Garden Terrace Healthcare Center of Federal Way

The facility failed to ensure safe handling and storage of liquid narcotic medication (Oxycodone) for a hospice resident, with multiple documented spillages, missing medication, and medication that changed color, potentially leaving the resident undertreated for severe pain. The facility conducted an internal investigation, suspended two staff members, notified law enforcement, provided staff in-service training on medication management, and consulted with a pharmacist to implement preventive measures including proper storage with rubber stoppers. While the investigation was unsubstantiated for intentional tampering, the systemic failures in narcotic medication handling represented serious risks to resident comfort and safety, and the facility's response demonstrated appropriate corrective actions with follow-up monitoring that achieved compliance by the October follow-up inspection.

This follow-up inspection found four uncorrected repeat deficiencies from June 2025, including incomplete pre-admission assessments for two residents, inadequate service agreements, missing required staff training for four employees, and incomplete background checks for three staff members. These systemic failures placed nine residents at risk of unmet care needs and potential harm from inadequately vetted or trained caregivers. The facility failed to correct previously cited deficiencies despite a two-month period, demonstrating inadequate response and resulting in $1,600 in civil fines. The pattern of repeat violations across critical areas (admissions, care planning, staffing qualifications, and safety screening) indicates fundamental operational and compliance failures.

The April 2025 inspection identified five fire and life safety code violations at this residential care facility: missing sprinkler system annual forward flow report, improper fusible link ratings requiring heat survey, egress path obstruction by landscaping, and missing generator fuel sample records. The facility demonstrated a good response by correcting all violations within 30 days, as confirmed by the May 2025 follow-up inspection showing full compliance. While the violations represented moderate safety concerns related to fire protection systems and emergency egress, none posed immediate life-threatening danger, and the facility's timely corrective action prevented escalation of risk.

The March 2024 inspection identified multiple fire safety code violations including loaded sprinkler heads in the kitchen and laundry room, an outdated hood suppression system certificate, and an improperly mounted fire extinguisher in the riser room. These violations affected critical fire protection systems but did not pose immediate life safety threats. The facility responded appropriately with a timely correction of all violations, as confirmed by the May 2024 follow-up inspection showing full compliance and approved status within approximately six weeks.

The facility had multiple procedural violations including menu planning errors, unsigned service agreements for 2 of 7 residents, failure to post current license and inspection reports, late administrator notification, lack of group activities for assisted living residents, and missing medication safety monitoring documentation. While these violations affected care quality and resident rights to information, none posed immediate safety threats. The facility responded appropriately by immediately correcting posting deficiencies during inspection, scheduling required training, and submitting a comprehensive plan of correction with completion dates, demonstrating good engagement with regulatory requirements.

This was a routine fire safety inspection conducted by the Washington State Fire Marshal on March 16, 2023, with no violations observed. The facility demonstrated full compliance with fire protection requirements, requiring no corrective actions. The facility's proactive maintenance of fire safety standards reflects good operational practices and commitment to resident safety. This represents successful baseline compliance rather than a response to specific deficiencies.