Inspection Reports for Port Townsend Senior Living
1201 Hancock St, Port Townsend, WA 98368, WA, 98368
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 5, 2025, found multiple deficiencies related to fire safety, including blocked electrical panels, missing inspection reports for fire and generator systems, and failure to maintain fire doors. Earlier inspections showed recurring issues with infection control, staff fit testing for N95 respirators, and failure to follow negotiated service plans, some of which resulted in civil fines totaling at least $1,500. Complaint investigations substantiated failures in reporting injuries and fall prevention, and enforcement actions included fines up to $1,500, but no license suspensions or immediate jeopardy findings were listed in the available reports. Prior fire safety inspections also noted numerous documentation and maintenance deficiencies. The facility’s inspection history shows ongoing challenges in safety compliance and resident care practices, with some repeated deficiencies and fines, indicating a need for continued corrective efforts.
Deficiencies (last 3 years)
Deficiencies (over 3 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
58 residents
Based on a January 2025 inspection.
Occupancy over time
Inspection Report
Life Safety
Deficiencies: 8
Date: Mar 5, 2025
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the facility on March 5, 2025.
Findings
The inspection found multiple violations including blocked electrical panels, improper use of extension cords, missing fire system inspection reports, fire extinguisher lacking annual inspection, failure to maintain fire doors, and failure to provide annual generator inspection reports.
Deficiencies (8)
Multiple electrical panels in kitchen manager's office being blocked by various items.
Extension cord in use in room 170 and extension cord used to charge scooters outside of dining area.
Facility failed to provide annual inspection report, five-year internal pipe inspection, three-year dry system full flow trip test, and annual trip test for sprinkler systems.
Kitchen suppression system in yellow status; new cooking arrangement does not match installed suppression system.
Facility failed to provide 1st and 2nd semi-annual inspection reports of the kitchen suppression system.
Fire extinguisher outside of kitchen manager's office did not have its annual inspection.
Facility failed to provide annual inspection report for the generator.
Facility failed to maintain fire doors: 1st floor chart room door and 1st floor staff laundry room door not latching.
Report Facts
Next inspection scheduled date: Apr 5, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raul Murcia | Deputy State Fire Marshal | Signed as Deputy State Fire Marshal conducting the inspection |
| Darren Walla | Maintenance Director | Signed as Owner or Authorized Representative |
Notice
Deficiencies: 0
Date: Feb 14, 2025
Visit Reason
This letter confirms the scheduling of an Informal Dispute Resolution (IDR) meeting requested by the facility administrator to dispute citations related to a Statement of Deficiencies and a Civil Fine.
Findings
The document does not contain inspection findings but addresses the scheduling and procedural details for the IDR process disputing specific citations.
Report Facts
License number: 2408
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Peder Berg | Administrator | Facility representative participating in the IDR process. |
| Laci Traulsen | Program Specialist 2/ Volunteer Coordinator | Author of the scheduling letter for the IDR. |
| Matt Hauser | Compliance Specialist | Mentioned as copied on the letter. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 8, 2025
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 2025-01-08 for an Assisted Living Facility.
Findings
After review of all materials, oral statements, and records, the decision was made to not change the original SOD report dated 2025-01-08. 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 |
| Cory Cisneros | Field Manager | Contact person for mailing Plan/Attestation Statement |
Inspection Report
Follow-Up
Census: 58
Deficiencies: 4
Date: Jan 8, 2025
Visit Reason
The Department of Social and Health Services completed a follow-up visit to the assisted living facility to verify correction of previously cited deficiencies.
Findings
The facility was found to have multiple uncorrected deficiencies related to infection control, background checks, service agreement planning, and medication services, resulting in civil fines totaling $1,500.
Deficiencies (4)
Failure to provide necessary handwashing supplies to six resident rooms, placing residents, staff, and visitors at risk for spread of disease or illness.
Failure to have a Washington State name and Date of Birth background check completed for one contracted agency caregiver prior to working at the facility.
Failure to implement and develop a 30-day negotiated resident service plan for one new resident.
Failure to ensure residents were administered their medications as ordered for one resident.
