Inspection Reports for Weatherly Inn Tacoma
6016 N Highlands Pkwy, Tacoma, WA 98406, United States, WA, 98406
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12
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6
3
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Inspection Report
Follow-Up
Deficiencies: 2
Sep 5, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to tuberculosis screening of staff.
Findings
The follow-up inspection on 09/05/2025 found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previous deficiencies related to failure to screen staff for tuberculosis within three days of employment were corrected.
Deficiencies (2)
| Description |
|---|
| Failure to ensure 4 of 5 sampled staff were screened for tuberculosis within three days of employment as required, placing residents and staff at risk of exposure to TB. |
| Failure to ensure 1 of 5 sampled staff received tuberculosis test within three days of employment as required, placing residents and staff at risk of exposure to TB. |
Report Facts
Sampled staff not screened for TB within three days: 4
Sampled staff not screened for TB within three days: 1
Sample size for resident review: 12
Total current residents during complaint investigation: 114
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Heinz | Long Term Care Surveyor | Department staff who conducted on-site verification and inspections |
| Laurie Anderson | Community Field Manager | Signed follow-up inspection letter |
| Staff A | Executive Director | Interviewed and acknowledged staff were not screened within three days of hire |
| Staff B | Wait Staff / LPN | Sampled staff not screened for TB within three days of employment |
| Staff C | Wait Staff | Sampled staff not screened for TB within three days of employment |
| Staff D | Caregiver | Sampled staff not screened for TB within three days of employment |
| Staff E | Wait Staff | Sampled staff not screened for TB within three days of employment |
| Shirley Grew | LTC Surveyor | Department staff who inspected the facility during complaint investigation |
| Cory Myers | NCI ALF Licensor | Department staff who inspected the facility during complaint investigation |
| Staff A | Human Resources Coordinator | Acknowledged providing all TB testing records on file for sampled staff |
Inspection Report
Enforcement
Deficiencies: 1
Jul 25, 2025
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to Weatherly Inn to assess compliance and enforce corrective actions related to previously cited deficiencies.
Findings
The facility failed to ensure that four staff members were screened for tuberculosis within three days of employment, an uncorrected deficiency previously cited on May 23, 2025. This violation resulted in a civil fine of $400.
Deficiencies (1)
| Description |
|---|
| Failure to ensure four staff were screened for tuberculosis within three days of employment as required. |
Report Facts
Civil fine amount: 400
Number of staff not screened: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter |
| Manfay Chan | Field Manager | Contact person for plan of correction and inquiries |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 10, 2025
Visit Reason
A complaint investigation was conducted due to a fire alarm incident at Weatherly Inn involving a resident starting a fire in a toaster.
Findings
The fire was contained, the sprinkler system did not activate, the resident was moved from the room until repairs were made, the building was not evacuated, there were no injuries, and the fire department responded.
Complaint Details
Complaint #179017 involved a fire alarm caused by a burnt toast incident. The sprinkler system did not activate, no evacuation occurred, no injuries were reported, and the fire department responded.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Peterson | General Manager | Signed as Owner or Authorized Representative related to the complaint investigation. |
| Raul Murcia | Deputy State Fire Marshal | Signed as Deputy State Fire Marshal conducting the inspection. |
Inspection Report
Life Safety
Deficiencies: 10
Jun 10, 2025
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the Weatherly Inn facility to assess compliance with fire protection and safety codes.
Findings
The facility was disapproved due to multiple fire safety violations including failure to maintain fire-resistance-rated construction, missing fire/smoke damper inspections, inadequate sprinkler system maintenance and documentation, failure to provide fire alarm and smoke alarm inspection reports, blocked pull station, insufficient emergency lighting tests, and issues with fire door gaps and hardware.
