linens and equipment. These failures placed residents at risk for unmet needs, untreated pain, and healthcare-associated infections.
Deficiencies (3)
F 0658 - The facility failed to ensure physician ordered parameters for medications were followed for multiple residents, failed to clarify unclear medication orders, and failed to monitor weights as ordered, placing residents at risk for unmet needs and delayed treatments.
F 0697 - The facility failed to provide safe and appropriate pain management, including failure to administer pain medications according to prescribed parameters and failure to provide non-pharmacological interventions, placing residents at risk for untreated pain and decreased quality of life.
F 0880 - The facility failed to maintain an infection prevention and control program, including failure to follow Contact and Enhanced Barrier Precautions, improper use of PPE by staff, and failure to prevent cross contamination from shared equipment, placing residents at risk for healthcare-associated infections.
Report Facts
Residents sampled for medication parameters: 17
Residents with unclear medication orders: 5
Residents reviewed for nutrition weight monitoring: 4
Residents affected by infection control failures: 5
Pain medication dosing errors: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director of Nursing | Stated importance of following physician orders for medication and pain management; acknowledged failures in medication administration and infection control. |
| Staff N | Registered Nurse | Noted unclear medication orders for Residents 18 and 166 and failure to clarify with provider. |
| Staff O | Unit Care Coordinator | Reviewed unclear physician orders and stated they should have been clarified. |
| Staff M | Unit Care Coordinator | Described facility protocol for re-weighing residents and noted failure to follow protocol for Resident 115. |
| Staff E | Unit Care Coordinator | Stated staff should have checked edema and called for pain medication promptly. |
| Staff S | Infection Preventionist | Stated all staff should follow PPE and contact precautions policies and noted incorrect signage and failures. |
| Staff W | Certified Occupational Therapy Assistant | Observed entering Resident 167's room without PPE despite Contact Precautions. |
| Staff T | Certified Nurse's Assistant | Observed entering Resident 47's room without PPE despite Contact Precautions. |
| Staff U | Housekeeping Assistant | Observed cleaning Resident 265's room without gown and expressed confusion about precautions. |
| Staff V | Physical Therapy Assistant | Observed not wearing PPE when transporting and working with Resident 270 who required Contact Precautions. |
Inspection Report — Feb 7, 2025
Date: Feb 7, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of practice regarding pressure ulcer care and treatment at the facility.
Findings
The facility failed to provide necessary treatment for a resident's pressure ulcer as ordered, resulting in delayed wound care and transfer to hospital. Staff interviews confirmed the treatment order was not implemented as required.
Deficiencies (1)
WAC 388-97-1060(3)(b) - The facility failed to ensure a resident with a pressure ulcer received the ordered medicated honey-based treatment, resulting in delayed wound care and potential harm.
Report Facts
Residents affected: 1
Wound measurement: 2.5
Inspection Report — Jan 16, 2025
Complaint Investigation
Date: Jan 16, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to implement abuse and neglect policies, specifically concerning an incident of physical abuse involving Resident 1.
Complaint Details
The complaint investigation focused on Resident 1 who dislocated their left hip prosthesis during a brief change at the facility. Resident 1 reported staff were rough and did not follow hip precautions. Staff interviews revealed no abuse investigation was conducted and hospital orders were not incorporated into the care plan. The allegation was substantiated by the findings.
Findings
The facility failed to thoroughly investigate an allegation of physical abuse for Resident 1, who suffered a dislocated left hip prosthesis during care. Staff did not follow required precautions or conduct an abuse investigation, placing residents at risk of harm.
Deficiencies (1)
F 0607 - Develop and implement policies and procedures to prevent abuse, neglect, and theft. The facility failed to investigate an allegation of physical abuse involving Resident 1 and did not ensure staff followed care precautions.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Resident Care Manager | Stated they did not ask Resident 1 how the hip was dislocated and did not investigate abuse |
| Staff B | Director of Nursing | Unaware of hospital transfer and expected nursing staff to notify for investigation |
| Staff C | Administrator-In-Training | Reviewed medical records and noted missing hospital orders in care plan |
| Staff A | Administrator | Acknowledged investigation should have been conducted but was not |
Inspection Report — Dec 3, 2024
Complaint Investigation
Date: Dec 3, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to provide timely written transfer/discharge notices to residents and their representatives, and to ensure the facility environment was free from accident hazards with adequate supervision to prevent falls.
Complaint Details
The complaint investigation revealed that the facility did not provide required written transfer/discharge notices for Residents 1, 6, and 7, and failed to provide adequate supervision and fall prevention for Resident 1, a high-fall risk resident. The facility acknowledged missing notices due to staff transition and confirmed lack of safety assessments and monitoring for fall prevention. These findings substantiate the complaint.
Findings
The facility failed to provide written transfer/discharge notices as required for 3 residents discharged to the hospital, placing them at risk for uninformed transfers. Additionally, the facility did not ensure adequate supervision and fall prevention measures for a high-fall risk resident, including lack of safety assessment for bed positioning and insufficient monitoring, which placed residents at risk for injury.
Deficiencies (2)
F 0623 - Provide timely notification to the resident and their representative before transfer or discharge, including appeal rights. The facility failed to provide written transfer/discharge notices for 3 residents discharged to the hospital as required.
F 0689 - Ensure the nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. The facility failed to provide adequate supervision and fall prevention for 1 high-fall risk resident, including lack of safety assessment for bed positioning and no frequent visual checks.
Report Facts
Residents affected: 3
Residents affected: 1
Inspection Report — Apr 16, 2024
Routine
Date: Apr 16, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, medication management, nutrition, rehabilitation, 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 and feeding tube management, respiratory care, pain management, dementia care, psychotropic medication use, food safety and sanitation, infection prevention and control, rehabilitation services, resident record accuracy, and vaccination administration. Several residents were at risk due to these deficiencies, but no immediate life-threatening harm was documented.
