Guardian Angel Homes (the Cottage)

The facility failed to implement effective systems for safe medication administration for 7 of 7 residents, resulting in multiple medication errors including missed doses, unauthorized administration, and failure to follow physician-ordered parameters.

Facility failed fire marshal inspections: gas appliances on casters lacked restraining devices; missing documentation for annual forward flow test; missing quarterly sprinkler system inspections; technician for 10/09/2025 inspection lacked proper certifications.

Licensee failed to ensure staff had a valid Washington state name and date of birth background check completed every two years for one staff member.

Facility failed to ensure required DSHS background authorization forms were submitted every two years for 2 of 3 staff members.

Staff E and F did not have current Washington state name and date of birth background checks in their personnel files. Facility failed to ensure staff completed HCA application within 14 days, 70-hour training within 120 days, and developmental disability specialty training for multiple staff members.

Facility failed to ensure prescribed medications were obtained in a timely manner for 3 of 9 residents, resulting in missed doses of propranolol, nystatin powder, and alendronate.

Facility failed to investigate and document circumstances regarding resident-to-resident incidents and falls for Residents 2 and 6, or implement preventative measures.

Facility failed to develop systems to ensure nursing services were provided as ordered, specifically blood sugar monitoring for Resident 5 and daily wound care for Resident 6.

The facility failed to maintain current immunization and examination documentation for resident pets.

The facility failed to follow their emergency preparedness plan and notify the fire department during a fire incident, and failed to maintain documentation for a required fire watch when the fire protection system was out of service.

Facility was unable to provide documentation of a fire watch while a required fire protection system was potentially out of service.

Facility staff failed to follow the emergency preparedness plan and did not notify the fire department after a fire occurred in the generator transfer switch panel.

The facility failed to ensure agency staff had access to resident records and were properly trained and oriented, leading to an agency caregiver being unaware of a resident's fall risk and transfer status, contributing to a fall incident.