Riverview Manor

The facility failed to conduct proper pre-admission assessments for residents, using an unqualified assessor in violation of WAC 388-78A-2080. This procedural violation occurred across multiple cases but did not result in immediate resident harm. The facility's response was adequate, with investigators finding that current residents received appropriate care and medication management, though the pre-admission process deficiency indicates a need for improved compliance with assessment qualification requirements.

The facility had systemic medication management failures affecting multiple residents, including failure to obtain medications timely, staff documenting medications as administered when they were unavailable, and residents missing doses of critical medications including heart and psychiatric drugs. This was a repeat citation from January 2025. The facility responded with immediate medication cart audits, staff retraining, implementation of daily MAR audits, and establishment of tracking systems with multiple staff oversight. All deficiencies were corrected by the November follow-up inspection.

The facility had multiple routine fire safety documentation deficiencies including missing annual sprinkler/fire alarm service records, unfused multi-plug adapters, unlocked electrical panels, missing fire drill documentation, and an office penetration. These were typical maintenance and recordkeeping issues with no immediate safety threat. The facility demonstrated an exemplary response by correcting all violations within two months across follow-up inspections on 6/5/25 and 7/1/25, with final approval granted after comprehensive remediation.

Initial fire inspection on 05/06/2025 identified multiple routine fire safety documentation and maintenance deficiencies including missing drill records, unlocked electrical panels, multi-plug adapter use, and lack of documentation for various fire system inspections and testing. Follow-up inspection on 06/05/2025 found only three remaining documentation issues. The facility corrected the vast majority of deficiencies between inspections and achieved full compliance by 07/29/2025, demonstrating a prompt and thorough response to fire safety concerns.

The facility had multiple routine fire safety documentation deficiencies including missing sprinkler system testing records, fire alarm service documentation, and fire drill records. Additional violations included unsecured electrical panels, improper multi-plug adapters, missing hood cleaning documentation, and a fire-rated construction penetration. The facility failed to correct these issues between the May and June inspections, with critical documentation violations remaining unresolved after a full month, demonstrating minimal corrective action and poor follow-through on compliance requirements.

The facility failed to obtain Home Care Aide certifications for two staff within required timeframes (248 and 81 days overdue), and failed to provide prescribed medications for a resident with depression, diabetes, and vitamin D deficiency for over four months. The facility responded with comprehensive corrective actions including hiring an office manager to track certifications, switching to a single pharmacy with cycle fill medication delivery, and implementing a triple-check medication verification system. All deficiencies were corrected by the March 2025 follow-up inspection.

A resident requiring mandatory two-person transfer assistance fell when a staff member attempted a solo transfer from shower to wheelchair, resulting in a right hip fracture requiring hospitalization, inpatient rehabilitation, and permanent discharge due to increased care needs. The facility conducted an immediate investigation confirming the caregiver failed to follow the negotiated service agreement, then implemented comprehensive corrective actions including auditing all resident care plans, enhancing fall risk assessments, establishing supervisor-led change notification protocols, and ongoing administrator audits. The follow-up inspection on 01/07/2025 found all deficiencies corrected and the facility in full compliance.

The facility failed to conduct frequent monitoring for a resident experiencing changes from their baseline functioning, violating requirements for identifying and responding to changes in residents' physical, emotional, and mental status. This represents a pattern of inadequate surveillance that could affect resident well-being. The facility responded appropriately by planning staff training on monitoring protocols and implementing safety checks in resident records. No plan-of-correction submission was required by the department.