Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 1
Apr 18, 2025
Visit Reason
The inspection was conducted due to a complaint that the Named Resident (NR) left the Assisted Living Facility (ALF) and went missing.
Findings
The ALF failed to include in their assessment that the NR was able to leave the facility unsupervised. The NR was returned by police the next day. The ALF updated the care plan and corrected the assessment failure for newly admitted residents. A consultation was issued under WAC 388-78A-2090 (6)(d) Full assessment topics.
Complaint Details
The Named Resident left the Assisted Living Facility and went missing. The NR was brought back by police the next day. The ALF was found to have failed in assessment related to the NR's ability to leave unsupervised.
Deficiencies (1)
| Description |
|---|
| Failure to include in the assessment that the Named Resident was able to leave the Assisted Living Facility unsupervised. |
Report Facts
Total residents: 37
Resident sample size: 3
Closed records sample size: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wesler Dumecquias | Community Complaint Investigator | Investigator who conducted the complaint investigation |
| Anthony Devito | Field Services Administrator | Signed letter regarding the consultation and correction process |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Jan 16, 2025
Visit Reason
The inspection was a follow-up complaint investigation triggered by allegations including a resident fall and inappropriate touching by staff, as well as failure to report incidents to the Complaint Resolution Unit Hotline.
Findings
The facility was found to have failed to report multiple unwitnessed falls with injuries to the Complaint Resolution Unit Hotline, resulting in a citation for noncompliance with WAC 388-78A-2630(1)(a). The allegation of inappropriate touching was not substantiated. The follow-up inspection found no deficiencies and the facility met licensing requirements.
Complaint Details
The complaint involved a Named Resident (NR) who had multiple unwitnessed falls with injuries and an allegation that a Named Staff (NS) touched the NR inappropriately. The facility failed to report the falls to the Complaint Resolution Unit Hotline, which was cited as a failed provider practice. The inappropriate touching allegation was investigated and not substantiated.
Deficiencies (1)
| Description |
|---|
| Failure to report to the department's Complaint Resolution Unit hotline when a resident had five unwitnessed falls, four with injuries. |
Report Facts
Total residents: 38
Resident sample size: 3
Number of unwitnessed falls: 5
Number of falls with injuries: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wesler Dumecquias | Community Complaint Investigator | Investigator who conducted the complaint investigation and follow-up inspection |
| Kimberley Ripley | Field Manager | Signed the follow-up inspection report |
| Staff B | Wellness Director | Interviewed regarding reporting of falls and acknowledged failure to report prior incidents |
Inspection Report
Follow-Up
Census: 43
Deficiencies: 2
Oct 16, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to infection control and other licensing laws.
Findings
The follow-up inspection found no deficiencies and confirmed that previously cited deficiencies related to infection control and compliance with licensing laws were corrected. The prior complaint investigation found failures in reporting COVID-19 cases and outbreak management, resulting in citations.
Complaint Details
Complaint investigation found multiple residents sick with symptoms compatible with COVID-19; the facility failed to quarantine sick residents, failed to report cases to the Department of Health, and failed to investigate a potential outbreak. Citation issued for noncompliance with WAC 388-78A-2650 (3) Reporting Fires and Incidents and WAC 388-78A-2371 (1) Investigations.
Deficiencies (2)
| Description |
|---|
| Failure to determine and report positive COVID-19 cases and outbreaks to the local health department, placing residents at risk of infection. |
| Failure to obtain a medical testing site waiver (MTSW) license for blood glucose testing, risking inaccurate clinical laboratory services. |
Report Facts
Total residents: 43
Resident sample size: 7
Closed records sample size: 2
Investigation date range: 2024-07-19 to 2024-08-15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wesler Dumecquias | Community Complaint Investigator | Conducted the complaint investigation and follow-up inspection |
| Kimberley Ripley | Field Manager | Signed the follow-up inspection letter |
| Staff A | Executive Director | Provided statements regarding resident hospitalizations and testing practices |
| Staff C | Memory Care Coordinator | Provided statements about resident testing and hospitalizations |
| Staff D | Caregiver | Reported quarantine practices and PPE use |
| Staff E | Med Tech | Reported resident symptoms, positive COVID-19 test, and contracting infection |
| Staff F | Med Tech | Reported resident symptoms and PPE use |
| Staff G | Caregiver | Reported PPE use and resident care observations |
| Staff H | Regional Nurse | Reported on outbreak case reporting and testing practices |
Inspection Report
Follow-Up
Census: 42
Deficiencies: 6
Apr 24, 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 the Assisted Living Facility licensing requirements. The report details prior deficiencies related to food and nutrition services, medication management, investigations, and reporting abuse and neglect, all of which were corrected.
