Inspection Reports for Jefferson House Memory Care Community
12217 NE 128th St, Kirkland, WA 98034, United States, WA, 98034
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24
18
12
6
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Census Over Time
Inspection Report
Life Safety
Deficiencies: 12
Aug 12, 2025
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at Jefferson House Memory Care Community to assess compliance with fire protection and safety codes.
Findings
The inspection identified multiple fire safety violations including inadequate working space around electrical panels, missing over current protection on power adapters, failure to provide documentation for semi-annual hood cleaning and kitchen suppression servicing, improperly tethered kitchen oven appliance, propped open fire-rated doors, malfunctioning fire doors, ordinary temperature heads on sprinkler systems, missing delayed exit signs, and door code not posted within six feet of the main entry.
Deficiencies (12)
| Description |
|---|
| Less than three foot working space around electrical panel in Electrical Room third floor. |
| Power adapter needs over current protection in Activity Director office. |
| Facility failed to provide documentation for semi-annual hood cleaning. |
| Kitchen stove grease trap full with accumulation. |
| Kitchen oven appliance not tethered to the wall. |
| Fire rated door from the staff lounge to the corridor was propped open with a door wedge. |
| Fire rated cross corridor door did not close or latch from the fully open position near room 308. |
| The walk-in type cooler and freezer with automatic defrost has ordinary temperature heads installed. |
| Facility failed to provide documentation for kitchen suppression semi-annual servicing. |
| Missing delayed exit sign on emergency delayed egress door next to post office. |
| Emergency delayed egress door near room 307 did not have the required instructions for delayed egress. |
| Door code not posted within six feet in main entry. |
Report Facts
Provider Number: 2548
Next inspection scheduled: Sep 11, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandon G. Brown | Deputy State Fire Marshal | Signed inspection report |
Inspection Report
Re-Inspection
Deficiencies: 22
Oct 3, 2024
Visit Reason
An unannounced Fire and Life Safety Code re-inspection was conducted at Jefferson House Memory Care Community by the Washington State Patrol, State Fire Marshal's Office to determine compliance with applicable codes.
Findings
Multiple deficiencies were cited related to fire safety compliance, including lack of documentation for annual fire wall inspections, fire/smoke damper testing, sprinkler servicing, kitchen suppression system servicing, emergency lighting and power testing, fire extinguisher inspections, and fire drills. Some items were corrected, while others remained deficient.
Deficiencies (22)
| Description |
|---|
| Facility unable to provide record of annual fire wall inspection and/or repairs for all fire-resistant-rated construction. |
| Facility unable to provide documentation for last fire/smoke damper testing; report did not indicate number or location of dampers. |
| Annual sprinkler servicing deficient; quarterly sprinkler servicing not documented. |
| Facility unable to provide service reports showing kitchen suppression system serviced semi-annually in past 12 months. |
| Facility unable to provide documentation showing 90-minute annual testing of emergency lighting performed in last 12 months. |
| Facility unable to provide documentation showing annual servicing of emergency generator performed in last 12 months; weekly visual inspections and monthly load tests not conducted or documented. |
| Facility unable to provide documentation showing fire extinguishers inspected monthly; inspections conducted on some extinguishers only. |
| Facility unable to provide documentation for completion of twelve planned and unannounced fire drills in previous 12 months. |
| Facility unable to provide documentation for semi-annual hood cleaning. |
| Facility unable to provide documentation for annual and semi-annual hood cleaning. |
| Facility unable to provide documentation for annual and semi-annual hood cleaning. |
| Unsecured oxygen cylinder in room next to Med room at nurses station on 3rd floor. |
| Facility unable to provide documentation showing fire extinguishers inspected monthly. |
| Facility unable to provide inventory record of annual inspection and/or repairs for all fire-resistant-rated doors; several doors did not close or latch properly. |
| Excessive gaps in fire doors at multiple locations; some doors did not close or latch properly. |
| Facility unable to provide documentation for fire extinguisher inspections on a monthly basis. |
| Facility unable to provide documentation for annual and quarterly sprinkler servicing and forward flow test. |
| Facility unable to provide service reports showing kitchen suppression system serviced annually and semi-annually in past 12 months. |
| Facility unable to provide documentation showing annual servicing of emergency generator and required weekly visual inspections and monthly load tests. |
| Facility unable to provide documentation showing 30-second monthly testing of emergency lighting and 90-minute annual testing of emergency lighting. |
| Facility unable to provide documentation showing 90-minute annual testing of emergency lighting. |
| Facility unable to provide documentation for completion of twelve planned and unannounced fire drills in previous 12 months. |
Report Facts
Next inspection scheduled: Nov 2, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mana Pulu | Executive Director | Signed as Owner or Authorized Representative |
| Cozetta Christian | Deputy State Fire Marshal | Signed as Deputy State Fire Marshal |
Inspection Report
Follow-Up
Census: 39
Deficiencies: 0
Sep 6, 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 09/06/2024 found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previous deficiencies related to failure to notify physician and resident representative of significant weight loss were corrected.
