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Source: WA Dept. of Social & Health Services
The document is a follow-up letter confirming that deficiencies cited in reports 76016 and 70804 were corrected.
The facility failed to ensure staffing ratios were met with properly credentialed mental health professionals.
The facility incorrectly assumed staff did not need pharmacy training due to having a nurse on-site.
Staff B did not have documentation of required First Aid training within 30 days of hire.
Failed to hold or document monthly person-centered service planning team meetings for 7 of 7 sampled residents.
Failed to provide copies of PCSPs to the department case manager and failed to obtain case manager signatures for 7 of 7 residents.
Staff A, B, C, and D lacked documentation of medication-related education and training provided by a licensed pharmacist.
Resident 4's initial PCSP was not signed by nursing staff or the department case manager.
Staff C completed national fingerprint background check 125 days after hire, exceeding the 120-day limit.
Staff B did not have documentation of TB testing upon hire.
There is a separate document dated 05/07/2026 indicating that these deficiencies were corrected. The 'Date correction will be completed' field in the POC document states 05/01/2026.
Facility failed to obtain case manager signatures or maintain signed PCSPs in files for 7 of 7 residents.
Facility failed to ensure 1 of 4 staff had a completed fingerprint background check within 120 days of hire (Staff C).
Facility failed to ensure all individuals on the PCSP team signed the initial comprehensive service plan for 1 of 7 residents.
Facility failed to ensure 1 of 4 staff (Staff B) was screened for TB upon employment.
Facility failed to ensure the PCSP team met at least monthly for 7 of 7 sampled residents.
Facility failed to ensure 4 of 4 staff received education and training by a licensed pharmacist on medication-related subjects.
Facility failed to ensure 1 of 4 staff (Staff B) completed First Aid training within 30 days of hire.
Next inspection scheduled on or after 04/11/2026. Approval Status: Disapproved.
Fire rated cross corridor door near room 10 failed to close and latch from fully open position.
Facility unable to provide documentation for annual 90-minute power test for emergency lights.
Annual fire alarm testing from 11/4/2025 has uncorrected deficiencies.
Facility unable to provide documentation for annual fire resistance rated construction material inspection.
Extinguisher near room 12 missed annual maintenance; extinguisher near kitchen removed due to broken shield.
Documentation for twelve fire drills missing; multiple specific shifts/quarters identified as missing.
Facility unable to provide documentation for annual fire door inspection.
Facility unable to provide documentation for monthly 30-second activation test for emergency lights.
Missing documentation for annual forward flow test and quarterly sprinkler system inspections.
This document is an IDR (Informal Dispute Resolution) results letter. The DSHS decided not to make any changes to the Statement of Deficiencies (SOD) report dated 01/21/2026. The facility is instructed to submit a Plan of Correction (POC) for the deficiencies identified in that report.
A follow-up inspection on 12/22/2025 found no new deficiencies and confirmed previous citations were corrected.
This is a scheduling letter for an Informal Dispute Resolution (IDR) meeting regarding a Statement of Deficiencies dated January 21, 2026. The meeting is scheduled for February 12, 2026.
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