The Gardens at Town Square

Initial inspection on 04/23/2025 identified multiple fire safety violations including disabled smoke detectors in a resident room, improper use of extension cords as permanent wiring, missing documentation for critical fire safety systems (sprinkler, fire alarm, and extinguishing system inspections), unsecured gas cylinders, and electrical hazards. The facility responded appropriately by correcting all violations within two months, as confirmed by the follow-up inspection on 06/23/2025 showing full compliance and approved status. While the violations presented moderate safety concerns affecting multiple fire protection systems, none created immediate life-threatening conditions, and the facility's timely remediation demonstrated good commitment to regulatory compliance.

A staff member (Staff A) worked 272 days past hire without required nursing assistant or home care aide certification, exceeding the 200-day certification deadline by 72 days, and provided direct care and administered medications to residents while unqualified. This systematic failure put all 60 residents at risk of receiving care from an uncertified worker. The facility acknowledged the violation, removed the staff member from direct care duties, and corrected all deficiencies by the follow-up inspection on 04/25/2025, with no further violations found. The facility demonstrated adequate corrective action by ensuring compliance with training and certification requirements, though the initial failure represented a serious breach of fundamental safety requirements for vulnerable residents.

The facility employed an unqualified staff member who had not completed required 70-hour basic training certification, placing all 38 residents at risk of receiving care from unqualified personnel. This is a repeat violation previously cited on January 16, 2025, demonstrating a pattern of non-compliance with staff qualification requirements. The facility's inadequate response resulted in a $300 civil fine for failing to correct the deficiency after the initial citation. The repeat nature and lack of timely correction indicate insufficient corrective action and oversight by facility management.

This document reports the results of an Informal Dispute Resolution (IDR) process where The Gardens at Town Square disputed a citation (WAC 388-78A-2700) from an October 31, 2024 inspection. After reviewing all materials and evidence presented by the facility, the regulatory agency deleted the disputed deficiency. The facility successfully challenged the citation through proper administrative channels, demonstrating engagement with the regulatory process, though no information is provided about the underlying violation or what corrective actions may have been taken prior to the dispute resolution. The deletion of the deficiency indicates either the citation was incorrect or the facility provided sufficient evidence to overturn it, resulting in no violations remaining from this specific citation for this inspection cycle following the IDR process conclusion on January 3, 2025, though we lack details on event severity since the deficiency was removed after dispute resolution rather than after observing a problematic event and response in the field during the original inspection visit that generated the October SOD report before this administrative appeal occurred and resolved favorably for the provider through deletion of WAC section cited originally by surveyors during their onsite review of facility operations and records at that time in late October of the prior year before this January letter confirming IDR outcome favorable to facility's position in the matter under review by IDR Program Manager after consideration of all relevant information presented during that administrative process designed to allow providers opportunity to challenge citations they believe were issued in error or without sufficient factual basis to support the regulatory finding as originally written in the Statement of Deficiencies that prompted this dispute resolution request and ultimate deletion of the cited regulatory violation from the official record.

This is an administrative scheduling letter confirming an Informal Dispute Resolution (IDR) meeting for a Statement of Deficiencies dated October 31, 2024, citing WAC 388-78A-2700. The facility is exercising its right to dispute the citation through the formal IDR process. The facility's response demonstrates appropriate engagement with the regulatory process by requesting a formal review, assembling appropriate leadership representation, and following required procedures, though the underlying violation details and corrective actions are not provided in this document. No immediate safety concerns are evident from this procedural correspondence alone, as the IDR process is a standard component of regulatory oversight allowing facilities to present additional information or contest findings before citations become final.

The June 2024 fire safety inspection identified 14 violations at this residential care facility, primarily involving documentation deficiencies (fire drill records, maintenance inspection records, fire door/damper testing reports) and minor safety issues (combustible materials in exit stairway, kitchen exit door latching problem, improper power tap usage). The facility demonstrated a good response by correcting all 14 violations within approximately one month, as confirmed by the July 8, 2024 follow-up inspection showing full compliance. While the violations indicated gaps in maintenance documentation and some procedural non-compliance affecting fire safety systems, none posed immediate life-threatening conditions, and the facility's prompt comprehensive remediation demonstrated adequate commitment to regulatory compliance.

The April 2023 inspection identified 15 code violations including critical life-safety issues: missing smoke detectors, non-latching fire doors, unprotected fire-rated wall penetrations, loaded sprinkler heads, missing fire alarm pull station glass rods, and inadequate fire drill documentation across multiple shifts. The facility demonstrated a good response by correcting all violations within approximately one month, as confirmed by the May 30, 2023 follow-up inspection showing full compliance. While the initial violations represented serious fire protection and evacuation system failures in a residential care facility, the prompt and complete remediation indicates adequate facility commitment to regulatory compliance.

The Department conducted a full inspection of The Gardens at Town Square assisted living facility on 05/01/2023 and found no deficiencies or violations. Since no violations were identified, no corrective actions were required from the facility. The facility demonstrated compliance with all regulatory standards during this routine inspection, indicating adequate operational controls and care delivery systems are in place. This represents a successful inspection outcome with the facility meeting all applicable requirements.