Complaint Details
Complaint investigation conducted from 05/17/2024 through 07/03/2024 regarding dietary services and quality of care allegations including served cold food, overgrown toenails, and unintended significant weight loss. The investigation found no failed practice for food service or nail care, but identified a failure to notify the physician and resident representative of significant weight loss for one resident, resulting in a citation.
Report Facts
Total residents: 39
Resident sample size: 1
Closed records sample size: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kailash Sharma | ALF Licensor | Department staff who conducted the on-site verification and complaint investigation |
| Laurie Anderson | Field Manager | Signed follow-up inspection report and statement of deficiencies |
| Staff A | Regional Director of Operations | Interviewed regarding weight loss and notification failure |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 1
Sep 6, 2024
Visit Reason
The inspection was conducted as an unannounced on-site complaint investigation related to a second failed fire marshal inspection.
Findings
The facility failed to ensure that all 36 residents resided in a safe environment approved by the State Fire Marshal, resulting in multiple fire safety violations and noncompliance with fire safety regulations. A citation was issued due to these deficiencies.
Complaint Details
Complaint investigation related to a second failed fire marshal inspection. The facility was found out of compliance with fire marshal regulations at the time of investigation. Citation issued.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure 36 of 36 residents resided in a safe environment approved by the State Fire Marshal, placing residents at risk of harm, injury, and potential fire hazards related to unsafe environmental conditions. |
Report Facts
Total residents: 36
Resident sample size: 0
Closed records sample size: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kailash Sharma | ALF Licensor | Investigator who conducted the inspection and on-site verification. |
| Staff A | Director of Resident Services | Interviewed regarding awareness of fire marshal noncompliance and corrective actions. |
| Staff B | Maintenance Director | Interviewed regarding corrective actions taken on fire marshal deficiencies. |
Inspection Report
Re-Inspection
Census: 39
Deficiencies: 15
Aug 23, 2024
Visit Reason
Follow-up inspection to verify correction of previous deficiencies found during the full inspection on 06/25/2024.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previous deficiencies related to record retention, ventilation, signing negotiated service agreements, staff training, tuberculosis testing, negotiated service agreement content, infection control, and other areas were corrected.