Report Facts
Civil fine amount: 1500
Residents at risk: 58
Rooms lacking handwashing supplies: 6
Days to return SOD: 10
Days for appeal via IDR: 10
Days for formal hearing request: 28
Interest rate: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the letter regarding civil fines and deficiencies. |
| Cory Cisneros | Field Manager | Contact person for submitting plan of correction and inquiries. |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 2
Date: Jan 6, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on allegations that the facility did not comply with previous citations and had unsecured medications in residents' rooms.
Complaint Details
The complaint alleged that the facility was not in agreement with a citation and did not attempt to get back in compliance, and that residents had unsecured medications in their rooms. The investigation confirmed these issues and citations were written.
Findings
The facility was cited for failure to comply with infection control prevention and medication safety regulations. Specifically, the facility did not attempt to correct a prior infection control citation and had unsecured medications in residents' rooms without proper policies in place.
Deficiencies (2)
Facility did not comply with infection control prevention citation (WAC 388 78A 3152 15abc).
Unsecured medications found in residents' rooms; lack of policies to ensure safe medication practices (WAC 388 78A 2610 2l).
Report Facts
Total residents: 58
Resident sample size: 6
Residents with unsecured medications: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Celeste Vashey | ALF LTC Licensor | Investigator who conducted the complaint investigation |
| Anissa Bearden | Licensor | Department staff who did on-site verification |
| Cory Cisneros | Field Manager | Signed follow-up inspection letter |
Notice
Deficiencies: 0
Date: Dec 9, 2024
Visit Reason
The document informs the facility administrator that the Informal Dispute Resolution request for the Statement of Deficiencies dated October 24, 2024, was denied due to the request being postmarked after the required deadline.
Findings
The letter states that the IDR request was denied without further process because it was postmarked on December 3, 2024, which is after the November 26, 2024 deadline for submitting such requests.
Report Facts
Date of Statement of Deficiencies: Oct 24, 2024
Date SOD received by facility: Nov 12, 2024
IDR request postmark date: Dec 3, 2024
IDR request deadline: Nov 26, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Friesz | IDR Unit Manager | Signed the denial letter on behalf of Rebecca Fueston |
Inspection Report
Follow-Up
Census: 58
Deficiencies: 3
Date: May 17, 2024
Visit Reason
Follow-up inspection to verify correction of previous deficiencies related to respiratory protection program and fit testing of staff.
Complaint Details
Complaint investigation revealed infection control concerns including failure to ensure all staff were fit tested for N95 respirators and failure to report a COVID-19 positive case to the local health jurisdiction. The complaint was substantiated with findings of failed provider practices.
Findings
The facility was found to have corrected previous deficiencies related to respiratory protection and fit testing of staff. However, prior inspections and complaint investigations revealed failures to ensure all staff were medically cleared and fit tested for N95 respirators, placing residents and staff at risk of infection. Additionally, the facility failed to report a COVID-19 positive case to the local health jurisdiction as required.
Deficiencies (3)
Failed to ensure all staff were medically cleared for fit testing of N95 respirators before use for 3 of 3 sampled staff.
Failed to ensure all staff were fit tested for N95 respirators for multiple staff members, including 6 of 6 sampled staff in one investigation.
Failed to report a COVID-19 positive case to the local health jurisdiction as required.
Report Facts
Resident census: 58
Sampled residents: 5
Sampled staff not fit tested: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Phan Pham | Nurse Surveyor | Conducted complaint investigation and inspections. |
| Paul Aube | ALF NCI | Conducted follow-up inspections and plan of correction verifications. |
| Cory Cisneros | Field Manager | Signed follow-up inspection and compliance determination letters. |
| Staff A | Executive Director | Interviewed regarding fit testing and respiratory protection program. |
| Staff B | Wellness Director | Interviewed regarding fit testing and reporting of COVID-19 case. |
| Staff C | Medication Technician | Interviewed regarding fit testing status. |
| Staff D | Caregiver | Interviewed regarding fit testing status. |
| Staff E | Housekeeper | Interviewed regarding fit testing status. |
| Staff F | Caregiver | Interviewed regarding fit testing status. |
| Staff G | Server | Interviewed regarding fit testing status. |
| Staff H | Dietary Aide | Interviewed regarding fit testing status. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Apr 10, 2024
Visit Reason
The Department of Social and Health Services completed a follow-up visit to the assisted living facility to verify correction of previously cited deficiencies.
