The Cottages at Mill Creek

The facility failed to ensure staff was available in a secured memory care cottage to monitor and supervise a resident, leading to the resident exiting the cottage unnoticed at night.

The licensee failed to investigate, determine the circumstances, and institute preventative measures when a staff member administered medication without following the prescribed orders for one resident.

The facility failed to investigate, determine circumstances, and institute preventative measures following a medication administration error. No incident report or investigation was conducted until the DSHS investigator arrived 13 days later.

The facility failed to follow the hospice medication order for one resident; staff administered Phenobarbital for agitation without contacting the hospice provider prior to administration.

Facility unable to provide 2025 quarterly inspection reports, 5-year internal pipe inspection report, and annual forward flow report; escutcheon ring missing in building D laundry room.

Unprotected penetrations in fire-resistance-rated construction found in building sprinkler room; spray foam used to fill holes.

Missing documentation for 2025 quarterly inspections, 5-year internal pipe inspection, and annual forward flow. Additionally, an escutcheon ring is missing in the laundry room of building D.

Penetrations in fire-resistance-rated construction found in building sprinkler room; improper use of spray foam to fill holes.

Facility failed to ensure 1 of 2 staff (Staff F) had a valid biennial Washington State background check, resulting in a lapse of 68 days.

Facility failed to maintain courtyard fence at the required 72-inch height; sections were missing or broken.

Facility failed to submit background check authorization forms for 2 of 6 staff (Staff B and C) within one business day of hire.

Facility failed to maintain hot water temperatures between 105 F and 120 F in B-Cottage; readings were as low as 66.6 F.

Facility failed to ensure staff (Staff D and F) completed valid in-person CPR/First Aid training.

Facility failed to ensure 1 of 4 staff (Staff C) completed the second step of TB testing within the required timeframe.

Facility failed to ensure 2 of 4 staff (Staff B and D) completed TB testing within three days of hire.

Facility failed to disclose that an LPN/RN were no longer on-site and failed to notify residents of changes in service availability.

The facility failed to investigate, document, and institute preventative measures for two incidents where a resident eloped by climbing through a window.

The facility failed to provide intermittent nursing services for a resident with a MRSA-infected wound. Wound care was performed by an unqualified staff member (Nursing Assistant) rather than a licensed nurse, placing the resident at risk of harm.