Peters Creek Retirement Community

Required sprinkler documentation was not provided, including annual sprinkler, annual trip, annual forward-flow, quarterly inspection, five-year internal pipe, and five-year FDC hydrostatic test reports. Painted sprinkler heads were also observed in the first-floor dining room and kitchen.

The kitchen janitor closet door frame's fire-rated identification tag had been painted over.

The third-floor double doors near room 303, second-floor double doors by the residents' laundry, and the kitchen main door did not properly close and latch.

Two kitchen fire extinguishers were installed out of compliance with the required mounting height.

The annual forward-flow test report was not provided during the December 2025 and March 2026 inspections.

The kitchen janitor closet was missing a fire-rated door.

Semi-annual hood-cleaning documentation was not provided.

Kitchen hood cleaning frequency needed to be increased to every three months.

The first and second semi-annual automatic extinguishing-system service reports were not provided.

An annual fire alarm inspection report was not provided at the time of inspection.

Detailed documentation and maps of fire door locations, including annual inspection reports documenting testing dates, modifications, and repairs, were not provided.

Detailed documentation and maps of fire door locations, including annual inspection reports, testing dates, modifications, and repairs, were not provided.

The required annual 90-minute battery power test for emergency lighting had not been performed or documented.

Documentation was not provided for 12 planned and unannounced fire drills during the previous 12 months; drills were missing for the first, second, and third shifts in all four quarters.

Detailed documentation and maps of carbon monoxide detector locations, including monthly inspection reports documenting testing dates, modifications, and repairs, were not provided.

The facility did not provide detailed documentation and maps of fire-rated construction locations, including annual inspection reports, testing dates, modifications, and repairs.

Facility failed to ensure 2 of 4 newly hired staff completed TB one test requirements despite having completed blood tests.

Facility failed to secure housekeeping utility cart containing hazardous chemicals (disinfectant wipes, aerosol sprays) in the memory care unit.

Facility failed to ensure 1 of 1 pet on-site received regular veterinary exams and certification of being free of diseases transmittable to humans.

Resident 8 used a bed enabler with a 12-inch by 12-inch gap that posed an entrapment risk; staff attempted to cover the gap with a pillowcase, which was deemed inappropriate by the Director of Nursing.

Facility failed to ensure 5 of 15 sampled staff completed initial and/or second-step TB skin testing within required timeframes.

Memory care courtyard was unsafe due to an uncovered garbage can containing used incontinence products and an unsecured, unlocked storage box large enough for a human.

Facility failed to post or make menus available in the memory care unit.

The licensee failed to ensure three staff completed required continuing education.

This is an uncorrected deficiency previously cited on July 9, 2025.

Missing annual report for fire alarm and detection systems.

Missing semi-annual servicing reports for automatic fire-extinguishing systems.

Facility failed to provide documentation for 12 planned and unannounced fire drills across all shifts/quarters in the previous 12 months.

Facility failed to provide documentation and maps of carbon monoxide detector locations and monthly inspection reports.

Annual 90-minute power test for battery-powered emergency lighting had not been performed and documented.

Specific doors (double doors #50, laundry breeze way, kitchen main door) failed to latch; kitchen janitor closet missing fire-rated door; fire tag painted over; lack of required documentation and maps for fire doors.

Missing documentation for two semi-annual hood cleanings; facility needs to increase cleaning frequency to every 3 months.

Two fire extinguishers in the kitchen were found to be out of compliance.

Missing annual forward flow test documentation; missing annual sprinkler system report; painted sprinkler heads in 1st floor dining room and kitchen.

Facility failed to maintain detailed documentation and maps of fire-rated construction locations and maintenance records.

Required inspection documentation not provided.

Documentation and maps of carbon monoxide detector locations and monthly inspection reports were not provided.

Two fire extinguishers in the kitchen are out of compliance.

Detailed documentation and maps of fire-rated construction locations and annual inspection reports were not provided.

Documentation for first and second semi-annual hood cleaning missing; facility instructed to increase cleaning frequency to every 3 months.

Annual forward flow test documentation missing; painted sprinkler heads observed in 1st floor dining room and kitchen.

First and second semi-annual servicing reports for automatic fire-extinguishing systems were not provided.

Annual report for fire alarm and detection system maintenance was not provided.

3rd floor double doors #50, 2nd floor double doors by laundry, and kitchen main door failed to latch.

Missing documentation/maps; Kitchen janitor closet missing fire-rated door; frame has a fire-rated tag painted over.

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

Documentation for 12 planned and unannounced fire drills in the previous 12 months is missing across all shifts and quarters.

Missing documentation for first and second semi-annual hood cleaning.

Facility did not have a schedule or records for annual inspection of fire-resistance-rated construction.

Missing documentation for annual 90-minute power test.

Missing documentation for annual report, sensitivity testing, and monthly alarm tests.

Missing documentation for 30-second monthly activation testing.

No schedule or documentation for annual fire door inspections.

Multi-plug found in use near 2nd floor nurses cart during 06/24/2024 inspection; noted as corrected.

Missing various annual/quarterly reports; sprinkler heads in kitchen had dust; riser tags expired.

Fire extinguisher found on kitchen floor; inspection past due.

Missing documentation for first and second semi-annual service.

Missing documentation for fire/smoke damper inspection.

1st floor storage found in sprinkler riser room during 06/24/2024 inspection; noted as corrected in subsequent inspections.

No documentation for monthly testing and maintenance of CO alarms.

Missing documentation for 12 planned/unannounced fire drills; multiple drills missing for all shifts.

2nd floor double doors will not latch; 2nd/3rd floor doors held open with wedges.

Failed to ensure 5 of 6 staff members were screened for tuberculosis within three days of employment.

Failed to complete a Washington State Name and Date of Birth background check every two years for 2 of 6 staff members.

Failed to document in Negotiated Service Agreements (NSA) the care needs, interventions for diagnoses, and physician ordered medical treatments for 3 of 11 residents, specifically failing to note side effects and safety plans for blood thinners.

Documentation for fire door annual inspection not provided.

Facility cannot provide documentation for the completion of twelve planned and unannounced fire drills in the previous 12 months.

Documentation for carbon monoxide alarms and detectors testing and maintenance not provided.

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

Power strip plugged into another power strip used at nurses carts (noted 5/24/2023, corrected by 6/27/2023).

Documentation for fire/smoke damper 4-year inspection not provided.

Combustible storage found blocking access to the electrical panel in kitchen (noted 5/24/2023, corrected by 6/27/2023).

Fire doors at residents room 208D and stairwell door on main floor would not latch or close.