Overlake Terrace

The facility had multiple moderate violations across safety and compliance areas: lack of lockable storage for 3 residents with self-administered medications, unsecured hazardous cleaning chemicals on housekeeping carts and in memory care units, incomplete staff training (4 of 4 staff lacking required dementia/mental health/CPR/continuing education), and improper assessment and maintenance of bed rails for multiple residents creating entrapment risks. The facility responded appropriately by conducting immediate audits, purchasing and installing locks, securing all hazardous materials, scheduling mandatory staff training, educating families on bed rail risks, ordering protective covers, and implementing quarterly audit systems across all deficiency areas. All corrections were completed or scheduled by the follow-up inspection on 2/7/2025, which found no remaining deficiencies.

A medication administration error occurred when staff gave a blood thinner (Eliquis) three days earlier than ordered at the previous higher dose to a resident recently hospitalized for rectal bleeding, resulting in rehospitalization for worsening bleeding. Staff failed to follow facility medication policies by not clarifying discrepancies between physician orders and pharmacy records before administration. The facility promptly investigated, acknowledged the failure in their medication verification systems, and committed to corrective action including staff retraining and enhanced monitoring procedures.

The facility committed a minor procedural violation by storing the administrator of record's personnel file at the corporate office in Utah rather than on-site as required by regulation. This is a documentation compliance issue with no impact on resident safety or care quality. The facility's response was limited to acknowledging the location of the records without evidence of immediate corrective action to bring the file on-site, though the violation itself is administrative in nature.

The facility had a pattern of failing to complete required Washington state background checks and national fingerprint checks for multiple staff members across three separate compliance determinations (September 2023, November 2023). This included the Registered Nurse Delegator, Director of Operations, and contracted staff, placing residents at risk from personnel with unknown backgrounds. The facility conducted investigations and submitted background applications when deficiencies were identified, but the repeated nature of violations (including an uncorrected deficiency from September re-cited in November) indicates incomplete corrective action and inadequate monitoring systems. A January 2024 follow-up inspection confirmed all deficiencies were ultimately corrected.

The facility failed to ensure two staff members completed required Nurse Delegation training for medication and insulin administration, placing four residents at risk of medication errors and health decline. This is a recurring deficiency cited three times in 2023 (June, September, November), demonstrating a pattern of systemic non-compliance. The facility's response was inadequate, as evidenced by repeated failures to correct the same violation despite previous citations, resulting in escalating enforcement with an $800 civil fine. The persistent failure to implement effective corrective actions indicates poor response quality and lack of systemic change.

The facility failed to complete required Washington State background checks for two staff members, placing all residents at risk for potential abuse, neglect, or exploitation. This represents an uncorrected repeat deficiency previously cited on September 19, 2023, demonstrating a pattern of non-compliance with fundamental safety requirements. The facility's inadequate response to the initial citation necessitated a follow-up visit and civil fine of $400. The failure to correct this systemic issue after the first citation indicates minimal corrective action and insufficient commitment to compliance.

The facility failed to ensure two staff members completed required Nurse Delegation training for diabetes management, resulting in unqualified staff administering insulin injections to two residents. This placed residents at significant risk of medication errors and health decline. This was an uncorrected repeat deficiency previously cited in June 2023, demonstrating systemic failure to implement corrective actions. The facility's inadequate response to the initial citation resulted in a $400 civil fine and continued non-compliance over a three-month period.