Inspection Report
Follow-Up
Deficiencies: 0
Nov 25, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility on 11/25/2024 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. Previous deficiencies listed in the report dated 09/27/2024 were corrected.
Report Facts
Residents reviewed: 7
Total residents: 53
Residents affected by medication deficiency: 5
Residents affected by outdoor access deficiency: 16
Residents affected by apartment access deficiency: 53
Residents affected by ventilation deficiency: 53
Residents affected by infection control deficiency: 53
Ladders stored unsafely: 2
Ladder lengths: 10
Ladder lengths: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Forkgen | ALF Licensor | Department staff who did the on-site verification |
| Kathy Young | Licensor | Department staff who did the on-site verification |
| Laurie Anderson | Field Manager | Signed multiple documents related to inspection and compliance |
| Staff I | Interviewed regarding medication administration and medication cart audits | |
| Staff M | Licensed Practical Nurse | Interviewed about expired medication and medication administration |
| Staff N | Licensed Practical Nurse | Interviewed about medication expiration and refilling procedures |
| Staff J | Interviewed about dietary manual availability and food service | |
| Staff K | Cook | Interviewed about dietary manual availability |
| Staff H | Assistant General Manager | Confirmed lack of dietary manual |
| Staff L | Facility Director | Interviewed about outdoor access, ventilation issues, and infection control |
| Staff O | Housekeeper | Interviewed about housekeeping cart keys and chemical storage |
| Staff F | Dietary Services Manager | Interviewed about meal menus and posting |
| Staff J | Interviewed about meal menus and dietary manual | |
| Staff H | General Manager | Interviewed about COVID positive resident and infection control |
| Staff I | Director of Nurses | Interviewed about family notifications of COVID positive resident |
Inspection Report
Life Safety
Deficiencies: 10
Aug 6, 2024
Visit Reason
An unannounced Fire and Life Safety Code inspection was conducted at Weatherly Inn at Lake Meridian by the Washington State Patrol, State Fire Marshal's Office to determine compliance with applicable fire safety codes.
Findings
Multiple violations were observed including combustible material storage in mechanical rooms, improper use of power strips, lack of documentation for hood cleaning, fire drills, sprinkler testing, and fire alarm testing, malfunctioning exit signs, loaded sprinkler heads, and doors not closing properly.
Deficiencies (10)
| Description |
|---|
| Combustible material stored in mechanical rooms. |
| Resident Manager's office has an AC plugged into a power strip. |
| Facility unable to provide documentation for current hood cleaning. |
| Fire alarm room located outside has an unsealed conduit. |
| Several doors did not close or latch properly when tested. |
| Facility unable to provide documentation for annual sprinkler, forward flow test, and quarterly sprinkler report. |
| Facility unable to provide documentation for annual fire alarm testing. |
| Exit signs did not work properly when tested. |
| Locations have loaded sprinkler heads. |
| Facility was not able to provide documentation for completion of twelve planned and unannounced fire drills in the previous 12 months. |
Report Facts
Number of doors not closing properly: 7
Number of locations with loaded sprinkler heads: 3
Number of planned and unannounced fire drills required: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cozetta Christian | Deputy State Fire Marshal | Conducted the inspection and signed the report |
| Son Kim | Facility Director | Named as Owner or Authorized Representative on the report |
Inspection Report
Follow-Up
Deficiencies: 9
Sep 6, 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 Assisted Living Facility licensing requirements. Previously cited deficiencies related to tuberculosis testing and respiratory protection program were corrected or addressed.
Deficiencies (9)
| Description |
|---|
| Failed to ensure 1 of 7 staff had a chest X-ray or medical evaluation after a positive tuberculosis blood test, placing residents at risk of TB exposure. |
| Failed to ensure 2 of 7 staff were screened for tuberculosis with the required two-step skin testing within required timeframes. |
| Failed to implement required respiratory protection program policy for 32 of 62 staff, including fit testing and medical evaluation for respirator use. |
| Appointed an administrator who did not meet Washington State qualifications and requirements for assisted living facility administrator. |
| Failed to notify the department within 10 calendar days of the effective date of a change in the assisted living facility administrator. |
| Failed to provide documentation of current CPR certification for 2 of 7 staff. |
| Used plug-in type air fresheners with liquid cartridges accessible to residents, posing a risk of ingestion. |
| Failed to post a current assisted living facility license in a conspicuous place accessible to residents and visitors. |
| Failed to ensure secured outdoor areas were accessible to residents without staff assistance. |
Report Facts
Staff with tuberculosis screening deficiencies: 3
Staff with respiratory protection program deficiencies: 32
Staff with missing CPR documentation: 2
Residents served: 49
Staff employed: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | General Manager/Administrator | Failed to meet administrator qualifications; hired 11/01/2022; change of administrator notification delayed |
| Staff B | Director of Nursing Services | Interviewed regarding tuberculosis testing and respiratory protection program deficiencies |
| Staff C | Caregiver | Failed to have chest X-ray after positive TB skin test; respiratory protection program deficiency |
| Staff D | Caregiver | Failed to complete two-step TB skin testing; respiratory protection program deficiency |
| Staff KK | Vice-President of Corporate Operations | Provided support to administrator; submitted administrator change notification |
| Laurie Anderson | Field Manager | Signed follow-up inspection report and enforcement letter |
| Steven Garrett | LTC Licensor | Conducted inspections |
| Claudia Machado | Community Complaint Investigator | Conducted inspections |
| Angelica Rios | ALF Licensor | Conducted inspections |
Inspection Report
Life Safety
Deficiencies: 24
Aug 8, 2023
Visit Reason
An unannounced Fire and Life Safety Code inspection was conducted at Weatherly Inn at Lake Meridian by the Washington State Patrol, State Fire Marshal's Office to determine compliance with applicable codes.