Deficiencies (10)
| Description |
|---|
| Main laundry room had multiple ceiling penetrations. |
| Facility failed to provide fire/smoke dampers 4 year inspection. |
| Facility failed to provide documentation for fire sprinkler system annual forward flow test and fire department connection hydrostatic test; sprinkler system leaks and not functioning properly. |
| Main dining back nook area has a missing escutcheon ring; multiple areas have sprinkler heads loaded with debris. |
| Facility failed to provide reports that kitchen suppression system is inspected twice a year. |
| Facility failed to provide annual inspection report of fire alarm system and monthly inspection report of smoke alarms; fire alarm report from 2/25/2025 did not show all 5 doors that failed to release were fixed; pull station at front desk blocked by decoration; fire alarm electrical breaker needs a breaker lock. |
| Facility failed to provide monthly 30 second test of exit signs and emergency lights. |
| Facility failed to provide 1.5 hour power test of exit signs and emergency lights. |
| Generator report from 1/15/25 states fuel lines and belt need to be replaced. |
| Memory care employee bathroom door has more than 1/16 inch gap around door and can see into bathroom; door needs to have no more than 1/16 inch gap around door and no more than 3/4 inch below door. |
Report Facts
Inspection interval: 4
Fire alarm report date: Feb 25, 2025
Monthly test duration: 30
Annual power test duration: 1.5
Generator report date: Jan 15, 2025
Next inspection date: Jul 16, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Raul Murcia | Deputy State Fire Marshal | Signed inspection report |
| Andrea Peterson | General Manager | Owner or Owner's Representative |
| Stephen Smalley | Maintenance | Owner or Authorized Representative |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 1
May 3, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation due to reports that residents were positive for a communicable disease.
Findings
The investigation found failed provider practices related to infection control, specifically failure to ensure staff were properly fit tested for respirators, placing all residents and staff at risk during a communicable disease outbreak. Citations were written under WAC 388-78A-2610 (2)(a) and (2)(c).
Complaint Details
The complaint alleged residents were positive for a communicable disease. The investigation substantiated failed provider practices related to infection control and respirator fit testing.
Deficiencies (1)
| Description |
|---|
| Failure to ensure 6 of 8 sampled staff were fit tested with appropriate respirators, risking spread of infection. |
Report Facts
Total residents: 72
Resident sample size: 2
Staff sample size: 8
Residents tested positive: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Heinz | Long Term Care Surveyor | Investigator who conducted the complaint investigation and on-site verification. |
| Manfay Chan | Field Manager | Signed the follow-up inspection letter. |
| Andrea Peterson | Administrator | Administrator who signed the Plan/Attestation Statement. |
| Staff A | Executive Director | Interviewed on 05/20/2024 regarding caregivers not fit tested with respirators. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 8, 2023
Visit Reason
The Department completed a complaint investigation of the Assisted Living Facility on 11/08/2023 following complaint number 101478 regarding a resident found deceased in her room.
Findings
The investigation found a system failure in verifying the resident's location, with the resident ultimately found deceased between the nightstand and bed. Facility-wide staff training was completed after the event, and no changes to residents' health were noted prior to the event.
Complaint Details
Complaint investigation related to a resident found deceased in her room. The complaint was substantiated by findings of a system failure in resident location verification.
Deficiencies (1)
| Description |
|---|
| Failure to follow facility policy on monitoring, wandering, and elopement, resulting in a resident not being identified as missing until found unresponsive. |
Report Facts
Complaint number: 101478
Compliance Determination number: 31960
Closed records sample size: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Mason | NCI ALF Licensor | Department staff who did the inspection and provided consultation |
| Manfay Chan | Field Manager | Signed the letter regarding the investigation |
Inspection Report
Life Safety
Deficiencies: 5
Jul 31, 2023
Visit Reason
The Office of the State Fire Marshal conducted an inspection at the Weatherly Inn facility on 07/31/2023 to assess compliance with fire safety codes and regulations.
Findings
The inspection identified multiple violations including storage blocking electrical panels, use of extension cords as permanent wiring, unprotected penetrations in fire-resistant construction, lack of documentation for sprinkler system testing, and missing Class K placard near the kitchen fire extinguisher.
Deficiencies (5)
| Description |
|---|
| Storage located within designated working spaces blocking access to electrical panels throughout the facility. |
| Extension cord utilized as permanent wiring under vending machine on first floor in the service hallway. |
| Multiple unprotected penetrations found throughout the building's fire-resistance-rated construction in corridor walls and rated ceilings. |
| Facility unable to provide documentation showing the last 3-year full flow trip test report for the dry fire sprinkler system. |
| No Class K placard found conspicuously placed near the K Class fire extinguisher in the kitchen. |
Report Facts
Next inspection scheduled on or after: Aug 30, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lysandra Davis | Deputy State Fire Marshal | Conducted the inspection and signed the report |
| Atash Naraya | Director of Maintenance | Facility representative signing the report |
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