Inspection Report Summary
The most recent inspection on January 16, 2025, found no deficiencies, confirming that previously cited issues related to resident assessments, negotiated service agreements, food sanitation, background checks, training, tuberculosis testing, and emergency preparedness were corrected. Earlier inspections showed a pattern of recurring deficiencies involving implementation of negotiated service agreements, respiratory protection program compliance, and failure to obtain required approvals for changes in unit use. Several substantiated complaint investigations identified issues with medication administration, staffing shortages, resident supervision, and failure to prevent or investigate sexual abuse incidents; these led to civil fines totaling at least $1,300. Enforcement actions included multiple civil fines and a stop placement order that was later lifted; fines ranged from $300 to $1,000, and no license suspensions or revocations were listed in the available reports. The facility’s recent clean inspections suggest improvement after a period of mixed and recurring deficiencies.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
14 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
122% worse than Washington average
Washington average: 6.3 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
53 residents
Based on a January 2025 inspection.
Occupancy over time
Inspection Report
Follow-Up
Census: 53
Deficiencies: 7
Date: Jan 16, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility on 01/16/2025 to verify correction of previously cited deficiencies from Compliance Determinations #52257 and #49479.
Findings
The follow-up inspection found no deficiencies, indicating that the facility corrected the previously cited issues related to resident assessments, implementation of negotiated service agreements, food sanitation, background checks, training and certification requirements, tuberculosis testing, and emergency preparedness.
Deficiencies (7)
Failure to obtain sufficient information to assess resident capabilities, needs, and preferences within fourteen days of move-in.
Failure to implement the negotiated service agreement for a resident requiring daily compression stocking use.
Failure to manage food service facilities in compliance with food safety regulations, including improper handwashing and ineffective sanitizing solution monitoring.
Failure to ensure fingerprint background checks were completed for all staff.
Failure to ensure staff completed required CPR training and continuing education.
Failure to ensure tuberculosis testing was completed within three days of employment for staff.
Failure to ensure emergency food and water supplies were non-expired and readily available.
Report Facts
Residents at risk: 53
Sample residents reviewed: 7
Residents census: 53
Expired food items: 70
Expired emergency water supply cases: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Medication Technician | Failed to obtain fingerprint background check, incomplete CPR training, and tuberculosis testing not completed |
| Staff E | Resident Care Director | Unaware of side rail on Resident 2's bed and confirmed Resident 3's edema and TED hose use |
| Staff F | Executive Director | Stated residents must self-manage oxygen and confirmed staff training and continuing education status |
| Staff G | Food Services Director | Failed to follow proper handwashing technique and acknowledged failure to monitor sanitizing solution and food temperature logs |
| Staff D | Medication Technician | Observed Resident 3's TED hose use and refusal |
| Staff K | Personal Care Assistant | Reported Resident 3 refused to wear TED hose |
Inspection Report
Follow-Up
Census: 64
Deficiencies: 1
Date: Jan 7, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to compliance determinations 52625 and 49502.
Findings
The follow-up inspection found no deficiencies, indicating that the previously cited issues were corrected. The deficiencies related to the Respiratory Protection Program and fit-testing of healthcare workers were addressed.
Deficiencies (1)
Failure to follow a Respiratory Protection Program by ensuring 2 of 17 healthcare workers were fit-tested for respirator masks annually, placing 64 residents at risk of COVID-19 exposure.
Report Facts
Residents at risk: 64
Healthcare workers not fit-tested: 2
Resident census: 69
Resident sample size: 2
Healthcare workers with unrenewed fit tests: 27
COVID-19 positive residents: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hayley Pinkham | ALF Licensor | Department staff who conducted inspections and investigations. |
| Staff A | Executive Director | Confirmed that Staff B and Staff C's respirator mask fit-tests had not been renewed annually and confirmed all 27 HCWs' fit tests had not been renewed. |
| Staff B | Healthcare worker whose fit test was expired and not renewed annually. | |
| Staff C | Healthcare worker whose fit test was expired and not renewed annually; confirmed providing direct care to COVID-19 positive residents. | |
| Jamie Singer | Field Manager | Signed multiple documents related to inspections and compliance determinations. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 6, 2025
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 conducted on 2025-01-06 found no deficiencies, indicating that previously cited licensing law and regulation deficiencies were corrected.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hayley Pinkham | ALF Licensor | Department staff who did the On Site verification |
| Jamie Singer | Field Manager | Signed the follow-up inspection letter |
Notice
Deficiencies: 0
Date: Dec 12, 2024
Visit Reason
The document confirms the scheduling of an Informal Dispute Resolution (IDR) meeting requested by the facility to dispute a Statement of Deficiencies dated October 15, 2024, and a Civil Fine dated October 24, 2024.