Deficiencies (15)
| Description |
|---|
| Failed to retain residents' medication administration records for 16 residents, placing them at risk for health complications due to unknown medication management history. |
| Failed to ensure ventilation in 9 rooms, placing residents at risk for diminished quality of life and potential respiratory illness. |
| Failed to ensure 2 of 3 residents or their representatives signed the current service plan, risking uninformed care. |
| Failed to ensure 3 of 6 staff completed all required training, risking unmet care needs. |
| Failed to ensure 2 of 6 staff were screened for Tuberculosis within three days of hire, risking exposure to tuberculosis. |
| Failed to document negotiated service agreements for 3 of 7 sampled residents, risking unmet care needs and potential worsening medical conditions. |
| Failed to implement infection control policies and requirements to protect all 39 residents from potential spread of infectious illnesses. |
| Failed to ensure staff were fit tested for N-95 respirators as required by respiratory protection program. |
| Failed to ensure housekeepers received appropriate infection control training. |
| Failed to maintain readily available and clearly marked first aid supplies and a complete disaster plan. |
| Failed to provide Medicaid Statement of Understanding to all residents as required. |
| Failed to complete character, competence, and suitability review for one staff member with background check results requiring review. |
| Failed to post the most recent full licensing report in a common accessible area. |
| Failed to include alternate entrée choices on menus. |
| Failed to document dementia and cognitive condition assessments for residents. |
Report Facts
Residents sampled: 7
Residents total census: 39
Deficiencies cited: 16
Staff training incomplete: 3
Staff tuberculosis screening incomplete: 2
Residents with unsigned service plans: 2
Residents with undocumented negotiated service agreements: 3
Residents at risk of infection: 39
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laurie Anderson | Field Manager | Signed enforcement letter and correspondence related to inspection. |
| Jane Hermano | NCI | Department staff who did on-site verification. |
| Steven Garrett | LTC Licensor | Department staff who did on-site verification. |
| Staff A | Executive Director | Interviewed regarding ventilation, tuberculosis screening, staff training, infection control, and other findings. |
| Staff B | Director of Resident Services | Interviewed regarding infection control, service plans, and staff training. |
| Staff C | Caregiver | Personnel record reviewed for training deficiencies. |
| Staff E | Caregiver | Personnel record reviewed for tuberculosis screening and fit testing deficiencies. |
| Staff F | Caregiver | Personnel record reviewed for CPR and continuing education deficiencies. |
| Staff G | Personnel record reviewed for character, competence, and suitability review. | |
| Staff I | Licensed Practical Nurse | Observed administering medications. |
| Staff J | Housekeeper | Observed handling linens improperly. |
Inspection Report
Follow-Up
Census: 26
Deficiencies: 4
Jun 13, 2023
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to tuberculosis testing and administrator change notification.
Findings
The follow-up inspection on 06/13/2023 found no deficiencies and confirmed the facility meets licensing requirements. Previous deficiencies related to tuberculosis testing and failure to notify the department of administrator changes were corrected.
Complaint Details
Investigation was complaint-driven based on allegations of failure to report change in administrator timely and improper tuberculosis testing for newly hired staff. The investigation found failed provider practices and citations were written.
Deficiencies (4)
| Description |
|---|
| Failure to read Tuberculosis (TB) test results within 48 to 72 hours for sampled staff. |
| Failure to notify the Department of a change in assisted living facility administrator within 10 days of hire. |
| Failure to do initial two-step TB skin testing within three days of hire for sampled staff. |
| Failure to determine if staff with positive TB test had chest X-ray or evaluation for TB symptoms. |
Report Facts
Total residents: 26
Resident sample size: 0
Closed records sample size: 0
Days late for administrator notification: 137
Number of sampled staff with TB testing deficiencies: 5
Number of sampled staff with initial TB skin test deficiency: 3
Number of sampled staff with positive TB test without proper follow-up: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Forkgen | ALF Licensor | Department staff who conducted inspections and investigations |
| Staff A | Executive Director | Interviewed during complaint investigation regarding administrator change |
| Staff B | Director of Resident Services | Staff with TB testing deficiencies |
| Staff C | Activities Assistant | Staff with TB testing deficiencies |
| Staff E | Regional Director | Administrator prior to Staff A |
| Staff F | Business Office Manager | Interviewed regarding TB testing follow-up |
| Staff G | Activities Director | Staff with TB testing deficiencies |
| Staff H | Business Office Manager | Interviewed regarding TB testing follow-up |
| Staff I | Cook/Activities Assistant | Staff with TB testing deficiencies |
| Staff M | Resident Assistant | Staff with positive TB test without proper follow-up |
| Staff D | Administrator (former) | Administrator prior to Staff A |
Inspection Report
Enforcement
Deficiencies: 1
Apr 28, 2023
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to Jefferson House Memory Care Community to assess compliance and enforce corrective actions related to previously cited deficiencies.
Findings
The facility failed to read Tuberculosis test results for two staff members within the required 48 to 72 hours, placing residents at risk of contracting Tuberculosis. This deficiency was previously cited and remains uncorrected, resulting in a civil fine.
Deficiencies (1)
| Description |
|---|
| Failure to read Tuberculosis test results for two staff within 48 to 72 hours after initial administration. |
Report Facts
Civil fine amount: 300
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter regarding the civil fine. |
| Laurie Anderson | Field Manager | Contact person for plan of correction and appeals. |
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