Findings
The facility was cited for failing to ensure all staff were medically cleared for fit testing of an N-95 respirator before use for three staff members, placing residents and staff at risk of infection. This deficiency was uncorrected and recurring from previous citations.
Deficiencies (1)
Failure to ensure all staff were medically cleared for fit testing of an N-95 respirator before use for three staff.
Report Facts
Civil fine amount: 750
Number of staff not medically cleared: 3
Previous citation dates: February 26, 2024; January 5, 2024; October 6, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the letter regarding the civil fine and inspection. |
| Cory Cisneros | Field Manager | Contact person for plan of correction and appeals. |
Notice
Deficiencies: 0
Date: Mar 21, 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 January 11, 2024, and an associated Civil Fine dated January 22, 2024.
Findings
The letter does not contain inspection findings but references disputed citations under WAC 388-78A-2160 and the associated civil fine.
Report Facts
Civil Fine Date: Jan 22, 2024
Statement of Deficiencies Date: Jan 11, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Peder Berg | Administrator | Facility representative participating in the IDR process |
| Kathy Westcott | DON | Facility representative participating in the IDR process |
| Kim Friesz | IDR Program Manager | Author of the letter |
| Staci Dilg | Referenced as contact and IDR Program Manager |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 27, 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 January 11, 2024.
Findings
After review of all materials, oral statements, and records, the decision was made not to change the original Statement of Deficiencies report dated January 11, 2024.
Report Facts
Correction timeframe: 45
Statement of Deficiencies report date: January 11, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staci Dilg | IDR Program Manager | Signed the IDR results letter |
| Matt Hauser | ALF Compliance Specialist | Mentioned in copy recipients |
Inspection Report
Enforcement
Census: 57
Deficiencies: 1
Date: Feb 26, 2024
Visit Reason
A follow-up visit was conducted to assess correction of previously cited deficiencies and resulted in the imposition of a civil fine due to recurring violations.
Findings
The facility failed to ensure all staff were medically cleared for fit testing of an N-95 respirator before use for three staff members, placing residents, staff, and visitors at risk of communicable disease transmission. This was an uncorrected and recurring deficiency previously cited on January 5, 2024, and October 6, 2023.
Deficiencies (1)
Failure to ensure all staff were medically cleared for fit testing of an N-95 respirator before use for three staff.
Report Facts
Civil fine amount: 500
Resident census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter. |
| Cory Cisneros | Field Manager | Contact person for plan of correction and inquiries. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 11, 2024
Visit Reason
The Department of Social and Health Services completed a Complaint Investigation at Avamere at Port Townsend on January 11, 2024, resulting in civil fines for violations related to abuse and neglect reporting and failure to follow negotiated service agreements.
Complaint Details
Complaint investigation conducted on January 11, 2024. The deficiencies were substantiated and resulted in civil fines.
Findings
The facility failed to timely report a substantial injury of unknown cause to the appropriate authorities and failed to follow the negotiated service plan to prevent falls, resulting in harm to a resident. These deficiencies were recurring and resulted in civil fines.
Deficiencies (2)
Failure to ensure staff reported a substantial injury of unknown cause to the department’s Complaint Resolution Unit hotline in a timely manner.
Failure to ensure staff followed the negotiated service plan and checked the resident every two hours to prevent falls, contributing to harm and hospitalization.
Report Facts
Civil fine amount: 600
Civil fine amount: 750
Total civil fines: 1350
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cory Cisneros | Field Manager | Contact person for submission of Plan of Correction and inquiries |
| Matt Hauser | Compliance Specialist | Signed the imposition of civil fines letter |
Inspection Report
Enforcement
Deficiencies: 1
Date: Jan 5, 2024
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to the assisted living facility to assess compliance and imposed a civil fine based on violations found during the inspection.
Findings
The facility failed to ensure all staff were fit tested for an N-95 respirator for one staff member, placing residents and staff at risk of communicable disease spread. This was an uncorrected deficiency previously cited on October 6, 2023.
