Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 7
Aug 5, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding allegations that the facility did not provide medical records to interested parties on request, residents received incorrect or missed medications, and medications were improperly dispensed or administered outside the scope of practice.
Findings
The investigation found multiple deficiencies including failure to provide requested medical records, medication errors such as administering another resident's pain patch, missed injectable medication doses, and improper medication scheduling. Facility citations were issued for these failures, and the facility was found not in compliance with licensing laws and regulations.
Complaint Details
The complaint investigation was triggered by allegations including failure to provide medical records on request, medication errors involving wrong medication administration and missed doses, and improper medication dispensing and administration by staff. The investigation substantiated these allegations and citations were issued.
Deficiencies (7)
| Description |
|---|
| Facility failed to provide medical records to interested parties within two business days. |
| Resident received a pain patch prescribed for another resident, causing adverse effects. |
| Injectable medication ordered every 21 days was not administered for three doses, resulting in hospitalization. |
| Medication administration schedule was changed without proper consultation, resulting in delayed and improper dosing. |
| Medication given on two consecutive days instead of every other day as ordered. |
| Facility staff administered medications outside their scope of practice. |
| Facility failed to provide requested medical records for one resident, violating resident rights. |
Report Facts
Total residents: 64
Resident sample size: 5
Facility citations issued: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karri Hernandez | Community Complaint Investigator | Investigator who conducted the complaint investigation and on-site verification |
| James Sherman | Field Manager | Signed the follow-up inspection letter |
| Staff A | Executive Director | Interviewed regarding medication administration schedule changes and errors |
| Staff B | Acting Wellness Director | Interviewed regarding resident assessments and medication administration |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 17
Nov 7, 2024
Visit Reason
The inspection was conducted due to a complaint alleging that residents were not receiving housekeeping services once a week as agreed upon in their contracts.
Findings
The investigation found that residents did not receive housekeeping services for over a month, the facility failed to track which residents were skipped, and no compensation was provided to residents or families. Multiple deficiencies related to housekeeping, maintenance, emergency preparedness, training, and documentation were identified.
Complaint Details
The complaint alleged that residents were not receiving housekeeping services once a week as agreed upon in their contracts. The investigation confirmed this failure and identified multiple related deficiencies. The complaint was substantiated with citations written.
Deficiencies (17)
| Description |
|---|
| Residents did not receive housekeeping services for over a month, and the facility failed to track missed services or provide compensation. |
| Facility failed to ensure first aid kits were clearly marked, readily available, and appropriate for the facility size. |
| Licensed Practical Nurse and caregiver failed to complete specialized training for dementia and mental illness within required timeframes. |
| Facility failed to complete annual assessments and change of condition assessments for residents. |
| Facility failed to obtain signatures on negotiated service agreements for sampled residents. |
| Facility failed to ensure proper food safety and sanitation practices in the kitchen, placing all 61 residents at risk of foodborne illness. |
| Facility failed to ensure water temperatures were maintained within safe ranges in resident apartments and common areas. |
| Facility failed to maintain air exchange ventilation systems properly, placing all 61 residents at risk of poor air quality and respiratory distress. |
| Facility failed to ensure housekeeping carts with hazardous chemicals were locked and unattended, exposing residents to potential hazards. |
| Facility failed to provide clean and comfortable living environments for sampled residents, placing them at risk due to unsanitary conditions. |
| Facility failed to ensure safe storage of hazardous supplies and equipment, including housekeeping carts with chemicals. |
| Facility failed to ensure bed enablers were safely used and monitored, placing residents at risk of entrapment. |
| Facility failed to obtain approval from Construction Review Services for changing a resident common room to a massage room. |
| Facility failed to ensure water temperature safety in resident apartments and common areas, placing all 61 residents at risk of burns. |
| Facility failed to complete Washington state background checks for staff timely, placing all 61 residents at risk of abuse or neglect. |
| Facility failed to maintain premises free of hazards, including a locked massage room and unsecured housekeeping carts. |
| Facility failed to ensure emergency and disaster preparedness, including secure installation of medical devices for residents. |
Report Facts
Total residents: 61
Resident sample size: 9
Days late for background check completion: 214
Days late for background check completion: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Forkgen | ALF Licensor | Department staff who inspected the Assisted Living Facility. |
| Kathy Young | Licensor | Department staff who inspected the Assisted Living Facility and did on-site verification. |
| Laurie Anderson | Field Manager | Field Manager who signed letters and correspondence related to the inspection. |
| Staff X | Maintenance/Housekeeping Director | Interviewed regarding housekeeping department issues and broken housekeeping cart. |
| Staff K | Lead Housekeeper | Interviewed regarding housekeeping service issues and broken cart lock. |
| Staff U | Licensed Practical Nurse/Wellness Director | Interviewed regarding awareness of care plan deficiencies. |
| Staff V | Caregiver | Interviewed regarding resident care and housekeeping assistance. |
| Staff W | Executive Director | Interviewed regarding failure to assist resident and awareness of care issues. |
| Staff A1 | Housekeeper | Interviewed regarding housekeeping cart and broken lock. |
| Staff JJ | Maintenance Assistant | Interviewed regarding housekeeping services and skipped apartments. |
| Staff AA | Business Office Director | Interviewed regarding staff background checks and housekeeping communication. |
Inspection Report
Life Safety
Deficiencies: 11
Aug 12, 2024
Visit Reason
An unannounced Fire and Life Safety Code inspection was conducted at The Lodge at Eagle Ridge by a representative of the Washington State Patrol, State Fire Marshal's Office to determine compliance with applicable codes.