Findings
The letter does not contain inspection findings but addresses the scheduling and participants of the IDR process related to disputed citations.
Report Facts
License Number: 2566
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Richard Luce | Executive Director | Named as participant representing the facility in the IDR process. |
| Paul Markovitch | VP of Operations | Named as participant representing the facility in the IDR process. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 2, 2024
Visit Reason
This document is the result of an Informal Dispute Resolution (IDR) process regarding disputed deficiencies identified in a Statement of Deficiencies report dated 2024-10-15 for an Assisted Living Facility.
Findings
After review of all materials, oral statements, and records, the decision was made to not change the original Statement of Deficiencies report dated 2024-10-15. The facility is instructed to begin correcting the disputed deficiencies immediately and submit a Plan/Attestation Statement within 10 calendar days.
Report Facts
Days to complete corrections: 45
Date of original SOD report: Oct 15, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Scotti Bower | IDR Program Manager | Signed the IDR results letter and provided contact information. |
| Jamie Singer | Field Manager | Recipient of the Plan/Attestation Statement for disputed deficiencies. |
Notice
Deficiencies: 0
Date: Nov 27, 2024
Visit Reason
The letter confirms the scheduling of an Informal Dispute Resolution (IDR) meeting requested by the facility to dispute citations related to a Statement of Deficiencies dated November 1, 2024, and a Civil Fine dated November 13, 2024.
Findings
The document does not contain inspection findings but serves as a formal notice for the IDR meeting to discuss disputed citations and related documentation.
Report Facts
License number: 2566
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Richard Luce | Executive Director | Named as participant representing the facility in the IDR process. |
| Laci Traulsen | Informal Dispute Resolution, Residential Care Services | Author of the scheduling letter. |
| Matt Hauser | Compliance Specialist | Mentioned in cc list related to the IDR process. |
Notice
Deficiencies: 0
Date: Nov 15, 2024
Visit Reason
The letter confirms the rescheduling of an Informal Dispute Resolution (IDR) meeting requested by the facility to dispute a Statement of Deficiencies dated October 15, 2024, and a Civil Fine dated October 24, 2024.
Findings
The document does not contain inspection findings but addresses the scheduling details and participants for the IDR process disputing a specific citation (WAC 388-78A-2880).
Report Facts
Citation date: Oct 15, 2024
Civil Fine date: Oct 24, 2024
IDR meeting date: Nov 26, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Richard Luce | Executive Director | Participant representing the facility in the IDR process |
| Paul Markovitch | VP of Operations | Participant representing the facility in the IDR process |
| Jake Call | Regional Director of Operations/VP of Operations | Participant representing the facility in the IDR process |
Inspection Report
Enforcement
Deficiencies: 1
Date: Nov 1, 2024
Visit Reason
The document is the result of an Informal Dispute Resolution (IDR) process initiated in response to a Statement of Deficiencies (SOD) report dated November 1, 2024, disputing findings related to the assisted living facility.
Findings
After review, a change was made to the SOD by removing an edited record review regarding a policy (WAC 388-78A-2730), but there was no change to the previously imposed enforcement action.
Deficiencies (1)
Edited record review regarding the policy WAC 388-78A-2730 was removed
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staci Dilg | IDR Program Manager | Signed as contact person for questions regarding the IDR results |
Inspection Report
Follow-Up
Census: 64
Deficiencies: 1
Date: Nov 1, 2024
Visit Reason
The Department of Social and Health Services completed a follow-up visit to Kenmore Senior Living to verify correction of previously cited deficiencies related to the Respiratory Protection Program.
Findings
The facility failed to ensure two healthcare workers were fit-tested annually for respirator masks, placing 64 residents at risk for COVID-19 exposure. This was an uncorrected and recurring citation, resulting in a civil fine.