Deficiencies (1)
Failure to ensure all staff were fit tested for an N-95 respirator for one staff member.
Report Facts
Civil fine amount: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter. |
| Cory Cisneros | Field Manager | Contact person for plan of correction and appeals. |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 2
Date: Jan 3, 2024
Visit Reason
The investigation was conducted due to a complaint alleging that a named resident fell and sustained a lower back fracture. The visit aimed to review the quality of care, fall prevention, and staff reporting practices.
Complaint Details
The complaint alleged that a named resident fell and sustained a lower back fracture. The investigation substantiated failures in staff reporting and fall prevention practices, resulting in citations.
Findings
The assisted living facility failed to ensure staff followed the negotiated service plan and did not check the resident every two hours to prevent falls. Staff also failed to report a substantial injury of unknown cause to the State Hotline timely. These failures placed the resident at risk for abuse, neglect, and harm.
Deficiencies (2)
Failed to ensure staff reported a substantial injury of unknown cause to the department's Complaint Resolution Unit hotline in a timely manner, placing the resident at risk for abuse and neglect.
Failed to ensure staff followed the negotiated service plan and checked the resident every two hours to prevent falls, contributing to harm to the resident who fell and fractured her lower back.
Report Facts
Total residents: 58
Resident sample size: 2
Closed records sample size: 2
Sampled residents for fall prevention deficiency: 4
Complaints referenced: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Phan Pham | Nurse Surveyor | Investigator who conducted the complaint investigation |
| Paul Aube | ALF NCI | Department staff who did the on-site verification during follow-up inspection |
| Cory Cisneros | Field Manager | Signed correspondence related to compliance determination |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 5, 2023
Visit Reason
The document reports the results of an Informal Dispute Resolution (IDR) process held on October 5, 2023, addressing a citation from the Statement of Deficiencies report dated August 21, 2023.
Findings
The IDR resulted in the removal of a sentence regarding housekeeping service from the findings and the removal of Resident #2 from the deficient practice statement, updating the Statement of Deficiencies accordingly.
Deficiencies (1)
Citation related to housekeeping service statement about Resident #1, which was edited to remove a sentence.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staci Dilg | IDR Program Manager | Signed the IDR results letter and communicated the changes to the Statement of Deficiencies. |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 1
Date: Aug 21, 2023
Visit Reason
The inspection was conducted in response to complaints regarding the physical environment (urine odor in a resident's room), dietary services (spoiled food stored in refrigerator), and quality of care (resident did not purchase incontinent and colostomy supplies).
Complaint Details
Complaint investigation involved allegations of urine odor in a resident's room, spoiled food in refrigerator, and lack of purchase of incontinent and colostomy supplies by a resident. The complaint number was 92939. The investigation found a failed provider practice related to sanitation and odor control.
Findings
The facility failed to maintain residents' quarters in a sanitary condition free of urine odor, specifically in the room of Resident 1 and Resident 2. This failure exposed Resident 1 to an unsanitary environment and risked decreased quality of life. Additional residents reviewed had no concerns.
Deficiencies (1)
Facility failed to ensure staff maintained residents' quarters in a sanitary condition and/or free of urine odor for two of three sampled residents.
Report Facts
Total residents: 56
Resident sample size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Phan Pham | Nurse Surveyor | Department staff who conducted the on-site verification and investigation |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jun 5, 2023
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Complaint Details
The complaint investigation involved allegations of accidents and bruises to a named resident. The investigation found failures in reporting a missing resident and a COVID-19 case to the Complaint Resolution Unit. The resident care plan was followed, but reporting failures were cited.
Findings
The follow-up inspection on 06/05/2023 found no deficiencies and confirmed the facility meets Assisted Living Facility licensing requirements. Previous deficiencies related to reporting abuse and neglect were corrected.
Deficiencies (3)
Failed to report an injury of unknown origin to the Department's Complaint Resolution Unit hotline for 1 of 3 residents, placing the resident at risk of abuse.
Failed to ensure staff reported when a resident went missing directly to the Department's Complaint Resolution Unit hotline for 1 of 3 residents, placing the resident at risk for harm and/or neglect.
