Inspection Report
Life Safety
Deficiencies: 14
Apr 29, 2025
Visit Reason
The Office of the State Fire Marshal conducted a fire protection inspection at Avista Senior Living Ellensburg (Meadows Place) to assess compliance with fire safety codes and regulations.
Findings
Multiple violations were observed including improper clearance from ignition sources, faded fire sprinkler riser room sign, failure to provide documentation for hood suppression cleaning, fire-resistance-rated construction inspection, sprinkler system inspections, kitchen hood suppression service, monthly testing of smoke alarms and carbon monoxide detectors, blocked exit door, and failure to document emergency lighting tests. All violations were corrected or noted with corrective actions.
Deficiencies (14)
| Description |
|---|
| In the kitchen, oven mits and towels were left on top of the stove oven. |
| The Fire Sprinkler Riser room sign located above the exterior riser room was faded and illegible. |
| The facility failed to provide documentation of the first semi-annual hood suppression cleaning within the past twelve months; the first cleaning was conducted on 12/15/2024. |
| The facility failed to provide documentation of the fire-resistance-rated construction inspection within the past twelve months. |
| The facility failed to provide documentation for the third quarter inspections for the fire sprinkler system within the past twelve months. |
| In the Kitchen the sprinkler head near the dishwasher was loaded with debris. |
| The facility failed to provide documentation of the first semi-annual kitchen hood suppression service within the past twelve months; second service was conducted on 01/06/2025. |
| The fire extinguisher located in the Laundry room had not been serviced within the past twelve months. |
| The facility failed to provide documentation of the monthly testing of single station smoke alarms within the past twelve months. |
| The facility failed to provide documentation of the monthly single station carbon monoxide testing within the past twelve months. |
| The exit door located near Room 126 was blocked by a garbage can on the exterior. |
| The facility failed to provide documentation of the 30-second activation testing of emergency exit lighting for the past twelve months. The month of February of 2025 was provided. |
| The facility failed to provide documentation of the 90-minute annual power test of emergency lighting within the past twelve months. |
| The exit door located in the Dining room was exceeding 15lbs of pressure when opened from the closed position. |
Report Facts
Inspection date: Apr 29, 2025
Next inspection scheduled: Mar 31, 2026
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Ely | Deputy State Fire Marshal | Signed and conducted the inspection |
| Arlene Walther | Executive Director | Owner or Authorized Representative signing the report |
Inspection Report
Follow-Up
Census: 27
Deficiencies: 1
Apr 23, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previous deficiencies related to the facility's failure to return their plan of corrections within the required timeframe.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. The prior deficiencies related to failure to return plans of correction were corrected.
Complaint Details
The visit was complaint-related due to the facility's failure to send their plan of corrections back to the Department within the required timeframe. The complaint was substantiated with failed provider practice identified and citations written.
Deficiencies (1)
| Description |
|---|
| Failure to return multiple Plans of Correction (POC) within the required timeframe for 4 citations. |
Report Facts
Total residents: 27
Resident sample size: 27
Number of citations: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Felicia Cantu | Community Complaint Investigator | Department staff who conducted the on-site verification and investigation |
| Laura Williams-Davis | ALF Field Manager | Signed the follow-up inspection report and statement of deficiencies |
Inspection Report
Follow-Up
Census: 26
Deficiencies: 1
Jan 10, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to resident assessments.
Findings
The follow-up inspection found no deficiencies, confirming that the previously cited deficiencies regarding failure to assess residents' ability to leave the facility unsupervised were corrected.
Complaint Details
The complaint alleged that a named staff member accepted a resident with dementia without assessing them as an elopement risk. The investigation found failed practice in assessing residents' ability to leave the facility unsupervised for 3 of 4 residents. The complaint was substantiated with failed practice identified.
