Inspection Reports for Mirror Lake Village Senior Living Community
WA, 98023
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Inspection Report
Life Safety
Deficiencies: 4
Jan 15, 2025
Visit Reason
An unannounced Fire and Life Safety Code inspection was conducted at Mirror Lake Village by a representative of the Washington State Patrol, State Fire Marshal's Office to determine compliance with applicable codes.
Findings
The inspection found multiple violations including penetrations in fire walls, fire doors not closing/latching properly, obstructions to sprinkler heads, and the absence of a required generator remote manual stop station.
Deficiencies (4)
| Description |
|---|
| Penetrations in the fire wall at the laundry room (2nd floor - Memory Care) and kitchen electrical room (1st floor). |
| Fire doors (Cross corridor 37a and 43b on 2nd floor) did not close or latch properly when tested. |
| A tree obstructing the sprinkler head in the 1st floor library area. |
| Generator remote manual stop station was not installed per NFPA 110 requirements. |
Report Facts
Next inspection scheduled date: Feb 14, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandon Grove | Maint. Director | Named as Owner or Authorized Representative signing the inspection documents |
| Cozetta Christian | Deputy State Fire Marshal | Conducted the inspection and signed the report |
Inspection Report
Follow-Up
Census: 65
Deficiencies: 7
Jan 2, 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 found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies related to negotiated service agreements and safety of medical devices were corrected.
Deficiencies (7)
| Description |
|---|
| Failed to document in residents' Negotiated Service Agreements the care needs and interventions for diagnoses and physician ordered medical treatments. |
| Failed to ensure side bed rails attached to residents' beds were free from safety risks, placing residents at risk of harm or death from unsafe medical equipment. |
| Failed to document in writing an initial agreement to use electronic monitoring, the duration of use, and quarterly reevaluations of electronic surveillance for a resident. |
| Failed to ensure staff completed required nurse delegation training and competency verification. |
| Failed to ensure staff were screened for tuberculosis within three days of employment. |
| Failed to implement infection control policies and requirements to protect residents from infectious illnesses, including lack of N95 respirator fit testing. |
| Failed to ensure residents or their representatives signed annual service plans. |
Report Facts
Residents reviewed: 15
Residents reviewed: 10
Staff requiring nurse delegation training: 14
Residents affected by unsafe side bed rails: 3
Staff not screened for tuberculosis within 3 days: 3
Residents at risk due to infection control failures: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff X | Director of Wellness | Acknowledged awareness of deficiencies related to medication assistance and side bed rail safety |
| Staff W | Executive Director | Acknowledged awareness of side bed rail safety risks and electronic monitoring deficiencies |
| Staff G | Registered Nurse Delegator | Responsible for nurse delegation training and supervision; admitted incomplete supervision and competency verification |
| Staff E | Resident Caregiver | Failed to complete required continuing education training |
| Staff F | Resident Caregiver | Failed to complete required continuing education training |
| Staff A | Executive Director | Unaware of TB screening and infection control requirements; acknowledged deficiencies |
| Staff B | Director of Wellness | Unaware of TB screening and infection control requirements; acknowledged deficiencies |
Inspection Report
Follow-Up
Deficiencies: 2
Nov 6, 2024
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to Mirror Lake Village assisted living facility to assess correction of previously cited deficiencies.
Findings
The facility was cited for uncorrected deficiencies related to failure to document care needs and interventions in residents' Negotiated Service Agreements and failure to ensure side bed rails were free from safety risks, resulting in civil fines.
Deficiencies (2)
| Description |
|---|
| Failure to document in five residents’ Negotiated Service Agreements the care needs and interventions for diagnoses and physician ordered medical treatments. |
| Failure to ensure two residents' side bed rails were free from safety risks. |
Report Facts
Civil fine amount: 1000
Civil fine amount: 1000
Total civil fines: 2000
Number of residents affected: 5
Number of residents affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laurie Anderson | Field Manager | Contact person for submission of Plan of Correction and inquiries |
| Matt Hauser | Compliance Specialist | Signed the enforcement letter |
Inspection Report
Enforcement
Deficiencies: 3
Sep 17, 2024
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to Mirror Lake Village assisted living facility to address previously cited deficiencies and impose civil fines based on violations found during the inspection.
Findings
The facility was cited for repeated deficiencies including failure to document care needs in residents' Negotiated Service Agreements, unsafe side bed rails posing entrapment hazards, and failure to document electronic monitoring agreements. These violations resulted in civil fines totaling $2,000.