Findings
Multiple fire and life safety code violations were observed including unapproved heaters and multi plug adapters, extension cords in use in various locations, missing ceiling tiles, doors not closing properly, lack of documentation for inspections and maintenance of fire safety systems, blocked fire extinguishers, unsecured compressed gas containers, and missing fire alarm breaker lock. The facility was disapproved due to these deficiencies.
Deficiencies (24)
| Description |
|---|
| The reception desk has an unapproved heater. |
| The reception desk has an unapproved multi plug adapter in use. |
| The employee break room has a power strip that is dangling in the air. |
| Extension cords are in use in the outside patio garden areas, salon, and reception desk. |
| The facility was unable to provide documentation for their annual and semi annual hood cleaning. |
| The facility was unable to provide record of their annual fire wall inspection and/or repairs for all fire-resistant-rated construction. |
| The clean linen room on level 3 is missing 2 ceiling tiles. |
| The clean linen room on level 3 and fire alarm breaker room have penetrations in the wall. |
| The facility was unable to provide inventory record of their annual inspection and/or repairs for all fire-resistant-rated doors. |
| The following doors did not close/latch properly when tested: Designer Closet, Boiler door by suite 3, Fireside room 1, Clean laundry level 1, Maintenance janitor closet. |
| The facility was unable to provide documentation for their last fire/smoke damper testing. |
| The facility has dirty sprinkler heads throughout the facility. |
| The facility was unable to provide their annual and quarterly fire sprinkler inspection documentation at the time of inspection. |
| The facility was unable to provide service reports showing that the kitchen suppression system has been serviced annually and semi-annually in the past 12 months. |
| The class k extinguisher in the kitchen is blocked by two carts. |
| The facility was unable to provide record of their annual inspection for their fire alarm system. |
| The facility was unable to provide documentation showing that testing of their CO detectors have been performed in the past 12 months. |
| The facility has unsecured oxygen in their oxygen supply room. |
| Fire alarm circuit breaker in the fire alarm breaker room is missing the required lock device–locking breaker in the 'ON' position. |
| The right exit door by the car will not open. |
| The facility was unable to provide documentation showing that the annual servicing of the emergency generator has been performed in the last 12 months. |
| The facility has not conducted/documented the required weekly visual inspections of the generator as required by NFPA 110 for the last 12 months. |
| The facility was unable to provide documentation for their 30 minute full load test of the emergency generator. |
| The facility was not able to provide documentation for the completion of twelve planned and unannounced fire drills in the previous 12 months. |
Report Facts
Missing ceiling tiles: 2
Number of planned fire drills required: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cozetta Christian | Deputy State Fire Marshal | Conducted the inspection and signed the report. |
| Scott Kijado | Facilities Director | Named as Facility Director and signed the report. |
Inspection Report
Enforcement
Deficiencies: 1
Jul 14, 2023
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to Weatherly Inn At Lake Meridian to assess compliance and impose a civil fine based on violations related to tuberculosis testing and evaluation.
Findings
The facility failed to ensure that one staff member received a chest X-ray or medical evaluation after a positive tuberculosis blood test, placing residents at risk of exposure. This deficiency was recurring and previously cited on May 18, 2023, and March 3, 2023.
Deficiencies (1)
| Description |
|---|
| Failure to ensure one staff had a chest X-ray or was medically evaluated after a positive tuberculosis blood test result. |
Report Facts
Civil fine amount: 600
Days to return Statement of Deficiencies: 10
Days to request formal hearing: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter |
| Laurie Anderson | Field Manager | Contact person for Plan of Correction and inquiries |
Inspection Report
Enforcement
Deficiencies: 3
May 18, 2023
Visit Reason
The Department of Social and Health Services completed a follow-up visit to Weatherly Inn At Lake Meridian to address previously cited deficiencies and impose civil fines for uncorrected violations.
Findings
The facility was found to have uncorrected deficiencies related to tuberculosis screening and respiratory protection policies for staff, resulting in civil fines totaling $900.00. These deficiencies placed residents at risk of exposure to infectious diseases.
Deficiencies (3)
| Description |
|---|
| Failure to ensure one staff had a chest X-ray after a positive Tuberculosis skin test. |
| Failure to ensure two staff were screened for Tuberculosis as required. |
| Failure to implement the required respiratory protection program policy for five staff. |
Report Facts
Civil fines total: 900
Civil fine amount: 300
Civil fine amount: 300
Civil fine amount: 300
Number of staff affected: 1
Number of staff affected: 2
Number of staff affected: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laurie Anderson | Field Manager | Contact person for submission of Statement of Deficiencies and follow-up. |
| Matt Hauser | Compliance Specialist | Signed the enforcement letter regarding civil fines. |
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