Amber Waves Alf LLC

Staff C, working as a cook/caregiver for 415 days, lacked required 70-hour training and Home Care Aide certification to provide feeding assistance.

Staff A had background check results that required a Character, Competence, and Suitability (CCS) review, which was never completed.

Staff D (Activities/Housekeeper) did not have a Washington state name/DOB background check or a national fingerprint background check completed.

Facility failed to ensure menus were posted for residents and failed to ensure menu items were not repeated for at least three weeks.

Staff B failed to sanitize hands between tasks (handling food, medication, and cleaning), potentially causing cross-contamination.

Staff F had not had a new background check completed in 1,132 days (required every two years).

Facility failed to identify, evaluate, and obtain a nursing assessment for Resident 1 following a change in condition/injury.

Facility failed to develop policy for on-going assessments, monitoring well-being, NSA content, and failed to implement investigation of incidents policy for 2 sampled residents.

Facility failed to evaluate and take appropriate action for changing needs of Resident 1, including monitoring after a catheter removal and a fall.

Facility failed to develop Negotiated Service Agreements (NSA) that documented defined roles and responsibilities for staff to address identified risks, needs, and behaviors for Residents 1, 2, and 3.

Failed to identify, evaluate, and take appropriate action to complete an assessment for two residents who had a change in condition or required the intervention of a medical practitioner.

Failed to ensure negotiated service agreements documented defined roles and responsibilities for care staff to address identified risks and care needs for two residents.

Failed to ensure policies and procedures were developed for on-going assessments, monitoring residents’ well-being, and negotiated service agreement contents.

Correction verified for previously cited fire suppression system interruption and fire watch failure.

Correction verified for coordination with first responders.

Correction verified for disaster plan update.

The facility failed to maintain a current disaster plan. Staff were unable to locate the manual during inspection, and the existing plan lacked required policies for internal disasters (water leaks, fire suppression failure) and fire watch procedures.

Correction verified for emergency assistance provisions.

Facility failed to develop Negotiated Service Agreements (NSA) that documented defined roles and responsibilities for care staff to address identified risks, needs, preferences, and behaviors for three residents.

Facility failed to ensure 6 of 8 staff and 1 volunteer had current, required background checks/national fingerprint checks.

Main exit door was obstructed by three recliner chairs and a small end table; exit from the resident room through the laundry room was obstructed by a twin bed.

Codes to the exit doors on the upper level were not updated/operable and were obstructing emergency egress.

Ceiling breach due to sprinkler pipe burst was initially covered with cardboard.

Quarterly service report dated 02/09/2024 was illegible.

Sprinkler pipe burst on Jan 17, 2024, causing a 6' x 8' ceiling breach; system was out of service for 90 minutes.

Incomplete documentation for annual fire alarm service; noted smoke detector deficiency.