Deficiencies (1)
Failure to follow a Respiratory Protection Program by ensuring two healthcare workers were fit-tested annually for respirator masks.
Report Facts
Civil fine amount: 500
Residents at risk: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the letter regarding the civil fine and inspection |
| Jamie Singer | Field Manager | Contact person for plan of correction and follow-up |
Inspection Report
Enforcement
Deficiencies: 1
Date: Oct 30, 2024
Visit Reason
The Department of Social and Health Services conducted a Full Inspection at Kenmore Senior Living on October 30, 2024, resulting in the imposition of a civil fine due to regulatory violations.
Findings
The licensee failed to implement the Negotiated Service Agreement for one resident prescribed to wear compression stockings daily, placing the resident at risk. This deficiency was recurring, previously cited multiple times in 2023 and 2024.
Deficiencies (1)
Failure to implement the Negotiated Service Agreement for a resident prescribed compression stockings daily.
Report Facts
Civil fine amount: 700
Previous deficiency citation dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter. |
| Jamie Singer | Field Manager | Contact person for plan of correction and inquiries. |
Notice
Deficiencies: 0
Date: Oct 28, 2024
Visit Reason
The letter confirms the scheduling of an Informal Dispute Resolution (IDR) meeting requested by the facility administrator to dispute specific citations from a Statement of Deficiencies dated October 16, 2024.
Findings
The document does not contain inspection findings but addresses the scheduling and participants of the IDR process related to disputed citations.
Report Facts
License number: 2566
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Richard Luce | Administrator | Facility administrator participating in the IDR process. |
| Jake Call | VP of Operations | Facility representative participating in the IDR process. |
| Paul Markovitch | Regional Director of Operations | Facility representative participating in the IDR process. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 16, 2024
Visit Reason
This document is the result of an Informal Dispute Resolution (IDR) process regarding disputed deficiencies identified in the Statement of Deficiencies (SOD) report dated 2024-10-16 for the Assisted Living Facility.
Findings
After review of all materials, oral statements, and records, the decision was made not to change the original SOD report dated 2024-10-16. The facility is instructed to begin correcting the disputed deficiencies immediately and submit a Plan/Attestation Statement within 10 calendar days.
Report Facts
Correction timeframe: 45
Plan/Attestation Statement submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Scotti Bower | IDR Program Manager | Signed the IDR results letter |
| Jamie Singer | Field Manager | Recipient for mailing the Plan/Attestation Statement |
Inspection Report
Enforcement
Deficiencies: 1
Date: Oct 15, 2024
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to Kenmore Senior Living to assess compliance and impose a civil fine related to a previously cited deficiency regarding unauthorized change in room use.
Findings
The facility failed to notify the Washington State Department of Health Construction Review Services or obtain written approval to change the use of Memory Care Unit apartments for Medicaid residents, resulting in a civil fine of $300. This deficiency was previously cited and remains uncorrected.
Deficiencies (1)
Failure to notify the Department of Health Construction Review Services and obtain approval for changing use of Memory Care Unit apartments to Medicaid resident use.
Report Facts
Civil fine amount: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter |
| Jamie Singer | Field Manager | Contact person for the plan of correction and appeals |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 1
Date: Jun 6, 2024
Visit Reason
The department conducted an unannounced on-site complaint investigation due to allegations including incorrect insulin dose administration, resident relocation to an apartment with a shared bathroom and no kitchenette, and billing errors.
Complaint Details
The complaint investigation included allegations of incorrect insulin administration, resident relocation to an apartment with shared bathroom and no kitchenette, and billing errors. The insulin error was substantiated but no failed practice was identified. The relocation and failure to obtain CRS approval were substantiated with deficient practice identified. Billing errors were corrected.
Findings
The facility failed to obtain written approval from Construction Review Services (CRS) for converting Memory Care Unit (MCU) apartments to assisted living apartments, placing 72 residents at risk. One resident received the wrong insulin dose but was monitored and staff retrained. The facility gave a resident a 7-day notice to move to a different apartment as part of conversion, which was consistent with policy. Billing errors for the resident were corrected.
Deficiencies (1)
Failed to obtain written approval from Construction Review Services to convert MCU apartments to assisted living apartments.
