Evergreen Inn, the

Facility failed to ensure 3 of 5 sampled staff (Staff D, F, and G) had required training/certification (Department of Health license) to work in an ALF.

Facility failed to complete two-step TB testing per regulation for 1 of 3 sampled staff (Staff F). Second step was not completed within one to three weeks of the first.

The licensee failed to ensure that one staff member had the required training and certification to work in an assisted living facility when this staff member had been caring for residents outside of the 200-day requirement per regulation. This is an uncorrected deficiency previously cited on July 30, 2025.

Facility failed two consecutive fire inspections by the Washington State Patrol Fire Protection Bureau and failed to complete required fire door repairs in over a year.

Facility failed to follow physician orders for medication holds and restarts. Specifically, a resident's medication was held for 5 days instead of the ordered 1 day.

Failed to provide annual fire door inspection; resident room doors 211 and 511 damaged; basement door fails to latch; multiple doors found out of compliance during follow-up.

Facility failed to maintain fire rated construction in generator room.

Facility failed to provide annual generator inspection report.

Southside exit from basement has combustible storage that shall be removed.

Failed to update assessment for Resident 5 when they could no longer self-administer insulin.

Failed to develop systems for safe medication service; 3 of 4 residents had expired medications, and one was administered an expired medication.

Facility failed to ensure pets had current vaccination records from a licensed veterinarian.

Failed to document or take appropriate actions regarding Resident 5's repeated refusal of prescribed blood glucose checks and insulin.

Facility failed to have documentation of two-step TB testing in staff personnel files for 3 sampled staff.

Facility failed to ensure hot water was between 105-120 degrees Fahrenheit at all times.