Inspection Report
Follow-Up
Census: 54
Capacity: 54
Deficiencies: 0
Nov 22, 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 Assisted Living Facility licensing requirements.
Report Facts
Sampled staff for tuberculosis screening: 5
Staff tuberculosis screening failure: 2
Sampled resident for medical tests: 1
Residents at risk due to policy failure: 44
Residents given Medicaid policy: 0
Residents with incomplete dementia training: 1
Residents at risk for unmet care needs: 6
Residents at risk for medication errors: 1
Residents with hazardous supplies exposure: 44
Residents at risk for discharge: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff S | Program Director | Failed to complete tuberculosis test within required timeframe |
| Staff T | Culinary aide/dishwasher | Failed to complete required tuberculosis test |
| Staff U | Human Resources Director | Interviewed regarding tuberculosis testing compliance |
| Staff A | Executive Director | Interviewed regarding tuberculosis testing compliance and facility policies |
| Staff V | Caregiver, Medication Technician | Performed delegated blood glucose checks for Resident 5 |
| Staff D | Resident Care Director | Failed to complete background check timely and unaware of MTSW license requirement |
| Staff B | Resident Care Coordinator | Failed to complete tuberculosis screening timely |
| Staff C | Nurses Aide/Caregiver | Failed to complete specialized dementia training |
| Staff O | Housekeeper | Failed to secure housekeeping carts as required |
| Staff N | Director of Plants Operations | Interviewed regarding housekeeping cart security |
| Staff R | Medication Technician | Performed blood glucose test for Resident 5 |
| Staff Q | Medication Technician | Unlicensed staff who dispensed medications to Resident 1 |
Inspection Report
Enforcement
Deficiencies: 2
Oct 11, 2024
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to The Watermark at Bellevue to impose civil fines based on uncorrected deficiencies previously cited related to tuberculosis screening and medical testing compliance.
Findings
The facility failed to ensure two staff were screened for tuberculosis and failed to follow required regulations for conducting medical tests for one resident, placing residents at risk of exposure to tuberculosis and medication errors. These deficiencies were previously cited and remain uncorrected.
Deficiencies (2)
| Description |
|---|
| Failure to ensure two staff were screened for tuberculosis (TB), placing residents at risk of exposure. |
| Failure to follow required federal and state regulations to conduct medical tests for one resident, risking medication errors. |
Report Facts
Civil fine amount: 200
Civil fine amount: 200
Total civil fines: 400
Days to return Statement of Deficiencies: 10
Days to request formal hearing: 28
Interest rate: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laurie Anderson | Field Manager | Contact for returning Statement of Deficiencies and questions |
| Matt Hauser | Compliance Specialist | Signed the enforcement letter |
Inspection Report
Follow-Up
Deficiencies: 0
Mar 31, 2023
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. Previous deficiencies cited in compliance determinations 21915 and 19138 were corrected.
Report Facts
Compliance Determination Completion Dates: Compliance Determination 21915 completed on 2023-03-31 and 19138 completed on 2023-02-03
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steven Garrett | LTC Licensor | Department staff who did the on-site verification |
| Claudia Machado | Community Complaint Investigator | Department staff who did the on-site verification |
| Laurie Anderson | Field Manager | Signed the follow-up inspection letter |
Inspection Report
Complaint Investigation
Census: 7
Deficiencies: 1
Dec 29, 2022
Visit Reason
The inspection was conducted as an unannounced on-site complaint investigation triggered by an allegation involving one COVID-positive resident.
Findings
The facility failed to implement and adhere to the required Respiratory Protection Program (RPP) by not fit-testing staff with appropriate N95 respirators, placing seven residents at increased risk of contracting and spreading COVID-19. A follow-up inspection on 03/09/2023 found no deficiencies and confirmed compliance.
Complaint Details
The complaint investigation was substantiated with failed provider practice identified and citations written related to COVID-19 infection control and respiratory protection program compliance.
Deficiencies (1)
| Description |
|---|
| Failure to implement policy ensuring 27 of 27 facility staff were fit-tested for N95 respirators to prevent COVID-19 transmission. |
Report Facts
Total residents: 7
Resident sample size: 2
Staff fit-tested required: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Corlis | Complaint Investigator | Conducted the on-site complaint investigation and verification |
| Laurie Anderson | Field Manager | Signed the follow-up inspection letter |
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