Report Facts
Total residents: 72
Resident sample size: 5
Resident moved notice period: 7
Resident apartments at risk: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hayley Pinkham | ALF Licensor | Department staff who inspected the Assisted Living Facility and conducted the complaint investigation |
| Staff A | Executive Director | Provided information about MCU closure and apartment conversions |
| Staff B | Resident Care Coordinator | Signed service summary and submitted it to HCS related to resident care contract acceptance |
| Jamie Singer | Field Manager | Signed official department correspondence |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 13, 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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Mcglon | Nursing Consultant Institutional | Department staff who did the on-site verification during the follow-up inspection. |
| Jamie Singer | Field Manager | Signed the follow-up inspection letter. |
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 2
Date: Feb 5, 2024
Visit Reason
The inspection was conducted as an unannounced on-site complaint investigation regarding allegations that a resident went without her full dose of medication for a week and that the assisted living facility administrative staff did not respond to requests for an explanation.
Complaint Details
The complaint alleged that a named resident went without her full dose of medication for a week and that the facility administrative staff did not respond to requests for explanation. The complaint was substantiated with deficient practices identified.
Findings
The investigation found that the facility failed to ensure timely medication administration for one resident, causing withdrawal symptoms, and failed to respond timely to resident grievances regarding the missed medication. Deficient practices were identified and citations were written.
Deficiencies (2)
Failure to ensure a resident received prescribed medications in a timely manner, resulting in missed medication for seven days causing withdrawal symptoms.
Failure to implement grievance policy by not responding timely to resident representative's concerns about missed medications.
Report Facts
Total residents: 76
Resident sample size: 2
Days medication missed: 7
Dates of investigation: Investigation conducted from 2024-02-05 through 2024-03-08
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hayley Pinkham | ALF Licensor | Investigator who conducted the complaint investigation and off-site verification |
| Jamie Singer | Field Manager | Signed official correspondence related to the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 11, 2024
Visit Reason
The Department of Social and Health Services completed a complaint investigation at Kenmore Senior Living related to failure to implement negotiated service agreement interventions for a resident with a history of sexually inappropriate behavior.
Complaint Details
Complaint investigation conducted on January 11, 2024. The violation was substantiated and resulted in a civil fine.
Findings
The licensee failed to implement supervision and monitoring interventions for one resident, resulting in inappropriate sexual behavior towards two residents and placing four female residents in the Memory Care Unit at risk for sexual abuse. This violation led to the imposition of a $1,000 civil fine.
Deficiencies (1)
Failure to implement the Negotiated Service Agreement interventions of supervision and monitoring for one resident with a history of sexually inappropriate behavior.
Report Facts
Civil fine amount: 1000
Number of residents at risk: 4
Number of residents involved in inappropriate behavior: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the letter regarding the civil fine and complaint investigation. |
| Jamie Singer | Field Manager | Contact person for plan of correction and appeals. |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 2
Date: Oct 25, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation into allegations of sexual abuse between residents at Kenmore Senior Living.
Complaint Details
The complaint involved allegations that multiple residents were sexually abused by other residents, including inappropriate touching of breasts and inner thighs. The facility staff, including the Administrator, Head Nurse, and Medication Technicians, failed to report or stop the behaviors, and no investigations were conducted despite multiple witnessed incidents.
Findings
The facility failed to investigate multiple allegations and witnessed incidents of sexual abuse involving four named residents. The facility did not implement measures to protect residents or prevent recurrence, resulting in citations for failed provider practices.
Deficiencies (2)
Failure to investigate and document investigative actions and findings for alleged sexual abuse incidents involving residents.
Failure to implement measures to prevent similar future incidents and protect residents from sexual abuse.
Report Facts
Total residents: 84
Resident sample size: 5
Number of female residents in Memory Care Unit: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cathy Prentice | Complaint Investigator | Conducted the on-site verification and investigation |
| Jamie Singer | Field Manager | Signed the compliance determination and statement of deficiencies |
Inspection Report
Follow-Up
Census: 84
Deficiencies: 1
Date: Oct 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 emergency lighting and oxygen therapy assistance.
Complaint Details
The complaint investigation was triggered by a resident fall during a power outage resulting in injury, lack of emergency lighting in hallways and common areas, and no assistance for residents requiring continuous oxygen therapy. The investigation found emergency lighting was functioning in hallways but absent in resident apartments. The Resident Service Director stated residents on oxygen were independent and staff did not assist with oxygen management. The complaint was substantiated with citation(s) written.
