The Cannon House

On August 19, 2025, a sprinkler system air compressor failure caused the fire alarm to activate at The Cannon House, and neither facility staff nor responding firefighters could silence the alarm or reset the sprinkler system, requiring a fire watch until a technician arrived over two hours later. The facility appropriately implemented fire watch procedures and coordinated with the fire department, but the September inspection revealed missing documentation for disaster drill policies, fire watch procedures, and the incident report itself. The facility corrected all violations by the October follow-up inspection, demonstrating adequate responsiveness to regulatory requirements, though the initial lack of written emergency procedures and the extended system downtime (4:30 PM to 6:40 PM) represent moderate compliance gaps.

A sprinkler system air compressor failure triggered both the sprinkler dry system and fire alarm on 8/19/2025, requiring fire department response and a 2+ hour fire watch until repairs were completed at 6:40 PM. Residents expressed serious concerns about evacuation procedures for wheelchair-bound individuals when elevators become inoperable during alarms, revealing inadequate emergency planning. The facility conducted an investigation and worked with the fire department, but the inspection revealed systemic gaps: missing disaster drill policies/procedures, no formal fire watch protocols, and incomplete documentation of the incident, resulting in facility disapproval and required corrective actions by 10/20/2025.

The facility failed to notify a resident's representative and physician when the resident experienced significant health decline requiring emergency hospitalization, leaving family unaware of the resident's condition and location until the resident called from the ER. The facility promptly investigated multiple complaints, appropriately addressed allegations of rough handling and inadequate monitoring (finding no violations), and corrected the notification deficiency by the follow-up inspection, demonstrating adequate corrective action and systems improvement.

The facility failed to ensure proper Nurse Delegation was completed for three residents before non-licensed staff administered skilled treatments and medications, placing residents at risk of harm from untrained staff. This is a recurring violation previously cited three times (October 2024, December 2024, March 2025), demonstrating a pattern of non-compliance with fundamental medication safety requirements. The facility's response has been inadequate, as evidenced by the recurring nature of violations and resulting $1,000 civil fine for failure to correct systemic issues. The repeated violations indicate the facility has not implemented effective corrective actions despite multiple citations for the same life-safety issue.

The facility failed to ensure proper nurse delegation was completed before a resident received skilled nursing treatments from non-licensed staff, creating significant risk of harm. This violation is particularly serious as it represents an uncorrected, recurring deficiency previously cited in October and December 2024, demonstrating a systemic failure in medication administration safeguards. The facility's response has been inadequate, evidenced by the recurring nature of the violation across three consecutive inspections, resulting in an $800 civil fine and escalating regulatory action. The pattern shows the facility has not implemented effective corrective measures despite multiple opportunities.

The facility had multiple fire safety code violations including missing annual inspections for fire doors and sprinkler systems, loaded sprinkler heads in the kitchen and dining room, and an uninspected vertical rolling door at the bottom of stairs. The facility responded appropriately by acknowledging the violations and committing to investigate and establish proper inspection schedules. A follow-up inspection on 02/05/2025 confirmed all violations were corrected, demonstrating timely remediation and good compliance with corrective action requirements.

The facility failed to maintain proper food service temperatures, with residents reporting meals served warm instead of hot and observations confirming service below recommended temperatures, violating WAC 388-78A-2300(1)(d). This represents a pattern of non-compliance affecting resident comfort and food safety across multiple meal services. The investigation involved appropriate sampling of residents, staff interviews, and direct observations of kitchen operations. A citation was issued, though the report does not detail specific corrective actions taken by the facility beyond the investigation findings.

The facility failed to ensure proper nurse delegation was completed before a resident received injections or skilled treatments from non-licensed staff, placing the resident at risk of harm. This is a repeat violation previously cited on October 10, 2024, resulting in a $400 civil fine. The facility's response was inadequate, as evidenced by the uncorrected deficiency persisting for over two months despite prior citation. The pattern of non-compliance with medication administration protocols represents a serious systemic failure in ensuring qualified staff provide skilled nursing services.

The facility failed to administer prescribed seizure medications to a resident, potentially contributing to a seizure requiring hospitalization. This represents a severe violation given the actual resident harm and is particularly concerning as this is a recurring medication administration deficiency cited seven times since February 2022. The facility's response demonstrates systemic failure, with repeated violations indicating inadequate corrective actions and no meaningful improvement despite multiple prior citations. A $1,200 civil fine was imposed due to the recurring nature and serious consequences of the violation.