Deficiencies (6)
| Description |
|---|
| Failed to serve resident meals reviewed and approved by a dietitian for 8 of 8 weekly menus, resulting in 42 residents not receiving nutritionally balanced meals. |
| Failed to obtain prescribed medications in a timely manner for 1 of 7 residents, placing residents at risk for medical complications. |
| Failed to notify physician and follow instructions when a resident refused medication, resulting in risk for untreated health care needs. |
| Failed to thoroughly investigate an incident where a resident was found injured on the floor, placing the resident at risk. |
| Failed to make a report to the Complaint Resolution Unit hotline for an unwitnessed incident resulting in a fractured hip, placing the resident at risk for harm. |
| Failed to administer medications accurately as prescribed, resulting in medication errors and risk for medical complications. |
Report Facts
Residents sampled for review: 7
Current residents: 42
Former residents: 0
Medication doses refused: 51
Medication administration errors: 1
Residents at risk due to medication issues: 3
Residents injured on floor: 1
Residents with unreported incidents: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christine Banta | ALF Licensor | Department staff who did the on-site verification |
| Kimberley Ripley | Field Manager | Signed compliance determination letters and correspondence |
| Betsy Frankie | Administrator | Signed Plan/Attestation Statements agreeing to corrective actions |
| Jodi Condyles | ALF Licensor | Department staff who inspected the Assisted Living Facility |
| Cristina Gonzalez | ALF Licensor | Department staff who inspected the Assisted Living Facility |
| Staff A | Executive Director | Provided information on food services and incident reports |
| Staff B | Wellness Director | Provided information on medication orders and pharmacy communication |
| Staff E | Resident Care Coordinator | Described medication administration procedures and refusals |
| Staff H | Cook | Provided information on food service menus and dietitian review |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 1
Mar 4, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on allegations of long call wait times resulting in resident falls and delays in care, as well as concerns about short staffing with only one caregiver overnight.
Findings
The investigation found that the facility's call pendant system was unreliable, with 3 of 3 sampled residents experiencing nonfunctioning or missing pendants, leading to delayed staff response and increased risk of injury. The facility was also short staffed and continuously hiring, contributing to long wait times for assistance. Citations were issued for noncompliance with communication system regulations.
Complaint Details
The complaint investigation was substantiated with findings that residents experienced long call wait times due to malfunctioning or missing call pendants, resulting in falls and delayed care. The facility was also short staffed with only one caregiver overnight.
Deficiencies (1)
| Description |
|---|
| Failure to ensure 3 of 3 residents received reliable, working call pendants, placing residents at risk of unmet care needs and potential injury. |
Report Facts
Total residents: 43
Resident sample size: 3
Closed records sample size: 0
Wait time: 45
Number of falls: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wesler Dumecquias | Community Complaint Investigator | Conducted the on-site complaint investigation |
| Jayne Hill | Field Manager | Signed follow-up inspection letter |
| Staff C | Med tech | Interviewed regarding call pendant issues and resident care |
| Staff A | Executive Director | Interviewed regarding lack of policy for pendant call system |
Inspection Report
Life Safety
Deficiencies: 7
Jun 26, 2023
Visit Reason
The Office of the State Fire Marshal conducted an inspection at the facility to assess compliance with fire protection and safety codes.
Findings
The inspection identified multiple violations related to fire detection and alarm systems, sprinkler system maintenance, commercial cooking system signage, fire alarm testing, fire department connection testing, carbon monoxide detector testing, and emergency lighting activation. The facility was disapproved due to these deficiencies.
Deficiencies (7)
| Description |
|---|
| The sprinkler heads in the kitchen cooler and freezer appear to be more than 5 years old and lack required replacement documentation. |
| Facility is unable to provide documentation for the 5 year internal piping inspection and the 3 year dry system full flow trip test of the sprinkler system. |
| Signage is missing on the exhaust hood or system cabinet indicating the type and arrangement of cooking appliances protected by the automatic fire-extinguishing system. |
| Defunct single station smoke detectors in rooms need to be maintained or removed. |
| Facility unable to provide documentation that the Fire Department Connection has been hydrostatically tested every 5 years as required. |
| Facility unable to provide documentation for monthly carbon monoxide detector testing. |
| Facility unable to provide documentation for the monthly 30 second activation test for emergency lights; emergency light by room 215 failed to illuminate on push button test. |
Report Facts
Age of sprinkler heads: 5
Hydrostatic test pressure: 150
Emergency lighting test duration: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Betsy Franke | Executive Director | Named as Owner or Owner's Representative on inspection report |
| Arthur Jesse Ward | Deputy State Fire Marshal | Conducted the inspection |
| Emir Karic | Maintenance | Named as Owner or Authorized Representative on final page |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
Apr 19, 2023
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations including medication errors, inadequate staffing, locked resident rooms, and lack of executive director.
Findings
The investigation found a medication error where a resident was given wrong medications due to staff distraction, and medications were given crushed without physician orders, constituting a failed practice. Other allegations such as locked rooms, wandering resident, and staffing were found to be adequately addressed. The facility hired a new Executive Director during the investigation period.
Complaint Details
The complaint involved seven allegations including wrong medications given to a resident, lack of resident identifiers, resident found on floor in another resident's room, inadequate staffing, locked resident rooms, inconsistent blood pressure monitoring, and absence of an Executive Director. The complaint was substantiated with a failed practice identified related to medication alteration.
Deficiencies (1)
| Description |
|---|
| Medications were given in an altered or crushed form without physicians' orders, placing residents at risk for medication malabsorption and adverse effects. |
Report Facts
Total residents: 46
Resident sample size: 5
Closed records sample size: 2
Wrong medications given: 5
Oral medications taken by Resident 1: 7
Oral medications taken by Resident 2: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wesler Dumecquias | Community Complaint Investigator | Investigator who conducted the complaint investigation |
| Christine Banta | Community Complaint Investigator | Department staff who did the on-site verification during follow-up inspection |
| Kimberley Ripley | Field Manager | Signed the follow-up inspection report |
| Betsy Frankie | Administrator (or Representative) | Signed the Plan/Attestation Statement for correction |
| Staff G | Memory Care Director (MCD) | Interviewed regarding medication administration |
| Staff F | Med Tech | Interviewed regarding medication administration |
| Staff A | Executive Director | Interviewed and provided information about medication orders |
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