Findings
The follow-up inspection found no deficiencies and confirmed that previously cited deficiencies regarding emergency lighting in resident apartments were corrected. The facility meets Assisted Living Facility licensing requirements.
Deficiencies (1)
The Assisted Living Facility failed to provide emergency lighting in individual resident apartments, which may have contributed to a resident fall and injury during a power outage.
Report Facts
Total residents: 84
Resident sample size: 4
Compliance Determination Completion Date: Sep 7, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Mcglon | Nursing Consultant Institutional | Department staff who conducted on-site verification and investigation |
| Jamie Singer | Field Manager | Signed follow-up inspection letter and compliance determination |
| Staff B | Maintenance Director | Interviewed regarding emergency lighting removal during apartment renovations |
| Staff A | Executive Director | Interviewed regarding plans to replace emergency lighting in resident apartments |
Inspection Report
Follow-Up
Census: 2
Capacity: 75
Deficiencies: 0
Date: Sep 28, 2023
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility on 09/28/2023 to verify correction of previous deficiencies.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets the Assisted Living Facility licensing requirements.
Report Facts
Residents present during inspection: 2
Total licensed capacity: 75
Deficiency counts: 21
Residents at risk: 77
Residents on Memory Care Unit: 10
Call pendant calls: 827
Call pendant calls exceeding 45 minutes: 309
Call pendant calls not answered between 40-45 minutes: 39
Call pendant calls not answered between 35-39 minutes: 53
Call pendant calls not answered between 30-34 minutes: 35
Call pendant calls not answered between 25-29 minutes: 52
Call pendant calls not answered between 20-24 minutes: 85
Call pendant calls not answered between 15-19 minutes: 114
Call pendant calls not answered between 10-14 minutes: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Singer | Field Manager | Signed multiple Plan/Attestation Statements and letters |
| Sunny Kent | Licensor | Department staff who inspected the facility |
| Faith Le | NCI | Department staff who inspected the facility |
| Staff A | Executive Director | Named in multiple interviews related to deficiencies and corrective actions |
| Staff K | Business Office Manager | Interviewed regarding eMAR documentation and background checks |
| Staff H | Resident Care Director | Interviewed regarding call light response and medication documentation |
| Staff F | Resident Care Director | Interviewed regarding refrigerator checks |
| Staff C | Medical Technician | Named in background check and orientation deficiencies |
| Staff D | Personal Care Assistant | Named in background check and orientation deficiencies |
| Staff E | Activities Director | Named in background check and orientation deficiencies |
| Staff B | Housekeeper | Named in background check and orientation deficiencies |
| Staff I | Personal Care Assistant | Interviewed regarding special diet |
| Staff J | Personal Care Assistant | Interviewed regarding special diet |
| Staff H | Cook | Interviewed regarding special diet and dietary manual |
Inspection Report
Follow-Up
Census: 75
Deficiencies: 7
Date: Aug 3, 2023
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to Kenmore Senior Living to assess correction of previously cited deficiencies.
Findings
Multiple uncorrected deficiencies were found, including failure to ensure pet vaccinations and certifications, unsafe exterior ramp conditions, failure to implement negotiated service agreements, incomplete tuberculosis screening for staff, incomplete staff orientation, and lack of resident consent for video monitoring. These deficiencies placed residents at risk in various ways.
Deficiencies (7)
Failure to ensure five pets owned by residents received certification from a veterinarian and three pets were up to date with vaccinations.
Failure to ensure an exterior ramp leading from the second floor to an outdoor resident area was kept free of hazards.
Failure to implement Negotiated Service Agreements when call lights for two residents were not answered timely or at all.
Failure to ensure two staff were screened for tuberculosis within three days of employment.
Failure to ensure one staff had completed orientation to the facility.
Failure to ensure one resident with video monitoring in their apartment had an evaluation or signed consent.
Failure to have a diet manual approved by a dietitian and reviewed and updated at least every five years.
