Kenmore Senior Living

The facility had multiple moderate violations across assessment accuracy, medication administration compliance, food safety protocols, staff training/background checks, and emergency preparedness. Key issues included failure to properly assess residents' medical device needs (oxygen, bed rails), non-implementation of prescribed compression stockings for edema, inadequate food safety monitoring (handwashing, sanitizer testing), incomplete staff credentialing (fingerprint background check, CPR certification, TB screening), and expired emergency supplies. The facility responded appropriately by acknowledging all deficiencies, developing corrective action plans with completion dates, and successfully correcting all cited violations by the January 2025 follow-up inspection, though some issues were recurring from prior inspections.

The facility violated residents' rights by improperly issuing discharge notices for non-payment when no payment was owed, and engaged in potential fraud by charging private pay rates while simultaneously receiving payments from another source. Additionally, the facility housed residents in apartments that did not meet environmental contract requirements without proper approval or waivers. The response was inadequate as violations were only identified through external complaint investigation, with fraud referral needed, indicating systemic financial and operational failures rather than proactive compliance measures.

The facility repeatedly violated regulations by converting Memory Care Unit apartments to Medicaid-contracted use without obtaining required Construction Review Services approval, placing at least one Medicaid resident in a 177-square-foot apartment lacking required kitchen facilities. This is an uncorrected repeat deficiency previously cited on 7/31/2024. Despite signing a plan of correction with a 9/13/2024 compliance date, the facility remained non-compliant during the 9/17/2024 follow-up inspection, demonstrating inadequate corrective action and continued systemic failure to follow regulatory processes for room use changes affecting vulnerable Medicaid residents' living conditions and contractual entitlements.

The facility had COVID-19 positive cases but failed to notify the Department of Health per required guidelines and did not implement their Respiratory Protection Policy for fit testing staff, representing a moderate violation of infection control protocols. The facility demonstrated a mixed response: they appropriately followed COVID testing guidelines for residents and worked with vendors to address the elevator issue in a timely manner, but gaps remained in completing required notifications and staff respiratory protection measures. A Statement of Deficiencies was issued for the COVID-related violations, while the elevator issue showed no deficient practice.

This inspection resulted in violations requiring an Informal Dispute Resolution process, with the original Statement of Deficiencies dated November 1, 2024 addressing WAC 388-78A-2730 compliance issues. The facility actively participated in the IDR process and successfully disputed one aspect (policy record review was removed from the citation). Despite this partial dispute success, enforcement action remained in place, indicating ongoing moderate compliance concerns that require corrective action and monitoring.

This is an IDR (Informal Dispute Resolution) results letter following a Statement of Deficiencies dated 10/16/2024. The facility disputed findings but after review of all materials and statements, the department upheld all original deficiencies without changes. The facility is required to complete corrections within 45 days and submit a Plan/Attestation Statement within 10 days. Without access to the underlying SOD report detailing the actual violations, only the administrative process can be assessed, showing the facility engaged the dispute process and the department conducted a thorough review.

This document is an Informal Dispute Resolution (IDR) decision letter upholding deficiencies from a 10/15/2024 Statement of Deficiencies report. The letter does not contain the actual inspection findings or violations, only administrative instructions for the facility to correct disputed deficiencies within required timeframes. Without access to the underlying SOD report detailing specific violations, no assessment of event severity or facility response can be made.

The facility failed to implement a Negotiated Service Agreement for a resident prescribed daily compression stockings, creating risk for compromised health. This is a recurring deficiency, previously cited three times in 2023-2024 (May 31, August 3, and January 11), demonstrating a pattern of non-compliance. The facility's response has been inadequate, as evidenced by the recurring nature of this violation and resulting $700 civil fine, indicating failure to implement effective corrective actions despite multiple prior citations.

This is an administrative scheduling letter for an Informal Dispute Resolution (IDR) meeting, not an inspection report with findings. No violations are detailed in this document - it merely confirms the facility's request to dispute citations from a November 1, 2024 Statement of Deficiencies through the formal IDR process. The facility is exercising its regulatory right to challenge findings, with the Executive Director participating in the scheduled review, demonstrating engagement with the compliance process.

The facility received a Statement of Deficiencies on October 15, 2024, resulting in a civil fine imposed on October 24, 2024, for violation of WAC 388-78A-2880. The facility responded promptly by requesting an Informal Dispute Resolution and is actively contesting the citation with three senior executives participating in the appeal process scheduled for November 26, 2024. While the specific nature of the violation is not detailed in this scheduling letter, the imposition of a civil fine indicates a compliance issue of moderate concern requiring formal regulatory action. The facility's organized dispute response with senior leadership involvement and scheduled IDR demonstrates engagement with the regulatory process, though the underlying violation merits attention pending resolution of the appeal.

This document is an administrative scheduling letter for an Informal Dispute Resolution (IDR) meeting, not an inspection report with findings. It confirms that Kenmore Senior Living requested to dispute a citation (WAC 388-78A-2880) from an October 15, 2024 Statement of Deficiencies and subsequent civil fine. Without access to the actual inspection report detailing the violation and facility response, no scoring can be performed. This letter only documents the facility's intent to dispute the finding through the IDR process.

The facility failed to ensure two healthcare workers were fit-tested annually for respirator masks as required under their Respiratory Protection Program, placing 64 residents at risk for COVID-19 exposure. This is a recurring violation previously cited in December 2022 and remains uncorrected from a September 2024 citation, demonstrating a pattern of non-compliance with infection control requirements. The facility's inadequate response, evidenced by repeated failures to correct this critical safety measure over nearly two years, resulted in a $500 civil fine. The systemic failure to maintain basic respiratory protection protocols despite multiple citations indicates poor management oversight of infectious disease prevention measures.