Findings
Multiple violations were observed including improper storage of combustible materials, missing receptacle covers, improper use of power strips, use of extension cords, lack of documentation for sprinkler system tests, non-functional carbon monoxide alarms, non-working exit signs, unsecured oxygen bottles, and fire door deficiencies such as doors not closing properly.
Deficiencies (11)
| Description |
|---|
| The Mechanical room in the kitchen has two propane bottles stored in it. |
| The Wellness office on 2nd floor is missing a receptacle cover. |
| The Wellness office has an AC plugged into a power strip on the 2nd floor. |
| The Vitality office on 1st floor has power strips plugged into power strips. |
| Extension cords are in use in the Massage room - Garden Level and Main kitchen - above coolers. |
| Facility unable to provide documentation for forward flow test and quarterly sprinkler inspections. |
| Facility needs a heat survey for commercial hood to determine fusible link rating; four 500 degree links currently in place. |
| Carbon monoxide alarm in mechanical room 344 did not work due to missing batteries on 3rd floor. |
| Exit sign in back dining room (by kitchen) did not work when tested. |
| Resident room 214 has unsecured oxygen bottles. |
| Multiple fire doors did not close or latch properly when tested in various locations including stairwell door #49, storage room 343, oxygen storage room #38, mechanical/electrical room 244, janitor's closet 219, nurse's station med room 209, laundry room by G-14, and stairwell by elevator room. |
Report Facts
Number of propane bottles: 2
Number of 500 degree fusible links: 4
Number of fire doors with closing/latching issues: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dave Holsather | Maintenance Director | Named as Owner or Owner's Representative signing the inspection report |
| Cozetta Christian | Deputy State Fire Marshal | Conducted the inspection and signed the report |
Inspection Report
Life Safety
Deficiencies: 16
Aug 3, 2023
Visit Reason
An unannounced Fire and Life Safety Code inspection was conducted at The Lodge at Eagle Ridge by a representative of the Washington State Patrol, State Fire Marshal's Office to determine compliance with all applicable codes.
Findings
Multiple violations of fire and life safety codes were observed, including issues with ceiling clearance, multiplug adapters, extension cords, door operation, sprinkler system deficiencies, extinguishing system service records, smoke control system deficiencies, and unsecured compressed gas cylinders.
Deficiencies (16)
| Description |
|---|
| Storage within 18 inches of sprinkler head in 1st floor Activities storage room and Fitness Center closet. |
| Unapproved multi plug adapter in TV reception area. |
| Power strip dangling by its cord at Nurses station on 2nd floor by room 209. |
| Extension cord in use by exit doors in Fitness Center. |
| Outlet cover needs to be screwed back into wall in Resident room G09. |
| Facility unable to provide documentation for current hood cleaning; last known date January 2023. |
| Cross corridor #35 missing its door handle by room 127. |
| Swinging fire doors did not close/latch properly at Nurses station on 2nd floor (#45) and Janitor door #051 on Ground floor. |
| Facility's damper report shows 5 dampers failed; unsure if fixed. |
| Dirty sprinkler heads in Laundry room and Women's bathroom/locker room in kitchen; sprinkler report shows deficiencies due to painted heads and recalled sprinklers; facility unable to provide quarterly sprinkler inspection reports. |
| Facility unable to provide service reports for kitchen suppression system for annual and semi-annual servicing in past 12 months. |
| Facility unable to provide record of annual inspection for fire alarm system. |
| Smoke control confidence test shows deficiencies: both elevator fans failed to provide required pressure and unable to verify damper. |
| Breeze way exit door requires extra force to open on ground floor by the chairs. |
| Activity room has basketball game activity blocking part of the exit door on 1st floor. |
| Unsecured compressed gas cylinders in Oxygen room (2nd floor), Resident room G09, and Activity storage - helium bottles (1st floor). |
Report Facts
Failed dampers: 5
Dates: 2023
Next inspection scheduled: Sep 2, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dave Holsather | Maintenance Director | Named as Owner's Representative and signatory on inspection documents. |
| Cozetta Christian | Deputy State Fire Marshal | Conducted the inspection and signed the report. |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 1
Oct 6, 2022
Visit Reason
The complaint investigation was conducted due to allegations related to COVID-19 testing and infection control practices at the assisted living facility.
Findings
The facility failed to implement and adhere to the required Respiratory Protection Program by not fit-testing staff with appropriate N95 respirators, placing residents at increased risk of COVID-19 transmission. The investigation confirmed multiple residents and staff tested positive for COVID-19, and the facility did not meet licensing requirements.
Complaint Details
The complaint investigation was substantiated with failed provider practice identified and citations written related to inadequate fit-testing of staff for N95 respirators during a COVID-19 outbreak.
Deficiencies (1)
| Description |
|---|
| Failure to ensure 16 of 20 facility staff were fit-tested for N95 respirators as required to prevent transmission of COVID-19. |
Report Facts
Total residents: 51
Resident sample size: 2
Staff fit-tested: 16
Investigation dates: 2022-09-13 to 2022-10-06
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Hayes | Licensor | Conducted the on-site verification and investigation |
| Laurie Anderson | Field Manager | Signed follow-up and enforcement letters |
| Staff B | Director of Nursing | Interviewed regarding staff fit-testing and infection control practices |
| Staff A | Executive Director | Interviewed regarding scheduling of fit-testing and staff turnover |
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