Report Facts
Civil fines total: 2100
Residents at risk: 75
Pets without certification: 5
Pets without up-to-date vaccinations: 3
Residents affected by call light issues: 2
Staff not screened for TB: 2
Staff without completed orientation: 1
Residents with video monitoring without consent: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the letter regarding civil fines and deficiencies. |
| Jamie Singer | Field Manager | Contact person for the plan of correction and appeals. |
Inspection Report
Follow-Up
Census: 83
Capacity: 100
Deficiencies: 1
Date: Jul 17, 2023
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previous deficiencies related to fire and life safety code compliance.
Findings
The follow-up inspection on 07/17/2023 found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previous deficiencies related to fire and life safety code violations were corrected.
Deficiencies (1)
Failure to comply with Washington State Patrol Office of State Fire Marshal (OSFM) fire and life safety inspections, including failure to provide documentation of smoke detector sensitivity tests and replacement of smoke detectors.
Report Facts
Residents present during inspection: 83
Total licensed capacity: 100
Number of smoke detectors needing replacement: 92
Number of smoke detectors needing replacement (earlier report): 102
Resident sample size: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Mcglon | Nursing Consultant Institutional | Department staff who did the on-site verification during follow-up inspection |
| Jamie Singer | Field Manager | Field Manager signing enforcement and deficiency letters |
| Keiko Kitano | Licensor | Department staff who inspected the Assisted Living Facility |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 7
Date: Apr 28, 2023
Visit Reason
The inspection was conducted as a follow-up to verify correction of previously cited deficiencies related to medication availability and compliance with licensing laws and regulations at Kenmore Senior Living Assisted Living Facility.
Complaint Details
Multiple complaints were investigated between 10/25/2022 and 12/20/2022 regarding staffing shortages, outdated care plans, medication availability, COVID infection control failures, medication errors, and resident falls with injury. All investigations resulted in findings of failed provider practices with citations issued.
Findings
The follow-up inspection on 04/28/2023 found no deficiencies and confirmed that the facility met Assisted Living Facility licensing requirements. Previous deficiencies related to medication nonavailability were corrected. Multiple complaint investigations conducted between 10/25/2022 and 12/20/2022 identified failed provider practices including medication availability, infection control, care plan updates, and respiratory protection program deficiencies.
Deficiencies (7)
Failed to ensure that 1 of 2 sampled residents had antipsychotic medication available, placing resident at risk for psychological harm.
Failed to ensure that 2 of 2 sampled residents had prescribed pain medication available, placing residents at risk for increased pain and withdrawal.
Failed to provide Personal Protective Equipment (PPE) including eye protection to healthcare workers during a COVID outbreak.
Failed to implement a Respiratory Protection Program (RPP) to ensure staff were fit tested and wore appropriate masks during infectious outbreak.
Failed to update Negotiated Service Agreements to reflect residents' current needs.
Failed to ensure the Named Resident received only their prescribed medications and did not receive narcotic topical medication prepared for another resident.
Failed to correctly identify the Named Resident's current mobility care needs in assessment and negotiated service agreement.
Report Facts
Resident census: 79
Resident census: 83
COVID positive residents: 27
Resident sample size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Mcglon | Nursing Consultant Institutional | Department staff who conducted inspections and investigations |
| Jamie Singer | Field Manager | Signed follow-up inspection report |
| Jayne Hill | Residential Care Services | Signed compliance determination letter |
| Staff A | Executive Director | Interviewed regarding medication availability and infection control |
| Staff B | Medication Technician/Caregiver | Interviewed regarding PPE provision |
| Staff C | Medication Technician/Caregiver | Interviewed regarding PPE provision |
| Staff D | Business Office Manager | Interviewed regarding Respiratory Protection Plan and PPE |
| Staff E | Residential Care Director | Interviewed regarding resident care needs |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 3
Date: Mar 23, 2023
Visit Reason
The inspection was conducted as a complaint investigation regarding an allegation that a named resident was given the wrong dose of an as-needed medication at the Assisted Living Facility.
Complaint Details
The complaint involved a named resident receiving the wrong dose of an as-needed medication. The complaint was substantiated with findings of failed provider practices and citations written.
Findings
The investigation found that the facility failed to have a system in place to ensure the Medication Administration Record matched the medication cart dosage and failed to ensure all staff were nurse delegated to administer oral medications. A medication error was confirmed involving an incorrect dose of lorazepam given to a resident.