Deficiencies (3)
| Description |
|---|
| Failure to document care needs and interventions in five residents' Negotiated Service Agreements. |
| Failure to ensure three residents' side bed rails were free of entrapment hazards. |
| Failure to document initial agreement, duration, and quarterly reevaluations for electronic monitoring for one resident. |
Report Facts
Civil fine amount: 600
Civil fine amount: 1000
Civil fine amount: 400
Total civil fines: 2000
Repeated deficiencies: 3
Uncorrected deficiencies: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter regarding civil fines. |
| Laurie Anderson | Field Manager | Contact person for the enforcement action and plan of correction. |
Inspection Report
Follow-Up
Deficiencies: 4
Jul 19, 2024
Visit Reason
The Department of Social and Health Services completed a follow-up visit to Mirror Lake Village assisted living facility to verify correction of previously cited deficiencies.
Findings
The facility was found to have multiple uncorrected deficiencies related to documentation of negotiated service agreements, safety of medical devices, electronic monitoring agreements, and staff training, resulting in civil fines.
Deficiencies (4)
| Description |
|---|
| Failed to document in five residents Negotiated Service Agreements the care needs and interventions for diagnoses and physician ordered medical treatments. |
| Failed to ensure three residents’ medical devices were safe and free from entrapment hazards. |
| Failed to document in writing an initial agreement to use electronic monitoring, the duration of use, and quarterly reevaluations for one resident. |
| Failed to ensure one staff completed all required training to perform their job duties and responsibilities. |
Report Facts
Civil fine amount: 300
Civil fine amount: 600
Civil fine amount: 200
Civil fine amount: 200
Total civil fines: 1300
Number of residents with undocumented negotiated service agreements: 5
Number of residents with unsafe medical devices: 3
Number of residents without documented electronic monitoring agreement: 1
Number of staff without completed training: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter |
| Laurie Anderson | Field Manager | Contact person for the enforcement and appeals |
Document
Deficiencies: 0
Jan 10, 2024
Visit Reason
This document is intended for informational purposes related to residential care services and is not an inspection or regulatory report.
Findings
No inspection findings or regulatory content present in the document.
Inspection Report
Life Safety
Deficiencies: 3
Jan 3, 2023
Visit Reason
The Office of the State Fire Marshal conducted inspections at Mirror Lake Village to determine compliance with fire and life safety codes, including follow-up on previous violations.
Findings
The inspection on 12/27/2022 found multiple fire and life safety code violations related to penetrations in fire-resistance-rated walls and unprotected joints and voids, resulting in a disapproved status. A follow-up inspection on 01/03/2023 confirmed that all previously noted violations had been corrected.
Deficiencies (3)
| Description |
|---|
| The electrical room in the kitchen has multiple penetrations in the fire wall. |
| Building A and B have open conduits on 2nd floor that need capped and/or filled. |
| Unprotected joints and voids in fire-resistance-rated walls, floors, smoke barriers, and exterior curtain walls. |
Report Facts
Provider Number: 2564
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cozetta Christian | Deputy State Fire Marshal | Conducted the fire and life safety inspections and signed inspection reports |
| Shannon Flores | Executive Director | Owner or Authorized Representative who signed the inspection documents |
Inspection Report
Life Safety
Deficiencies: 3
Jan 3, 2023
Visit Reason
The Office of the State Fire Marshal conducted a fire and life safety code inspection at Mirror Lake Village to determine compliance with applicable fire protection codes.
Findings
The inspection found multiple violations related to penetrations in fire walls and unprotected joints and voids in fire-resistance-rated construction, resulting in a disapproved status. Previous violations noted in earlier inspections were corrected by the latest inspection date.
Deficiencies (3)
| Description |
|---|
| Multiple penetrations in the fire wall in the electrical room in the kitchen. |
| Open conduits on the 2nd floor of Buildings A and B that need to be capped and/or filled. |
| Unprotected joints and voids in fire-resistance-rated walls, floors, smoke barriers, and intersections with exterior curtain walls. |
Report Facts
Provider Number: 2564
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cozetta Christian | Deputy State Fire Marshal | Signed inspection documents and conducted the inspection |
Document
Deficiencies: 0
R Mirror Lake Village Inspection 1 18 2023 TAB
Visit Reason
This document appears to be informational or directory content prepared for the Locator website by Residential Care Services, not related to any inspection or regulatory visit.
Findings
No inspection findings or regulatory content are present in the document.
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