Cristwood Retirement Community

The facility failed to renew a Washington state background check for one Certified Nursing Assistant Mentor for over one year (expired 07/20/2023, renewed 07/29/2024), which meant a staff member worked with 69 residents without current background verification. The facility promptly renewed the background check on the first day of the inspection and conducted a follow-up inspection on 08/30/2024 confirming all deficiencies were corrected. While the lapsed background check represented a procedural compliance failure with potential safety implications, the facility's immediate corrective action and successful follow-up inspection demonstrated an adequate response to address the violation once identified.

The facility failed to obtain prescribed medications in a timely manner for 3 of 3 sampled residents, with medication gaps ranging from 8-15 days in April 2024, primarily affecting eye drops for residents with medical conditions. The facility's policy required medication orders 5-7 days before running out, but staff waited until medications were depleted before contacting the pharmacy. The facility acknowledged the systemic failure, identified that medication technicians did not follow notification protocols, and the follow-up inspection on July 26, 2024 found all deficiencies corrected with no new violations, demonstrating effective remediation.

The October 2023 inspection identified four moderate fire safety documentation and maintenance violations: missing annual fire wall inspection records, missing fire shutter test documentation, a kitchen fire door that failed to latch, and missing 3-year dry sprinkler system test records for the Poplar building. The facility responded appropriately by correcting all violations within the 30-day reinspection period, as confirmed by the November 2023 follow-up inspection showing full compliance and approved status.

The facility failed to serve prescribed mechanical soft diets to two residents with swallowing difficulties, serving whole sausage links and bacon strips instead of properly modified textures. This created actual choking and aspiration risk for vulnerable residents requiring dietary modifications. The facility acknowledged the violations, corrected the deficiencies within the specified timeframe, and passed follow-up inspection on 06/08/2023 with no findings, demonstrating adequate corrective action and compliance restoration.