Deficiencies (3)
Failed to ensure the Medication Administration Record matched the medication cart dosage for a resident.
Failed to ensure all staff were nurse delegated to administer the resident's oral medications.
Failed to notify physician or health care team when resident needed a refill on an antipsychotic medication, placing resident at risk for psychological harm.
Report Facts
Total residents: 79
Resident sample size: 2
Compliance Determination Completion Date: Apr 28, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Mcglon | Nursing Consultant Institutional | Investigator who conducted the complaint investigation and on-site verification |
| Jamie Singer | Field Manager | Signed enforcement and follow-up inspection documents |
Inspection Report
Enforcement
Deficiencies: 1
Date: Mar 13, 2023
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to Kenmore Senior Living to assess compliance and issued a civil fine based on violations found during the inspection.
Findings
The facility was fined $300 for failing to ensure availability of antipsychotic medication for one resident, which placed the resident at risk for psychological harm. This was an uncorrected deficiency previously cited on December 21, 2022.
Deficiencies (1)
Failure to ensure that one resident had antipsychotic medication available in the facility.
Report Facts
Civil fine amount: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter |
| Jamie Singer | Field Manager | Contact person for the facility regarding the enforcement and plan of correction |
Notice
Deficiencies: 0
Date: Feb 16, 2023
Visit Reason
Notification that the stop placement order prohibiting admissions placed on the facility's license on December 6, 2022, is lifted effective February 16, 2023.
Findings
The letter formally lifts the previously imposed stop placement order that prohibited admissions to the facility.
Report Facts
Date stop placement order placed: December 6, 2022
Date stop placement order lifted: February 16, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the letter lifting the stop placement order |
| Jamie Singer | Field Manager | Contact person for questions regarding the stop placement order |
Notice
Deficiencies: 0
Date: Jan 13, 2023
Visit Reason
The document serves as a notice of a Continued Stop Placement Order on the license of Kenmore Senior Living based on a prior Statement of Deficiencies dated January 3, 2023.
Findings
The Continued Stop Placement Order was effective December 6, 2022, and remains in effect until formally lifted by the Department of Social and Health Services.
Report Facts
License number: 2566
Date of Statement of Deficiencies: Jan 3, 2023
Effective date of Stop Placement Order: Dec 6, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the notice of Continued Stop Placement Order |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 2
Date: Jan 3, 2023
Visit Reason
The Department of Social and Health Services completed a complaint investigation at Kenmore Senior Living on January 3, 2023, due to violations related to stop placement orders and staffing deficiencies.
Complaint Details
Complaint investigation completed on January 3, 2023, substantiated by findings of noncompliance with stop placement order and staffing deficiencies.
Findings
The investigation found that the licensee failed to comply with a stop placement order by readmitting 2 residents without Department approval and failed to provide sufficient care staff to meet the needs of 83 residents, including 17 residents with unmet assessed care needs, placing them at risk of harm.
Deficiencies (2)
Failure to comply with stop placement order by readmitting 2 residents without Department review and approval.
Failure to have sufficient care staff to meet the needs of all 83 residents, including 11 Memory Care Unit residents and 6 Assisted Living Facility residents, resulting in unmet care needs and risk of harm.
Report Facts
Civil fine amount: 1000
Residents affected by staffing deficiency: 17
Total residents present: 83
Memory Care Unit residents affected: 11
Assisted Living Facility residents affected: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Singer | Field Manager | Contact person for approval requests and plan of correction submission |
| Matt Hauser | Compliance Specialist | Signed the enforcement letter |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 3
Date: Jan 3, 2023
Visit Reason
The inspection was conducted as a complaint investigation regarding allegations of insufficient staffing, neglect of residents' care needs, failure to respond to call lights, missed medications, and inadequate supervision in the Memory Care Unit at Kenmore Senior Living.
Complaint Details
The complaint investigation was substantiated with findings of insufficient staffing, neglect of residents' care needs, failure to respond to call lights, missed medications, and unsafe conditions in the Memory Care Unit. Multiple citations were written.
Findings
The investigation found that the Assisted Living Facility was significantly understaffed, with only one caregiver on the night shift and insufficient staff on other shifts. This resulted in residents not receiving adequate care, including missed showers, delayed response to call lights, missed medications, and lack of supervision in the Memory Care Unit. Multiple residents were found at risk due to these deficiencies.