This is an administrative scheduling letter for an Informal Dispute Resolution (IDR) meeting, not an inspection report with findings. The facility is formally disputing two citations (WAC 388-78A-2660 and WAC 388-78A-2361) from an October 16, 2024 Statement of Deficiencies. The facility's response demonstrates appropriate engagement with the regulatory process by requesting an IDR, assembling senior leadership representation, and following proper procedures. Without access to the underlying Statement of Deficiencies, the actual violations and their severity cannot be assessed, so this represents a procedural document only.

The facility failed to obtain required written approval from the Department of Health Construction Review Services before changing the use of former Memory Care Unit apartments to Medicaid-contracted units, resulting in one Medicaid resident being placed in a non-compliant apartment. This is an uncorrected repeat deficiency previously cited on July 31, 2024, demonstrating a pattern of non-compliance with regulatory notification requirements. The facility's inadequate response to the initial citation necessitated a follow-up visit and civil fine of $300. While this violation represents a regulatory and contractual failure rather than immediate resident safety threat, the repeat nature and lack of timely correction indicate insufficient corrective action by the facility.

The facility failed to ensure a resident received her full medication dose for seven consecutive days due to lack of response to pharmacy refill requests, representing a significant breakdown in medication management processes. Additionally, administrative staff failed to follow the facility's grievance policy by not responding timely to family inquiries about the medication lapse. The facility's response was inadequate, showing minimal corrective action and poor communication, though no actual harm to the resident was documented.

The facility failed to implement a care plan requiring constant supervision of a male memory care resident with a documented history of inappropriate sexual behavior toward female residents, resulting in multiple incidents including attempted removal of clothing and unsupervised contact. Staff acknowledged not following the care plan, and observation revealed zero staff supervision in the memory care unit with residents left unmonitored. The facility conducted investigations and updated the care plan after incidents occurred, but enforcement was inadequate until regulators intervened; all deficiencies were corrected by the follow-up inspection in March 2024, though the response was reactive rather than proactive in preventing resident harm.

The facility failed to implement required supervision and monitoring interventions for a resident with a documented history of sexually inappropriate behavior toward female residents. This systemic failure resulted in actual incidents of inappropriate sexual behavior toward two residents and placed four female residents in the Memory Care Unit at risk for sexual abuse. The facility conducted some investigation and developed corrective actions as evidenced by submitting a plan of correction, but the response was insufficient given the preventable nature of the incidents - the negotiated service agreement interventions were already in place but not implemented, indicating inadequate staff compliance with existing care plans.

Multiple incidents of sexual abuse involving four vulnerable residents with dementia in the memory care unit, including unwanted touching of breasts, legs, and inner thighs. Despite staff and supervisors witnessing these incidents and receiving reports, the facility conducted zero investigations, failed to document most incidents, and took no protective action to separate residents or prevent recurrence. The facility's complete failure to investigate repeated sexual abuse of cognitively impaired residents who cannot protect themselves represents a severe breakdown in resident protection and regulatory compliance.

During a facility-wide power outage, a resident fell and sustained a laceration requiring emergency care after emergency lighting systems had been removed from resident apartments during renovations and not replaced, violating the resident's care plan requirement for adequate lighting. The facility had emergency lighting functioning in hallways and common areas, but failed to maintain it in at least two resident units. The facility immediately responded by calling 911 for the injured resident and initiated a plan to restore emergency lighting to all apartments, demonstrating appropriate corrective action though the systemic failure represented a serious lapse in safety protocol during renovations.

The facility had seven uncorrected repeat deficiencies from a prior May 2023 inspection, including failure to respond to resident call lights (causing actual harm and discomfort), inadequate staff TB screening and orientation, pet health documentation gaps, and missing dietary standards. The facility failed to correct any of these violations within the 2-month period between inspections, demonstrating inadequate response and systemic compliance failures. Civil fines totaling $2,100 were imposed due to continued non-compliance placing 75 residents at ongoing risk across multiple safety and care domains.

The facility failed to correct fire and life safety code violations after two independent inspections by the Washington State Fire Marshal, demonstrating a pattern of non-compliance with critical safety systems. Multiple follow-up inspections (December 2021, February 2022, August 2022) were required, indicating persistent issues. The facility did eventually respond to citations and submitted correction plans as required, but the repeated failures and extended timeline (spanning 8+ months across multiple inspection cycles) reflect slow corrective action and inadequate initial response to life-safety concerns.

The facility failed to ensure medication administration records matched actual dosages in the cart and failed to ensure all staff administering medications were properly nurse-delegated, resulting in a resident receiving an incorrect dose of as-needed medication. The investigation identified systemic issues with medication management processes and staff credentialing. While the facility's response is not explicitly detailed in the report, citations were written indicating acknowledgment of the violations, though the adequacy of corrective actions cannot be fully assessed from the limited information provided.

The facility had multiple serious violations including failure to provide required PPE during a COVID outbreak affecting 27 of 83 residents/staff, medication errors involving borrowing narcotics between residents without family notification, and outdated care plans/service agreements not reflecting current resident needs. The facility conducted investigations and acknowledged deficiencies, with the Executive Director stating proper protocols should be followed, but corrective actions were incomplete - this was a recurring infection control violation previously cited, indicating systemic issues remain unresolved despite prior opportunities for correction.

The facility failed to ensure a resident had antipsychotic medication available, placing the resident at risk for psychological harm. This represents a serious pattern of non-compliance as it was an uncorrected repeat violation previously cited in December 2022. The facility's response was inadequate, as evidenced by the failure to correct the deficiency after the initial citation, resulting in a $300 civil fine and follow-up enforcement action. The repeat nature and medication management failure affecting a vulnerable resident with mental health needs indicates systemic failure in medication oversight protocols.