The facility had multiple severe violations involving medication errors and delayed emergency response. Staff gave incorrect medication doses to a resident who then had seizures, and when found on the floor, the resident waited over 3 hours before 911 was called. The facility acknowledged the incidents and took some corrective action, but failed to properly document the medication error and demonstrated systemic failures in following their own policies and physician orders. The inadequate response to a resident's health crisis represents a serious lapse in care standards.

The facility had three deficiencies identified during the February 2024 inspection: failure to maintain a Respiratory Protection Program with current medical evaluations and fit-testing for staff (potentially exposing 59 residents to COVID-19 risks), incomplete national fingerprint background checks for 2 of 6 sampled staff, and missing Washington State background checks for 5 of 6 sampled staff. The facility immediately began corrective actions, completed all required background checks and fit-testing scheduling, and successfully corrected all deficiencies by the April 2024 follow-up inspection with no remaining violations found.

This inspection found severe medication administration failures affecting two residents, including one resident receiving unauthorized medication and another not receiving full dosages potentially leading to hospitalization. Most critically, the facility delayed calling EMS for 3 hours and 45 minutes after a resident fell and became unresponsive, placing the resident at serious risk of harm. The facility has demonstrated a pattern of non-compliance with five previous citations for medication violations between 2022-2023, indicating inadequate corrective actions and systemic failures in medication management and emergency response protocols.

The facility failed to complete annual assessments for 2 of 3 sampled residents, with assessments over a year overdue, placing residents at risk of unmet care needs. This was a repeat deficiency previously cited in June 2022. The facility acknowledged the violation, submitted a plan of correction with monitoring systems by the January deadline, and the March 2024 follow-up inspection found full compliance with all requirements corrected.

This routine inspection by the Washington State Patrol Fire Protection Bureau found no violations at The Cannon House residential care facility. The facility demonstrated full compliance with fire safety regulations, requiring no corrective actions. The facility's maintenance of adequate fire protection systems and safety standards reflects good operational practices and commitment to resident safety. This represents a baseline standard of competent facility management with no issues requiring remediation.

The investigation found medication assistance violations but the primary allegation regarding blood pressure equipment was unsubstantiated. The facility had both manual and automatic blood pressure equipment available and used manual equipment for the Named Resident as appropriate. While two citations were issued for medication-related compliance issues, the facility demonstrated adequate equipment availability and proper use of vital sign monitoring equipment for residents requiring manual measurement.

The facility failed to follow physician's orders to hold a resident's medication when blood pressure was below prescribed parameters, placing the resident at risk of health complications from hypotension. This is a recurring violation, previously cited three times in 2022-2023, demonstrating a pattern of systemic non-compliance with medication administration protocols. The facility's response has been inadequate, as evidenced by the repeated citations for the same issue over 18 months, resulting in a $600 civil fine. The lack of sustained corrective action despite multiple prior citations indicates minimal effectiveness in addressing this serious medication management deficiency.

The facility failed its second consecutive fire and life safety inspection, with two uncorrected violations from a previous inspection remaining outstanding after 33 days. The violations relate to fire safety systems requiring contractor repairs. The facility's response was inadequate, with bids for repairs awaiting corporate approval rather than being expeditiously completed, demonstrating delayed corrective action on critical life-safety issues. A citation was issued under WAC 388-78A-2040.

Initial inspection on 01/25/2023 revealed severe systemic failures in critical life-safety systems including non-functional emergency lighting and exit signs, fire doors that would not close/latch, uncorrected sprinkler system deficiencies from multiple prior inspections, and widespread lack of required documentation for fire safety equipment testing. The facility demonstrated a pattern of neglecting essential fire protection maintenance that created substantial risk to resident safety during emergencies. The facility responded adequately by correcting most violations within four months, though two critical issues (fire/smoke dampers needing repair and failed sprinkler system requiring fixes) remained outstanding at the final May 2023 inspection, indicating incomplete follow-through on the most significant system failures. The progression from 12 violations to full approval demonstrates commitment to compliance, but the initial state of disrepair and lingering critical system issues reflect inadequate preventive maintenance protocols.

The facility made systematic medication errors by giving a resident double doses of lorazepam (anti-anxiety medication) on 26 occasions over six weeks, causing the medication to run out twice and leaving the resident without medication for six days total. Staff admitted they did not follow the MAR and relied on memory instead of checking orders. The facility conducted a thorough investigation led by the LPN who identified the root cause, documented the timeline of errors, and determined which staff were involved, though the report does not detail all corrective actions taken beyond the investigation itself.