Deficiencies (18)
F 0625 Notify the resident or the resident's representative in writing how long the nursing home will hold the resident's bed in cases of transfer to a hospital or therapeutic leave. The facility failed to provide written bed hold notices to residents discharged to the hospital, placing them at risk of not being informed of their rights and costs.
F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. The facility failed to timely transmit Minimum Data Set (MDS) assessments for one resident, risking inaccurate monitoring of resident health status.
F 0641 Ensure each resident receives an accurate assessment. The facility failed to accurately assess oral/dental status and active diagnoses of dementia for two residents, risking unmet care needs.
F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. The facility failed to develop comprehensive care plans for seven residents, including failure to address nutrition, skin integrity, psychiatric conditions, and use of side rails.
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. The facility failed to provide required assistance with eating and personal grooming for two residents, risking aspiration, choking, and decreased quality of life.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. The facility failed to monitor and assess anticoagulation therapy and related skin conditions for one resident, risking unidentified bleeding and complications.
F 0692 Provide enough food/fluids to maintain a resident's health. The facility failed to timely assess nutritional status and develop nutrition care plans for two residents, failed to provide appropriate diet texture and meal replacements, and failed to monitor weight loss, placing residents at risk for malnutrition and weight loss.
F 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. The facility failed to document and track tube feeding formula and water administration for one resident, risking inadequate nutrition and hydration.
F 0695 Provide safe and appropriate respiratory care for a resident when needed. The facility failed to provide ordered incentive spirometry treatments and failed to obtain physician orders for supplemental oxygen, risking respiratory complications for two residents.
F 0697 Provide safe, appropriate pain management for a resident who requires such services. The facility failed to identify pain location, provide nonpharmacological interventions prior to PRN pain medication, and specify medication parameters for four residents, risking untreated pain and decreased quality of life.
F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. The facility failed to develop a person-centered care plan addressing dementia diagnosis and behaviors for one resident, risking unmet care needs and avoidable decline.
F 0758 Implement gradual dose reductions and non-pharmacological interventions prior to initiating or continuing psychotropic medication; and limit PRN psychotropic use. The facility failed to provide non-pharmacological interventions, re-evaluate PRN antipsychotic use, obtain consent, and identify target behaviors for two residents, risking unnecessary medication use and adverse effects.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. The facility failed to maintain sanitary kitchen and nourishment room conditions, including labeling and dating food, discarding spoiled food, cleaning vents, and maintaining refrigerators, risking foodborne illness.
F 0814 Dispose of garbage and refuse properly. The facility failed to keep outdoor garbage and recycling dumpsters covered and clean, risking pest infestation and disease transmission.
F 0825 Provide or get specialized rehabilitative services as required for a resident. The facility failed to provide physical and occupational therapy as assessed for one resident, limiting their ability to attain or maintain highest practicable function.
F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. The facility failed to ensure accurate and consistent resident records for two residents, including dementia diagnosis and advance directive documentation, risking unmet care needs and inaccessible health care instructions.
F 0880 Provide and implement an infection prevention and control program. The facility failed to implement appropriate isolation precautions and consistently perform hand hygiene for five residents and during meal service on two units, risking transmission of infections.
F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. The facility failed to administer pneumococcal vaccine to one resident and failed to follow up on vaccine administration, placing the resident at risk for pneumonia.
Report Facts
Weight loss: 9.4
Weight loss percentage: 6
Therapy sessions: 3
Medication administrations: 15
Medication administrations: 16
Inspection Report — Mar 21, 2023
Routine
Date: Mar 21, 2023
Visit Reason
The inspection was a routine survey of Garden Terrace Healthcare Center of Federal Way to assess compliance with regulatory requirements related to resident care, advance directives, discharge planning, care plans, nursing services, food safety, and medical record maintenance.
Findings
The facility was found to have multiple deficiencies including failure to maintain and implement advance directives, failure to provide required Medicare notices, incomplete and inaccurate care plans for multiple residents, nursing services not meeting professional standards, unsafe food handling practices, and incomplete resident medical records. All deficiencies were cited with minimal harm or potential for actual harm to residents.
Deficiencies (8)
F 0578 - The facility failed to ensure copies of Advance Directives were obtained and accessible in medical records for residents with ADs, and failed to follow up with family/representatives to complete ADs for residents with cognitive limitations.
F 0582 - The facility failed to provide Skilled Nursing Facility Advance Beneficiary Notices to a resident after Medicare skilled services ended, risking uninformed choices about further treatment or services.
F 0623 - The facility failed to notify the State Long-Term Care Ombudsman office of resident transfers or discharges to the hospital for two residents, preventing advocacy and education opportunities.
F 0656 - The facility failed to develop and implement comprehensive, measurable care plans addressing current resident needs, diagnoses, and discharge goals for multiple residents, placing them at risk for unmet care needs.
F 0657 - The facility failed to maintain, revise, and update care plans timely and accurately for multiple residents, including failure to document discontinued isolation, medication changes, and current conditions.
F 0658 - The facility failed to ensure nursing services met professional standards by administering pain medication outside ordered parameters, not monitoring psychotropic medications properly, not clarifying incomplete physician orders, signing for uncompleted tasks, and failing timely dressing changes.
F 0812 - The facility failed to ensure food was stored and prepared in a sanitary manner, including unlabeled frozen foods, improperly secured hairnets on kitchen staff, and contamination of food trays with floor debris and tray tickets.
F 0842 - The facility failed to maintain complete and accurate resident medical records, including failure to document resident refusals and inaccurate catheter documentation, risking unidentified refusal patterns and inaccurate records.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 5
Residents affected: 3
Residents affected: 3
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