Evergreen Court

Unannounced Fire and Life Safety Code re-inspection conducted to determine compliance.

Facility unable to provide documentation that monthly smoke detector testing had been performed and a report/log created. Inspection reports must verify no deficiencies exist or document corrections.

Facility unable to provide documentation of third quarter 2025 fire drill participation for all shifts.

Facility failed to provide documentation for fire alarm and fire detection system maintenance/testing; specifically missing reports for monthly smoke detector testing.

Facility failed to provide documentation for third quarter 2025 fire drills for all shifts.

Failed to complete required full assessment components for 1 of 7 sampled residents, risking harm from unidentified care needs.

Failed to notify and receive approval for the addition of 3 rooms (occupancy by Residents 8, 9, and 10), risking potential injury.

Facility failed to document in 1 of 7 resident service agreements a plan to monitor and address interventions for Resident 7's verbally aggressive behaviors and resistance to care.

The facility failed to ensure service plans were signed at least annually for 6 of 7 sampled residents.

The facility failed to ensure all 6 sampled staff were fit-tested for N95 respirators required for infection control during a COVID-19 outbreak.

The facility failed to submit a DSHS background authorization form for 1 of 6 staff within one day of hire.

Facility failed to notify and receive approval from the Department for the addition of 3 rooms to their licensed bed count and failed to submit a contract application.

Facility failed to document in 5 of 7 residents' service agreements a plan to monitor and address interventions for clinical needs.

Failed to ensure annual signatures on Service Plan Report for 1 of 7 sampled residents.

Facility failed to provide working ventilation fans in 4 of 5 rooms (men's bathroom, housekeeping/mop storage, common bathroom, and resident laundry room), placing residents at risk of diminished quality of life.

Facility failed to complete full assessments for 7 of 7 sampled residents that included required components like symptoms, medication side effects, or current medical equipment needs.

The facility failed to ensure 3 of 6 staff members were screened for tuberculosis within three days of employment.

The facility failed to maintain current veterinarian pet records, vaccinations, and health certifications for 3 of 3 pets residing in the facility.

Facility failed to complete and submit a DSHS background authorization form for 1 of 6 staff (Staff A) within one day of hire.

Facility failed to document in writing Resident 8's initial agreement to use electronic monitoring, the duration of use, and quarterly reevaluations.

Facility failed to provide working ventilation fans in 5 of 5 rooms and failed to secure 2 electrical panel access doors.

The facility failed to ensure one resident who required nurse delegation updated their verbal consent with a signed consent within 30 days as required.

The licensee failed to complete one resident's assessments that included the required full assessment components.

The licensee failed to ensure one resident or their representative, and a facility representative signed their Service Plan Report at least annually.

The licensee failed to notify and receive approval for the addition of three rooms and approval for occupancy.

The licensee failed to provide ventilation fans in four rooms that operated to provide proper air flow and ventilation to the outside of the facility.

The licensee failed to document in one resident's service agreements a plan to monitor and address interventions required to meet the current needs.

Storage found within 18 inches of sprinkler head in 1st floor storage room.

Combustible materials stored in 3rd floor stairwell.

Combustible materials stored on floor of electrical room.

Missing documentation for 12 fire drills across all shifts/quarters in the previous 12 months.

Open junction box found on 3rd floor electrical room.

Missing documentation for two semi-annual hood cleanings.

No schedule or documentation provided for annual inspection of fire-rated construction.

Room 163 and PPE room doors would not latch.

Missing records for 5-year internal pipe testing, 3-year dry system full flow trip test, annual trip test, annual forward flow test, 5-year FDC hydro testing, and quarterly inspections.

Missing records for semi-annual service of fire-extinguishing systems.

Missing documentation for monthly testing and maintenance of CO detectors.

Emergency lights not working in rooms 221, 227, and throughout stairwells.

Annual 90 minute power test had not been performed and documented.

Facility must establish a schedule for annual inspection of Fire Doors.

Missing annual report, sensitivity testing, and monthly fire alarm test documentation.

Exit sign on main floor by room 95 was non-functional.

30-second monthly activation testing had not been performed and documented.

Fire/smoke damper inspection will need to be performed and documented.

Facility cannot provide documentation for the completion of twelve planned and unannounced fire drills in the previous 12 months; multiple shifts missing across 4 quarters.

Missing records for 3-Year Dry System Full flow trip test and 5-Year forward flow test.

Annual fire door inspection documentation was not provided; the facility must establish and maintain an inspection schedule.

Facility failed to provide documentation/inventory of required fire-resistance-rated construction and needs to establish an inspection schedule.

Fire/smoke damper inspection documentation was not provided at the time of inspection.

Extension cord being used near bathrooms in lobby.

Annual inspection of fire-resistance-rated construction paperwork not provided.

Semi-annual servicing and annual replacement records not provided.

Fire extinguishers found on floors under reception desk and in activities office.

4-year inspection record not provided.

Fire drill report with participants listed not provided.

Daisy chain power strips found in activities room and break room.

Missing electrical box covers by resident room 143 and under steam table in dining room.

Hood in need of cleaning; cleaning schedule needs review.

2nd floor stairwell door, double doors to dining room, and kitchen door failing to latch automatically.

Monthly inspection log by facility maintenance not provided.

Monthly/annual testing records not provided; exit sign at 2nd floor room 143 not working.

Annual fire door inspection paperwork not provided.