Sails Washington Inc. (King)

Staff repeatedly left a client with cognitive impairments alone in their apartment to retrieve lunch from their vehicle, violating the client's Person Centered Support Plan requiring line-of-sight supervision at all times. The client locked staff out during one incident on 01/03/2025, and staff left the client alone again on 01/04/2025, placing the client at risk of injury, elopement, and inability to summon emergency services. The facility's response was inadequate—management was aware of the incidents but failed to file incident reports, rationalized the violations by claiming staff remained 'on property,' and demonstrated no evidence of corrective action, staff discipline, or systemic changes to prevent recurrence.

The facility failed to maintain accessible and updated Individual Instruction Support Plans (IISPs) for both residents, with one plan dating back to 2022 and another removed from the home entirely. One resident was discharged from hospital with a feeding tube but their IISP was never updated to reflect this significant care change. The facility acknowledged the violations and had some oversight procedures in place (the plan was removed for review), but the response was incomplete with delayed corrective action and gaps in ensuring staff had real-time access to current care instructions.

The facility failed to administer prescribed post-surgical eye medications to a resident on multiple occasions in November 2023, including missing four consecutive doses of anti-inflammatory drops and incorrectly withholding glaucoma medication due to an eye patch when medical guidance required patch removal for administration. The ophthalmologist confirmed these missed medications posed risk of harm following eye surgery. The facility acknowledged the medication errors during investigation but could not provide explanation as the responsible staff member had left employment, demonstrating an incomplete investigation with no evidence of systemic corrective actions or staff retraining to prevent recurrence.

This investigation identified 14 serious allegations including neglect of health/hygiene, multiple medication errors (residents without medications for over a month), alleged physical abuse (staff slapping resident), inappropriate restraint use, financial mismanagement, bruises of unknown origin, and failure to provide specialized diets. The facility critically failed to cooperate with the investigation by repeatedly refusing to provide requested client records despite numerous requests over 5+ months (October 2023-March 2024), preventing regulators from completing their investigation and placing all 8 residents at ongoing risk. The facility's response was grossly inadequate, with administrators acknowledging record requests but failing to produce documentation, citing poor record-keeping practices and former employee departures, demonstrating systemic organizational failure and obstruction of regulatory oversight that left serious safety allegations unresolved.

The inspection identified multiple moderate violations including lack of bathroom privacy for clients with cognitive disabilities, unauthorized storage of a client's personal property in a locked room without consent, water temperatures exceeding safe limits (125°F), incomplete financial record-keeping for vulnerable clients, missing refusal documentation for medical appointments, and unsecured hazardous chemicals and sharps accessible to a client with pica and blindness. The facility responded appropriately by immediately correcting most issues during the inspection: installing locking doorknobs, obtaining guardian consent, adjusting water temperature, securing all hazardous materials, and scheduling emergency staff retraining. While the violations represented a pattern of procedural non-compliance affecting care quality and client dignity, no actual harm occurred and the facility demonstrated prompt corrective action when deficiencies were identified.