The Courtyard at Colfax

The FACP room had penetration in ceiling near door.

Storage encroached on required ceiling clearance in resident rooms 209 and 210.

No documentation of fire drills during swing shift (1445-2315) during first quarter 2024.

Fire drills documented as silent or missing specific times for September 2023 and March 2024.

Appliances plugged into multiplug adapters in medication and nursing rooms.

Unfused multiplug adapters in use in multiple resident rooms.

Power tap cord for mobility chair running under a door in Room 317.

Missing documentation for two kitchen hood inspections; facility scheduled semi-annual cleaning.

Kitchen manual pull station for hood system partially obstructed.

Room 206 door blocked open.

Missing semi-annual hood suppression report.

Third floor elevator door did not close and latch automatically.

Monthly inspections not up to date for kitchen and basement extinguishers.

Missing annual sprinkler inspection documentation and wires found on supply lines in basement.

Two unsecured oxygen cylinders in Executive Director's office.

The facility failed to implement a policy for monitoring residents with bedrails, leading to resident entrapment and death.

Facility failed to include medical devices (bedrails/air mattress) in the resident's negotiated service agreement and lacked instructions for monitoring or safety assessments for said devices.

Facility failed to provide resident checks at the frequency agreed upon in the negotiated service agreement, contributing to a resident's death.

Failed to develop and implement policies defining staff monitoring frequency for residents using medical devices (bedrails). Staff were untrained and unaware of risks/safety checks, contributing to resident death via entrapment.

Staff A hired as LPN, but held no valid Washington state license/credential. Administered medications to residents.

Multiple staff members were working with expired food handler cards.

Facility failed to follow criteria for nurse delegation; Staff A performed nursing tasks without proper delegation.

Resident records were visible from the street/sidewalk through facility windows.

Hazardous chemicals were accessible to residents in laundry rooms, housekeeping carts, and external flower beds.