Inspection Report
Life Safety
Deficiencies: 6
Dec 20, 2024
Visit Reason
The Office of the State Fire Marshal conducted an inspection at Windsor Gardens Memory Care to assess compliance with fire protection and safety regulations.
Findings
The facility was found to have multiple violations related to fire sprinkler system testing and maintenance, fire alarm inspection, carbon monoxide detector testing, emergency lighting testing, battery-powered emergency lighting testing, and fire drills. The facility failed to provide required reports and inspections and failed several monthly and annual tests.
Deficiencies (6)
| Description |
|---|
| Facility failed to provide annual fire sprinkler inspection, annual forward flow, and quarterly fire sprinkler inspection reports; fire sprinkler trim ring missing in stairwell |
| Facility failed to provide annual fire alarm inspection; fire alarm found to have dialer 2 issue |
| Facility failed to provide monthly carbon monoxide detector testing; fire alarm found to have dialer 2 issue |
| Facility failed monthly emergency light testing |
| Facility failed to provide annual emergency light testing |
| Facility failed to provide fire drills as required |
Report Facts
Next inspection scheduled date: Next inspection scheduled on or after 2025-01-19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas D. Wolden | Deputy State Fire Marshal | Conducted the inspection and signed the report |
| Cameron Huegel | Owner or Authorized Representative | Signed the report as facility representative |
Inspection Report
Follow-Up
Census: 8
Deficiencies: 4
Apr 30, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility on 04/30/2024 to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies, and the facility meets the Assisted Living Facility licensing requirements. Previously cited deficiencies related to background checks and tuberculosis testing were corrected.
Deficiencies (4)
| Description |
|---|
| Failure to complete a national fingerprint background check within the required timeframe for 2 of 5 sampled staff. |
| Failure to ensure a Washington State name and date of birth background check was completed prior to employment for 1 of 5 sampled staff. |
| Failure to complete tuberculosis testing within three days of hire for 1 of 3 sampled staff. |
| Failure to ensure a full assessment was completed within 14 days of admission for 1 of 1 sampled residents. |
Report Facts
Current residents sampled: 4
Former residents sampled: 0
Staff sampled for background checks: 5
Days late for fingerprint background check completion: 134
Days late for fingerprint background check completion: 149
Days late for tuberculosis testing: Two-step TB testing for Staff C was completed late
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Siharath | ALF Licensor | Department staff who inspected the Assisted Living Facility |
| Kyle Gehlen | ALF Licensor - LTC | Department staff who inspected the Assisted Living Facility |
| Richard Westom | NCI, ALF Complaint Investigator | Department staff who inspected the Assisted Living Facility |
| Michael Burdick | Field Manager | Signed letters and correspondence related to inspection and follow-up |
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