Ambitions of WA INC (King County)

The facility failed to secure Client 1's medications in a locked cabinet as required, with the key left inserted in an unlocked cabinet in a shared living area, creating risk of unauthorized access. The violation affected a client with documented need for locked medication storage per their care plan. The facility acknowledged the violation during the investigation and their medication assistance policy was already in place, indicating awareness of requirements. The deficiency was documented with a clear citation and the facility was required to submit a plan of correction, though the investigation report does not detail specific corrective actions taken beyond the acknowledgment.

Multiple severe violations occurred during a behavioral incident on 06/01/2025 where Client 1 was physically restrained by staff for unclear duration, resulting in head injuries and bruises requiring emergency room evaluation. Staff failed to call behavioral support services per protocol, administered refused medication via law enforcement after client had calmed, left Client 2 unsupervised despite requiring 2:1 staffing, and failed to document restraint use or collect required behavioral data. The facility conducted an internal investigation and suspended involved staff pending review, but failed to ensure proper medical assessment immediately after the incident, did not adequately document injuries or restraint details, and lacked systematic data collection for behavior support plans as required.

The inspection revealed multiple serious violations including failure to report resident elopement to authorities, staff performing non-delegated nursing tasks, water temperatures exceeding safe limits (up to 145.9°F creating burn risk), and systematic failures in financial account reconciliation for all sampled clients. The facility demonstrated moderate response with acknowledgment of issues and some corrective actions (water temperature adjustments, alarm improvements), but the response was reactive rather than proactive, with gaps in staff training and monitoring systems. A follow-up inspection on 03/08/2024 confirmed all deficiencies were corrected, indicating eventual compliance but revealing systemic weaknesses in oversight and staff competency that required regulatory intervention to address.