St Andrews Place Assisted Living

Flammable material stored on top of stove in 1st floor activity room.

Combustible material stored in electrical room by dining room.

Missing documentation for sprinkler system (annual inspection, 5-year internal pipe inspection, annual trip test, annual forward flow test, 5-year fire dept connection hydrostatic test, quarterly reports). 3/13/25 dry sprinkler report shows uncorrected deficiencies.

Fire alarm report from 9/18/25 shows deficiencies without proof of correction.

Exit sign on 2nd floor in front of room 212 missing directional chevron.

Missing documentation showing 1.5 hour power test for exit signs and emergency lights.

Fire door between dining room and kitchen does not close due to delamination.

Facility failed to ensure staff had required credentials for delegation, failed to implement nursing delegation for 1 of 3 residents (Resident 2), and failed to update nursing services every 90 days for 3 of 3 residents (Resident 2, 4, and 8).

Facility failed to ensure staff (Staff G and Staff E) completed annual continuing education units (CEU) and required certifications within the required time frames.

Facility staff failed to follow proper hand hygiene and glove usage protocols, placing residents, staff, and visitors at risk for infection.

Facility failed to notify physicians as required and monitor residents after they refused medications; also failed to ensure medication administration as prescribed.

Facility failed to ensure milk served to residents was stored below 41 degrees Fahrenheit.

Facility failed to ensure the outside and inside resident living quarters were clean, safe and sanitary.

Facility failed to monitor and document changes in resident condition for 7 of 7 residents (Residents 5, 2, 7, 3, 4, 1, and 6) requiring intervention.

Facility failed to document necessary health support services in Negotiated Service Agreements (NSA) and failed to update care plans to reflect changes in resident needs.

Two caregivers did not have updated Washington state food worker cards.

Facility failed to ensure 3 of 3 sampled staff (Staff C, D, and E) received required two-step TB testing within the mandated time frames.

2 of 7 residents did not have all vitamins secured by the facility.

Kitchen ceiling tiles and fire rated double layer sheetrock were removed to fix a leak; penetration needs repair and tiles replaced.

Missing documentation for 3-year dry system full flow trip test and annual forward flow test for backflow. Fire department connection under repair due to pipe burst. Sprinkler heads in kitchen loaded with debris.

Fire alarm electrical breaker in electrical panel is missing a breaker lock.

Facility failed to develop, implement, and train staff on procedures for reporting/investigating allegations of financial exploitation, and failed to document investigations into multiple resident reports of theft.

Facility failed to maintain extension cord located in maintenance shop, which was plugged into a power strip and being used to power a microwave.

Facility failed to provide documentation showing annual inspection of fire-resistance-rated construction (fire wall inspection).

Facility failed to provide 4 year damper inspection report.

Facility failed to provide annual forward flow test on the backflow and missed the second quarter sprinkler system inspection.

Facility failed to manage food services in compliance with Food Code; left-over foods were not timely discarded and not properly dated/labeled in refrigerators.

The facility failed to ensure all 5 of 5 sampled staff members were fit tested for an N-95 respirator.