Deficiencies (1)
| Description |
|---|
| Failure to complete assessments of residents’ ability to leave the facility unsupervised for 3 of 4 residents, placing them at risk of not having assessed interventions when there were signs of exit seeking. |
Report Facts
Total residents: 26
Resident sample size: 4
Number of residents not assessed for ability to leave unsupervised: 3
Dates of complaint investigation: Investigation conducted from 2024-11-06 through 2024-11-20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Felicia Cantu | Community Complaint Investigator | Conducted the complaint investigation and follow-up inspection |
| Staff A | Administrator and Health and Wellness Director | Interviewed during investigation; acknowledged lack of awareness of elopement risk and missing documentation |
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 1
Oct 21, 2024
Visit Reason
The inspection was conducted as an unannounced on-site complaint investigation triggered by allegations including unclean resident apartments, lack of resident hygiene assistance, and missing money and food.
Findings
The investigation found that the facility failed to investigate and determine the circumstances of an allegation of missing money and food for a resident, constituting a failed provider practice. Other allegations regarding cleanliness and resident hygiene were not substantiated.
Complaint Details
The complaint investigation was substantiated with a failed provider practice identified related to failure to investigate allegations of missing money and food. The facility did not conduct an internal investigation or document the incident as required by policy and regulation.
Deficiencies (1)
| Description |
|---|
| Facility failed to investigate and determine the circumstances of an allegation of missing money and missing food for a resident. |
Report Facts
Total residents: 25
Resident sample size: 4
Cash amount missing: 300
Groceries missing: 180
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Felicia Cantu | Community Complaint Investigator | Investigator who conducted the complaint investigation and follow-up inspection |
| Laura Williams-Davis | Field Manager | Signed follow-up inspection report letter |
| Staff A | Administrator | Named in findings for failure to investigate and document allegations of missing money and food |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 3
Oct 3, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on multiple allegations including neglect of a resident upon admission, a resident stuck between bed rails, a resident passing away, failure to provide call light pennants, and a staff member coming to work intoxicated.
Findings
The investigation found failed practices related to neglect of a resident who was not monitored after admission and was found with no pulse, failure to provide timely medications to a resident, and failure to implement safety checks for newly admitted residents. Other allegations such as residents stuck between bed rails, call light pennants availability, and staff intoxication were not substantiated. Citations were written for the identified deficiencies.
Complaint Details
The complaint investigation included allegations of neglect upon admission, a resident stuck between bed rails, a resident passing away, failure to provide call light pennants, and a staff member coming to work intoxicated. The investigation substantiated neglect and medication administration failures but did not substantiate issues with bed rails, call light pennants, or staff intoxication.
Deficiencies (3)
| Description |
|---|
| Failure to monitor a resident after admission, resulting in the resident being found with no pulse. |
| Failure to provide timely medications to a resident, resulting in medication not given as ordered. |
| Failure to implement safety checks for a newly admitted resident. |
Report Facts
Total residents: 29
Resident sample size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Felicia Cantu | Community Complaint Investigator | Investigator who conducted the complaint investigation |
| Laura Williams-Davis | ALF Field Manager | Signed the follow-up inspection letter |
| Staff A | Administrator and Health and Wellness Director | Interviewed regarding medication responsibilities and alert charting |
| Staff B | Medication Technician | Interviewed regarding medication administration and alert charting |
| Staff C | Caregiver | Interviewed regarding alert charting and resident monitoring |
| Staff D | Caregiver | Interviewed regarding resident arrival time |
| Staff E | Activity Director | Interviewed regarding resident arrival time |
Inspection Report
Follow-Up
Census: 18
Deficiencies: 0
Jul 3, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility on 07/03/2024 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.
