Island House

The facility failed to update care plans with anticoagulant monitoring protocols for 4 of 4 residents on blood thinners, and failed to complete a timely full assessment for 1 of 7 residents. These documentation and procedural failures created potential risks but no actual harm occurred. The facility promptly acknowledged the deficiencies, with the Director of Health Services taking responsibility for the oversight, and corrected all issues within one month as verified by follow-up inspection, demonstrating good response with appropriate corrective measures.

The January 2025 inspection identified 11 violations related to fire safety documentation and maintenance, including missing fire drill records across all shifts, incomplete sprinkler and fire alarm system inspections, fire-rated construction penetrations, painted sprinkler heads, and a broken electrical receptacle. The facility promptly addressed all deficiencies, as confirmed by the March 2025 follow-up inspection showing full compliance. While the violations were primarily documentation-related with some maintenance issues, they represented a pattern of non-compliance across multiple fire safety systems requiring systematic correction.

The facility failed to provide a required discharge notice to a resident with dementia and elopement issues, notifying the family only via email without all legally mandated information including reason for discharge, effective date, destination location, and ombudsman contact details. The facility acknowledged the violation, submitted a plan of correction dated 9/9/24, and successfully corrected the deficiency as verified by a follow-up inspection on 10/22/24 that found no deficiencies. The violation represented a procedural failure affecting resident rights rather than immediate safety, and the facility demonstrated good compliance by promptly implementing corrective measures.

The facility was subject to a stop placement order prohibiting admissions from March 27, 2024 to April 23, 2024, indicating serious violations requiring immediate regulatory intervention to prevent further resident admissions. The underlying violations were significant enough to warrant a prohibition on new admissions, suggesting severe compliance failures or safety concerns. The facility successfully addressed the deficiencies within approximately one month, demonstrating adequate corrective action sufficient for the regulatory authority to lift the restriction. However, without details of the specific violations or corrective measures, the response reflects meeting minimum requirements rather than exemplary practice.

This inspection revealed severe and systemic life-safety violations including multiple fire doors that would not latch, blocked egress routes, blocked sprinkler heads, missing carbon monoxide detectors in multiple locations, and a non-functional special-purpose door required for egress. The facility failed to provide documentation for virtually all required safety inspections including fire drills, emergency lighting tests, fire alarm maintenance, sprinkler system testing, and fire door inspections spanning multiple years. The facility's response was grossly inadequate, demonstrating a pattern of non-compliance with fundamental fire and life-safety requirements with no evidence of corrective action or even basic maintenance of safety systems. The inspection status was 'Disapproved' reflecting the unacceptable condition of multiple critical life-safety systems.

The facility failed two consecutive fire and life safety inspections, with violations from December 2023 remaining uncorrected by February 2024, resulting in a Letter of Non-Compliance from the Deputy State Fire Marshal. This represents a severe life-safety violation affecting all 58 residents. The facility's response was inadequate, with the Maintenance Director only committing to corrections 'within a week or two' after the second failed inspection, demonstrating delayed action on critical fire safety systems. The facility was cited under WAC 388-78A-2040 for failure to maintain required fire safety standards.

The facility received a Stop Placement Order effective March 27, 2024, based on deficiencies identified during a March 14, 2024 inspection, indicating severe systemic compliance failures that prevent new admissions. The Stop Placement Order represents a serious regulatory action taken when violations pose significant risk to resident safety and care quality. The facility's response appears minimal, as evidenced by the Department's determination that conditions warranted preventing new placements, suggesting inadequate corrective action between the inspection and order issuance. No evidence of immediate corrective measures or comprehensive remediation plans is documented in this notice.

The facility failed Fire and Life Safety Inspections, placing 57 residents, staff, and visitors at immediate risk in the event of a fire. This violation is particularly serious as it represents the third occurrence of the same life-safety deficiency (previously cited in March 2023 and February 2022), demonstrating a pattern of systemic non-compliance with critical fire safety requirements. The facility's response has been inadequate, as evidenced by the recurring nature of identical violations over a two-year period, resulting in immediate stop placement orders and civil fines. The repeated failures indicate the facility has not implemented effective corrective actions or systemic changes to maintain compliance with fundamental life-safety standards required by the Washington State Patrol Office of State Fire Marshal.

The facility exceeded its licensed capacity of 55 residents by admitting 57 residents without department approval, and failed to ensure staff completed required health and safety training (CPR, TB screening). These are repeat violations previously cited on January 17, 2024, that remained uncorrected at the March 19, 2024 follow-up inspection, resulting in $1,000 in civil fines. The facility's failure to correct known deficiencies within the given timeframe demonstrates inadequate response and systemic compliance issues with staffing requirements and licensing regulations.

The facility failed their second fire and life safety inspection with nine uncorrected violations from a previous inspection three months prior, indicating a pattern of non-compliance with critical safety systems. The Administrator acknowledged the violations and stated they anticipated corrections would be completed by the next inspection, demonstrating awareness but slow corrective action. While fire safety violations present serious potential risk, there was no indication of imminent danger or actual resident harm, and the facility showed intent to remediate rather than denial or inaction.

This residential care facility had serious life-safety violations including malfunctioning fire doors, missing documentation for fire alarm/CO detector/generator inspections, insufficient fire drill records, and improper use of extension cords and multi-plug adapters. The facility demonstrated a good response by correcting all violations within approximately 45 days between the February 2023 re-inspection and the April 2023 approval, though the pattern of identical violations across multiple inspections (December 2022 and February 2023) suggests systemic documentation and maintenance issues that required external enforcement to address. The violations posed significant fire safety risks in a vulnerable population setting, particularly the malfunctioning fire door, fire alarm system in trouble mode, and lack of required safety system inspections.