Deficiencies (3)
The facility failed to have sufficient care staff to provide care for all 83 residents, including 11 in the Memory Care Unit, resulting in neglect of care needs such as assistance with transfers, showers, toileting, incontinence care, wound prevention, medication management, feeding, and supervision.
Hazardous chemicals and construction tools were stored insecurely and accessible to residents with cognitive deficits, placing them at risk for harm and injury.
The facility failed to comply with requirements when a stop placement was imposed on their license, admitting residents without Department approval, placing residents at risk of harm.
Report Facts
Total residents: 83
Resident sample size: 19
Call lights not answered within 45 minutes: 318
Recorded calls: 1128
Days with insufficient staffing on AL day shift: 21
Days with insufficient staffing on AL evening shift: 18
Days with insufficient staffing on MCU day shift: 5
Days with insufficient staffing on MCU evening shift: 7
Days with insufficient staffing on NOC shift: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Mcglon | Nursing Consultant Institutional | Investigator conducting the complaint investigation |
| Lisa Hauk | Complaint Investigator | Department staff who did on-site verification |
| Hayley Pinkham | ALF Licensor | Department staff who did on-site verification |
Inspection Report
Enforcement
Census: 83
Deficiencies: 1
Date: Dec 27, 2022
Visit Reason
The Department of Social and Health Services conducted an investigation at Kenmore Senior Living on December 27, 2022, resulting in a civil fine due to failure to comply with fire and life safety requirements.
Findings
The facility failed their sixth Fire and Life Safety Inspection by the Washington State Patrol Office of State Fire Marshal, placing 83 residents, staff, and visitors at risk. This deficiency is recurring and was previously cited multiple times.
Deficiencies (1)
Failure to ensure compliance with the Washington State Patrol Office of State Fire Marshal fire and life safety requirements.
Report Facts
Civil fine amount: 1000
Number of residents, staff, and visitors at risk: 83
Number of previous citations: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter. |
| Jamie Singer | Field Manager | Contact person for plan of correction and inquiries. |
Inspection Report
Routine
Deficiencies: 12
Date: Dec 5, 2022
Visit Reason
The Office of the State Fire Marshal conducted a routine inspection at the Kenmore Senior Living facility to assess compliance with fire safety codes and maintenance requirements.
Findings
The inspection found multiple violations including failure to provide documentation of smoke detector sensitivity testing within the past 3 years, deficiencies in fire sprinkler system maintenance, failed smoke/fire dampers, and lack of documentation for fire door inspections and fire drills. Several violations were noted as corrected or had scheduled repairs pending.
Deficiencies (12)
Facility unable to provide documentation showing a Smoke Detector Sensitivity test without deficiencies completed within the past 3 years.
Fire sprinkler system deficiencies including overdue 3-year full trip test, corroded sprinkler heads, painted sprinkler heads, missing escutcheon heads, and sprinkler head needing adjustment.
Smoke/Fire Damper in the Dining area of the Memory Care unit failed during testing.
Smoke/Fire Damper near the Maintenance Office failed during testing.
Fire rated door to activity room failed to fully close and latch; lack of documentation for fire door inspections within past 12 months.
Lack of documentation showing fire/smoke dampers inspected/tested with passing results within past 4 years.
Lack of documentation for quarterly and annual testing of automatic sprinkler system within past 12 months.
Dry sprinkler system has not received a full trip test within past 3 years.
Lack of documentation for annual backflow testing.
Lack of documentation for semi-annual servicing of kitchen suppression system within past 12 months.
Lack of documentation for annual testing of automatic fire alarm within past 12 months.
Facility failed to conduct required fire drills on any shift within the past 12 months; must conduct 1 fire drill per shift prior to re-inspection.
Report Facts
Smoke detectors needing replacement: 92
Smoke detectors needing replacement (updated quote): 102
Corroded sprinkler heads: 12
Missing escutcheon heads: 2
Next inspection scheduled: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brendan Magee | Deputy State Fire Marshal | Signed multiple inspection reports and noted in relation to findings. |
| Brandon G. Brown | Deputy State Fire Marshal | Signed multiple inspection reports and noted in relation to findings. |
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