Report Facts
Residents reviewed during unannounced on-site visit: 5
Residents failed assessment: 5
Residents failed NSA completion: 3
Residents failed medication assistance: 3
Staff missing TB screening within 3 days: 3
Staff missing CPR and First-aid certificates: 2
Staff missing continuing education: 2
Staff missing background check renewal: 1
Residents reviewed: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sherri Undercaffer | Administrator | Named as Administrator who signed Plan/Attestation Statements and involved in findings related to assessments and training. |
| Michelle Closner | Field Manager | Conducted follow-up inspection and signed correspondence. |
| Elaine Lopez | Licensor | Inspected the Assisted Living Facility during the initial inspection. |
| Robin Rainville | Assisted Living Facility Licensor | Inspected the Assisted Living Facility during the initial inspection. |
| Staff B | Health Service Manager/Licensed Practical Nurse | Provided multiple statements regarding medication administration, TB screening, and respirator fit testing. |
| Staff E | Assistant Administrator | Responsible for maintaining and tracking staff records; provided statements on staff training and certifications. |
| Staff C | Long-Term Care Worker | Failed to complete required basic LTCW training and specialty dementia and mental health training; missing TB screening. |
| Staff F | Medication Technician | Had invalid CPR/First-aid certificate and missing TB screening within required timeframe. |
| Staff D | Medication Technician | Missing TB screening within required timeframe and incomplete continuing education. |
| Staff A | Administrator | Missing required continuing education and CPR/First-aid certification. |
Inspection Report
Life Safety
Deficiencies: 20
Mar 19, 2024
Visit Reason
The Office of the State Fire Marshal conducted an inspection at Avista Senior Living Ellensburg (Meadows Place) to assess compliance with fire safety and electrical codes.
Findings
Multiple violations were observed including failure to maintain required ceiling clearance storage, lack of documentation for fire drills and inspections, open electrical junction boxes, blocked electrical panels, improper use of power taps and extension cords, exposed wiring on exterior lights, obstructed fire extinguishers and manual pull stations, and issues with fire doors and smoke alarms. Some violations were corrected during inspection, while others require follow-up.
Deficiencies (20)
| Description |
|---|
| Room 135 and Room 118 failed to maintain storage 24 inches below the ceiling in bedroom closets. |
| Facility unable to provide documentation of fire drills for multiple quarters. |
| Break Room had an open junction box underneath the desk. |
| Medication Room electrical panel was blocked with a magnetic wire document holder. |
| Activities Office had an unfused multiplug adapter plugged into another multiplug adapter. |
| Break Room fridge and microwave plugged into a power strip, not approved outlet. |
| Business Manager's Office fridge plugged into an unfused multiplug adapter, not approved outlet. |
| Executive Director's Office fridge plugged into an unfused multiplug adapter, not approved outlet. |
| Exterior lights at north exit door and patio had exposed wiring and damaged light covers. |
| Facility unable to provide documentation of rated wall inspections within past twelve months. |
| Facility unable to provide documentation of rated door annual inspection within past twelve months. |
| Cross corridor doors near Medication Room would not latch upon release. |
| Facility unable to provide documentation of annual backflow report with forward flow testing. |
| Facility unable to provide documentation of testing on quick response sprinkler heads older than 20 years. |
| Excessive particulate observed on sprinkler heads in kitchen near cooking operations. |
| Kitchen fire extinguishers were obstructed; corrected during inspection. |
| Facility unable to provide documentation of monthly single station alarm testing for resident rooms; smoke alarms not monitored by fire alarm system. |
| Resident room smoke alarms exceeding ten years from manufacture date shall be replaced. |
| Kitchen access to manual pull station obstructed by garbage can; corrected during inspection. |
| Dining Room access to manual pull station obstructed by stereo system; corrected during inspection. |
Report Facts
Inspection quarters missing fire drill documentation: 3
Number of rooms with ceiling clearance storage violations: 2
Next inspection scheduled date: Apr 18, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Barbara Maier | Deputy State Fire Marshal | Signed inspection report as Deputy State Fire Marshal |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 18, 2024
Visit Reason
The inspection was conducted as a result of an off-site fire and life safety complaint investigation at Avista Senior Living in Ellensburg, Washington.
Findings
The survey was conducted by staff from the Washington State Patrol, Fire Protection Bureau, and no citations were issued as a result of the investigation.
Complaint Details
Complaint #114506 regarding fire and life safety. No cause of fire, evacuation, injuries, or fire department response were reported. The complaint was not substantiated as no citations were issued.
Report Facts
Complaint Number: 114506
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Barbara Maier | Deputy State Fire Marshal | Signed the inspection report |
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