Failed to report a confirmed case of COVID-19 to the local health jurisdiction and Complaint Hotline Unit for 1 of 1 sampled resident, placing residents at risk for contracting the disease.
Report Facts
Total residents: 58
Resident sample size: 3
Closed records sample size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Phan Pham | Nurse Surveyor | Department staff who conducted the on-site verification and complaint investigation |
| Staff A | Executive Director | Named in deficiency related to failure to report injury of unknown origin and COVID-19 case |
| Staff B | Medication Tech | Interviewed regarding injury reporting and COVID-19 case reporting |
| Staff C | Caregiver | Interviewed regarding injury reporting |
Inspection Report
Renewal
Deficiencies: 12
Date: Apr 5, 2023
Visit Reason
The Office of the State Fire Marshal conducted a renewal licensing inspection at the facility on 04/05/2023 as part of regulatory oversight for the residential care facility.
Findings
The facility was disapproved due to multiple violations including failure to conduct required fire drills, maintain electrical outlets, provide documentation for damper inspections, sprinkler system testing, kitchen suppression system inspections, smoke alarm inspections, fire alarm system maintenance, carbon monoxide detector maintenance and installation, emergency lighting tests, and generator maintenance documentation.
Deficiencies (12)
Facility failed to conduct fire drills once per shift per quarter for the 4th quarter of 2022 and 1st quarter of 2023.
Facility failed to maintain electrical outlet on the 1st floor break room, missing plate cover.
Facility failed to provide documentation showing 4-year damper inspection.
Facility failed to provide documentation for the automatic sprinkler system including annual forward flow test, backflow report, 5-year fire department connection hydrostatic test, and quarterly inspection reports.
Facility failed to provide documentation of second semi-annual inspection for the kitchen suppression system.
Facility failed to provide documentation of monthly smoke alarms inspections.
Facility failed to maintain fire alarm system, trouble signal must be resolved.
Facility failed to provide documentation of testing and maintenance of carbon monoxide alarms/detectors.
Facility failed to add carbon monoxide detector in the 1st floor staff laundry room.
Facility failed to provide documentation showing 30-second monthly activation test of emergency exits and emergency lighting.
Facility failed to provide documentation showing 90-minute yearly activation test of emergency exits and emergency lighting.
Facility failed to provide documentation for the generator including log of weekly inspections and log of monthly 30-minute full load test.
Report Facts
Inspection date: Apr 5, 2023
Next inspection scheduled: May 7, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raul Murcia | Deputy State Fire Marshal | Signed as Deputy State Fire Marshal on inspection report |
| Peder Berg | Executive Director | Named as Owner or Owner's Representative |
Inspection Report
Enforcement
Deficiencies: 1
Date: Mar 8, 2023
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to the assisted living facility to address previously cited deficiencies and to impose a civil fine related to failure to report an injury of unknown origin.
Findings
The licensee failed to report an injury of unknown origin to the Department’s Complaint Resolution hotline for one resident, which placed the resident at risk for abuse. This was an uncorrected deficiency previously cited on December 14, 2022, resulting in a $300 civil fine.
Deficiencies (1)
Failure to report an injury of unknown origin to the Department’s Complaint Resolution hotline for one resident.
Report Facts
Civil fine amount: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter |
| Cory Cisneros | Field Manager | Contact person for plan of correction and inquiries |
Notice
Deficiencies: 0
Date: Avamere at Port Townsend 2408 8 21 2023 IDR Scheduling Letter 0923
Visit Reason
The document confirms the scheduling of an Informal Dispute Resolution (IDR) meeting requested by the facility administrator to dispute a Statement of Deficiencies dated August 21, 2023.
Findings
The letter does not contain inspection findings but addresses the dispute process for a cited regulation (WAC 388-78A-3090) and provides details about the IDR meeting date, time, and participants.
Report Facts
IDR meeting date: Scheduled for October 5, 2023 at 1:30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Peder Berg | Administrator | Facility representative participating in the IDR process |
| Kim Friesz | IDR Program Manager | Sender of the scheduling letter |
| Staci Dilg | IDR Program Manager | Contact person mentioned in the letter |
Report
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