Garden Courte Alzheimer Community

The facility failed to ensure staff documented mandatory safety checks for 3 residents following falls, and failed to ensure a timely urine sample was collected for a resident.

Facility failed to ensure a urine analysis (UA) sample ordered for R3 was collected and processed in a timely manner. The sample was left in a laboratory box and not picked up, causing a delay in treatment for R3's medical condition and potential contribution to falls.

Facility failed to document and determine investigative findings to rule out abuse or neglect for 2 of 2 residents reviewed with injuries of unknown origin.

Facility failed to evaluate and implement new preventative interventions after resident falls for 4 of 4 residents reviewed, failing to communicate these interventions to floor staff.

The licensee failed to take actions after falls occurred in the community which resulted in injuries for two residents reviewed, placing residents at risk for repeated falls and injury. This is an uncorrected deficiency previously cited on December 4, 2024.

The licensee failed to document and determine the investigative findings to rule out the possibility of abuse or neglect, and failed to document preventative measures to prevent recurrence, for two residents.

The facility failed to report allegations of sexual abuse involving a staff member and two residents to the Department in a timely manner.

Department found that deficiencies for this regulation were corrected.

Facility failed to properly secure medications in a locked compartment, resulting in a resident with memory loss consuming another resident's medication.

Failed to complete 30-day Service Plan Agreements for 3 newly admitted residents.

Facility failed to maintain a current, publicly accessible binder of inspection results.

Facility failed to maintain a safe, sanitary, and well-maintained environment (e.g., missing flooring, exposed raw wood). Note: Also lists a separate incident of a hole in a bathroom floor and damaged floor in South dining room.

Failed to have updated service plan agreements for Residents 1 and 2.

Failed to allow resident access to their rooms at all times; doors were found locked.

Failed to secure potentially hazardous supplies accessible to memory care residents.

Facility failed to secure oxygen cylinders properly and fire safety doors were propped open with various items (rubber wedges, wood blocks), creating fire safety risks.

Improper food storage/labeling (items on floor, open bags), unclean equipment (ice machine), and staff failed to perform proper hand hygiene/glove usage.

Failed to ensure 3 new staff members were screened for TB with the required two-step skin testing.

Failed to have Registered Nurse (RN) delegation written consent for Resident 1 and failed to document evaluation for new medication technicians regarding insulin administration.

Failed to maintain safe hot water temperatures (between 105F and 120F); observed temperatures as high as 127.0F.

Failed to ensure staff completed required orientation training and documentation.

Facility failed to ensure fire extinguishers were serviced timely and failed to keep fire/smoke barrier doors closed, with doors propped open by various objects.

Facility failed to provide a call system/pull cord in living areas for sampled residents to summon staff.

Issues with food storage/labeling, improper cleaning of kitchen areas, staff observed cross-contaminating food with gloved hands, and expired food handler cards for staff.

Facility failed to have the most recent inspection results publicly posted and accessible to residents and visitors.

Facility failed to complete a character, competence, and suitability (CCS) determination for 5 staff members before they were cleared to work.

Facility environment was not kept in a safe, sanitary, and well-maintained condition; includes unsanitary bathrooms, water leaks in ceiling, and trash/debris around exterior dumpsters.

Staff failed to perform hand hygiene and dragged soiled linen/trash bags on the floor, placing residents at risk for cross-contamination.

Facility failed to document medication administration (injections) on the MAR, resulting in inaccurate records.

Facility failed to provide a copy of the disclosure of services to family or resident representatives for 4 of 9 sampled residents upon admission.

Facility failed to administer medications as ordered by the physician for 2 of 2 residents (R10 and R11).

Facility failed to follow physician-ordered blood pressure parameters for R6 and R10, and failed to notify the physician for R11's out-of-range blood sugar readings.

Facility failed to allow residents access to their own rooms without staff assistance; doors were found locked automatically from the outside.

Facility failed to secure hazardous materials (bleach wipes, ointments, lotions) accessible to memory care residents.

Staff entered resident rooms without knocking or announcing themselves; facility also restricted families from visiting during mealtimes.

Facility failed to complete a 30-day service agreement for Resident 8.

Facility failed to post state agency/ombudsman contact information in areas accessible to residents, visitors, and staff.

Facility failed to ensure 3 of 4 sampled staff had updated Washington State background checks every two years.

Facility failed to ensure 4 of 7 sampled staff were screened for tuberculosis with the required two-step skin testing.

Facility failed to maintain confidentiality of resident records (papers left in hallway) and secure computer screens with resident information on medication carts.

Facility failed to have Registered Nurse delegation services and documentation in place for sampled residents, risking care by untrained staff.

Facility failed to have resident service plan agreements updated with the most accurate information.

Facility failed to have prescribed medication available for R10, resulting in the administration of another resident's medication.

Facility failed to dispose of medications for residents who no longer resided there, administered expired insulin, failed to follow physician orders for medication parameters, and administered medications not prescribed to the resident.

Facility failed to maintain safe water temperatures (105-120F) in resident rooms, with readings as high as 129.9F.

Facility failed to ensure staff completed required orientation training, safety training, and continuing education.

Facility failed to implement disaster policies during a gas leak; staff continued to work in the area rather than evacuating.