Victoria Place

Facility failed to provide report showing fire/smoke dampers 4-year inspection.

Facility failed to provide documentation showing carbon monoxide alarms/detectors are being inspected.

Facility failed to provide documentation showing annual fire-resistance-rated construction (fire wall inspection); fire wall penetration in Activity room.

Fire alarm electrical breaker located in electrical panel was missing electrical breaker lock.

Facility failed to provide report showing kitchen suppression system is being serviced twice a year.

Facility failed to provide documentation showing 1.5 hour power test for all exit signs and emergency lights.

Facility failed to provide report showing kitchen hood is being cleaned twice a year.

Facility failed to inspect portable fire extinguishers on a monthly basis and failed to maintain/mount portable fire extinguisher in activity room.

Facility failed to provide documentation showing fire doors are inspected annually. Employee bathroom by salon and employee break room doors failed to latch.

Facility failed to provide documentation for fire sprinkler system, including annual inspection report, 3-year dry system full flow trip test, annual trip test, annual forward flow test on backflow, and quarterly inspection reports.

Facility failed to maintain exit sign outside of salon area; sign inoperable.

On 8/28/25, a lithium bike battery started a fire in a field in the back of the building. The fire department responded and evacuated the building. The sprinkler system did not activate; there were no injuries.

Facility failed to ensure staff completed required facility orientation, DSHS five-hour orientation/safety training, CPR/First Aid training, dementia specialty training, and home care aide certification.

Facility failed to provide signed disclosure of services documentation for 5 of 5 sampled residents.

Facility failed to maintain hot water temperatures between 105 and 120 degrees Fahrenheit in multiple locations, putting 26 residents and 12 staff at risk of burns.

Facility failed to ensure Staff B submitted a new Washington state background check every two years.

Outlines requirements for construction document review and approval; referenced as a deficiency area.

Facility failed to implement safe food handling and storage practices. Findings include improper storage of raw food items, unsanitary kitchen conditions, presence of mold, and missing food worker cards for staff.

Facility failed to ensure confidentiality of resident records on medication cart computers, which were left unattended with screens displaying personal info.

Facility failed to provide Medicaid policy disclosures to 5 of 5 sampled residents.

Facility failed to complete ongoing assessments for 3 of 5 sampled residents (R2, R4, R5) regarding identified problems and related issues.

Facility employed a staff member (Staff D) with a disqualifying criminal history who had unsupervised access to residents; no safety plan was in place.

Facility failed to complete Washington State name and date of birth background checks for two contracted agency caregivers (Staff F and Staff G) prior to them working.

Facility failed to ensure 1 of 2 sampled staff (Staff D) received TB test within required timeframe.

Facility failed to follow safe food handling/storing practices in the kitchen; kitchen equipment was soiled/disorganized, and staff failed to perform proper hand hygiene.

Facility failed to ensure staff had required nurse delegation training/credentials for 5 of 5 staff reviewed, and failed to provide current nurse delegation documents for 3 of 3 sampled residents.

Facility failed to complete a character, competence, and suitability (CCS) determination for Staff B before allowing unsupervised access to vulnerable adults.

Failed to ensure staff completed required orientation, safety training, dementia specialty training, CPR/First Aid certification, and CEUs.

Facility failed to maintain fire safety per state fire marshal regulations regarding smoking. Observed smoking in a non-designated area, lack of suitable ash trays, and improper disposal of smoking materials.

Facility failed to maintain the required minimum liability insurance coverage of two million dollars per occurrence.

Facility failed to properly store medications; a cup containing nine unidentified medications was found in the medication cart.

Facility failed to ensure signed Service Agreements for 2 of 5 sampled residents (R3 and R5).

Facility failed to complete initial negotiated service agreements (NSA) for R3, failed to update NSA for R2 after condition changes/falls, and failed to complete NSAs within 30 days for R3 and R4.

Facility failed to provide a variety of food options as required; printer issues prevented posting of alternative menu.

Facility employed a staff member (Staff F) with a disqualifying negative background check result, allowing unsupervised access to residents.

Facility failed to have required Washington State name/date of birth and fingerprint background checks completed for multiple staff members and contractors.

Failed to ensure 4 of 4 sampled staff received TB testing within required timeframes.

Facility failed to publicly post and make inspection results easily accessible to residents and visitors.

Facility failed to provide handwashing supplies (soap and paper towels) in 7 of 7 areas reviewed, risking spread of infection.

Facility failed to provide a signed receipt of disclosure of services for 6 of 6 residents reviewed.

Facility failed to document the plan to provide necessary care, services, and behavioral interventions in the service agreements for 3 of 5 sampled residents (R2, R4, and R5).

Facility failed to provide Medicaid policy notice to 4 of 4 sampled residents.

Licensee failed to ensure qualified staff, failed to maintain awareness of facility leadership, and failed to take actions to ensure resident safety regarding medication administration.

Failed to maintain required background check records for 3 of 5 sampled staff and 2 of 2 sampled agency staff.

Facility failed to provide a safe, sanitary, and well-maintained environment. Findings include mold issues, unfinished construction exposing hazards, broken light fixtures, and unsecured room signage.

Facility failed to accommodate resident diets, provide a variety of food, document menu changes/substitutions, and maintain an approved dietary manual.

Facility failed to provide privacy by entering rooms without permission/knocking, and lacked a functioning grievance system.

Facility failed to identify changes in resident conditions for 3 of 5 residents and failed to implement interventions for a resident (R2) after 6 falls in one month.

Facility failed to complete a full assessment within 14 days of move-in for 1 of 2 sampled residents (R4).

Facility did not provide an updated Disclosure of Services form to residents with cognitive deficits.

Facility failed to provide background checks for Staff F and Staff G prior to their first day of work.

Staff E's CPR/First Aid certification was completed 57 days after the original plan of correction date.

Facility failed to complete kitchen repairs/remodel including missing cabinet doors/drawers, relying on makeshift cloth drapes.

Failed to ensure nurse delegation was completed and documented for three residents, resulting in medication services by unqualified staff.

Failed to ensure one staff had dementia specialty training and home care aide certification.

Failed to maintain and provide current nurse delegation documents for three residents, resulting in residents receiving medication services from unqualified staff.

Failed to ensure one staff received their Tuberculosis test within the required time requirements.

Failed to ensure residents were provided a Medicaid policy for four residents.

Failed to ensure one staff with disqualifying negative background check results was not employed by the facility.

Failed to have a Washington State name and Date of Birth background check completed for two contracted agency caregivers prior to them working at the facility.

Failed to ensure staff had required orientation, DSHS five-hour orientation/safety training, CPR/First Aid, dementia specialty training, and home care aide certification.

Failed to follow and implement safe food handling and storing practices in the kitchen.

Failed to provide a variety of food for one kitchen reviewed.

Failed to provide signed documentation that five residents received a copy of the facility's disclosure of services.

Complaint investigation regarding broken sprinkler pipes. On 2/8/25, a pipe broke and fire watch was initiated. On 2/12/25, a remediation worker stepped on a pipe, setting off the system. No fire occurred, and the system is currently in normal status.