Cogir Queen Anne

The facility failed to ensure a resident received prescribed medications as ordered, with medications found left unattended in the resident's apartment rather than administered by staff. This represents a pattern of non-compliance, as staff acknowledged this was not the first such incident and the violation was previously cited in 2022. The facility's Health and Wellness Director was unaware of the incident until the inspection, indicating inadequate internal monitoring. The facility acknowledged the deficiency and committed to corrective action by June 6, 2025, with a follow-up inspection on June 27, 2025 confirming all deficiencies were corrected.

The facility took eight residents (including two assisted living residents) on an overnight trip with only activity staff present, with no nurse or caregiver accompanying them. While the ALF residents were largely independent and took pre-packaged medications, the activity staff lacked required CPR and First Aid certification for off-premises outings with ALF residents. The facility's response was adequate, as they had policies in place for medication management during trips and conducted a proper investigation, though the initial lack of certified staff on the outing and communication gaps (one resident not signing out) indicate procedural weaknesses that were appropriately cited.

This inspection identified multiple moderate violations including delayed call light responses (15-60+ minutes causing resident discomfort and soiling), incomplete assessments for residents with diabetes and anticoagulant medications, missing tuberculosis testing documentation, expired background checks, and unsigned service plans. The facility demonstrated a good response by promptly correcting all deficiencies within the 45-day window, as confirmed by the follow-up inspection on 10/14/2024 showing full compliance. While systemic documentation and care coordination gaps existed, no immediate life-safety threats were present, and the facility took appropriate corrective action across all cited areas.

The facility violated food sanitation requirements by failing to properly label and discard expired refrigerated and pre-packaged foods, placing 84 residents at risk for foodborne illness. This is a recurring deficiency cited three times (June 25, July 15, and August 22, 2024) before escalating to a $700 civil fine on September 20, 2024. The facility's repeated failure to correct this violation demonstrates inadequate response and systemic non-compliance with food safety protocols. While the violation represents a moderate health risk rather than immediate life-threatening danger, the pattern of recurrence and lack of sustained corrective action resulted in regulatory enforcement.

The facility failed to properly discard expired ready-to-eat foods, with items found 6-10 days past their 7-day discard date, placing 80 residents at risk for foodborne illness. This is a recurring violation previously cited in June and July 2024, indicating a pattern of non-compliance with food safety protocols. The facility conducted retraining after initial complaints and the administrator acknowledged the violations during inspection, but the recurrence demonstrates incomplete corrective action and inadequate monitoring systems. No actual foodborne illnesses were reported, and the initial investigation showed the facility conducted appropriate inquiry into food safety complaints, though follow-through on systemic corrections was insufficient.

The facility repeatedly failed to discard refrigerated ready-to-eat foods within the required 7-day timeframe, placing 80 residents at risk for foodborne illness. This represents a severe violation as it is the third occurrence of the same food safety deficiency (June 25, July 15, and August 22, 2024), demonstrating a pattern of systemic non-compliance. The facility's response has been inadequate, with the same violation recurring despite two previous citations, resulting in escalation to a $500 civil fine. The continued failure to implement effective corrective measures indicates poor response quality and management oversight.

The facility failed to ensure ready-to-eat foods in one kitchen were properly labeled, dated, and safe for consumption, placing 84 residents at risk for foodborne illness. This violation was particularly concerning as it was an uncorrected repeat deficiency previously cited on June 25, 2024, resulting in a $300 civil fine. The facility's response was inadequate, as evidenced by the failure to correct the issue after the initial citation, demonstrating insufficient attention to food safety protocols and systemic compliance failures.

The facility had two serious violations: failure to implement a complete Respiratory Protection Program during a COVID outbreak (four staff lacked current N95 fit testing) and repeated failures of fire safety inspections (three consecutive failures over three months). The facility had infection control systems and policies in place but failed to fully implement critical respiratory protection requirements during an active outbreak. While basic systems existed, the delayed response to fire safety compliance and incomplete infection control implementation demonstrates inadequate corrective action and systemic gaps in safety protocols.

This residential care facility had recurring fire safety and documentation violations across multiple inspections from August 2023 through March 2024, including missing emergency evacuation drill records, lack of smoke alarm testing documentation, missing fire emergency plans, electrical hazards, and improper storage in mechanical rooms. The violations represent systematic compliance failures affecting fire safety preparedness rather than immediate life-threatening conditions. The facility demonstrated a good response by correcting all violations by the March 2024 inspection, receiving approval status after three consecutive disapprovals, indicating commitment to addressing the identified deficiencies despite the initial pattern of non-compliance.

Multiple complaints were investigated at this 94-bed assisted living facility, revealing a pattern of medication management failures including unavailability of prescribed medications for multiple residents (NR1, NR3, NR20) and improper narcotic destruction without discontinuation orders. Additional issues included extended call light response times for residents needing assistance and brief periods where residents went without ordered medications. The facility conducted investigations and had systems in place for most care processes, with assessments and service agreements documented, though corrective actions for medication availability and call light responsiveness were incomplete at the time of investigation, resulting in citations for failed provider practices.