12 Reports
Inspection Report — Dec 17, 2025
Complaint Investigation
Date: Dec 17, 2025
Visit Reason
The inspection was a follow-up complaint investigation triggered by multiple allegations involving a named resident's homicidal threats, aggressive behaviors, and improper eviction notice procedures.
Complaint Details
The complaint involved a named resident who made homicidal threats, displayed aggressive behaviors, and was given an eviction notice improperly. The investigation found the facility failed to implement suicide precautions and emergency policies, and failed to document discharge notices properly. Multiple suicide attempts by the resident were not properly managed by the facility. The complaint was substantiated with citations written.
Findings
The facility was found to have failed provider practices related to inadequate implementation of suicide precautions, emergency response policies, and discharge notice requirements. The follow-up inspection found no remaining deficiencies and confirmed correction of prior cited violations.
Deficiencies (2)
WAC 388-78A-2600 Policies and procedures. The assisted living facility failed to implement policies and procedures for emergency response, mental health crisis, and suicide precautions, resulting in inadequate care for a resident with suicidal ideation and attempts.
WAC 388-78A-2660 Resident rights. The facility failed to document reasons for discharge and include required advocacy information for a resident's discharge notice, placing the resident and legal representative at risk.
Report Facts
Total residents: 99
Resident sample size: 14
Closed records sample size: 4
Inspection Report — Oct 31, 2025
Enforcement
Date: Oct 31, 2025
Visit Reason
The Department of Social and Health Services conducted a complaint investigation at the assisted living facility, Greenlake Emerald City, which resulted in the imposition of a civil fine due to violations of policies and procedures related to resident care.
Complaint Details
This report is based on a complaint investigation completed on October 31, 2025, regarding failure to implement required policies for a resident with suicidal ideations and attempts. The deficiency was substantiated and resulted in a civil fine.
Findings
The licensee failed to implement required policies for a resident exhibiting suicidal ideations and attempts, resulting in inadequate mental health services and a second suicide attempt requiring hospitalization. This deficiency is recurring and has led to a $2,000 civil fine.
Deficiencies (1)
WAC 388-78A-2600 (1)(a)(b)(2)(f)(g)(p) Policies and procedures. The licensee failed to implement policies related to accidents, emergencies, mental health deterioration, psychiatric crisis, and suicide precautions for one resident, contributing to a second suicide attempt requiring hospitalization.
Report Facts
Civil fine amount: 2000
Inspection Report — Sep 23, 2025
Follow-Up
Date: Sep 23, 2025
Visit Reason
Follow-up inspection to verify correction of previously cited deficiencies at an Assisted Living Facility.
Findings
The follow-up inspection found no deficiencies and confirmed that all previously cited deficiencies were corrected.
Deficiencies (12)
WAC 388-78A-2474 Training and home care aide certification requirements. The facility failed to ensure 2 of 6 staff completed required facility orientation, placing 90 residents at risk of harm from untrained staff.
WAC 388-78A-3100 Safe storage of supplies and equipment. The facility failed to secure hazardous chemicals in a housekeeping cart, common bathroom, and resident room in the Memory Care Unit, placing 15 residents at risk of harm and poisoning.
WAC 388-78A-2260 Storing, securing, and accounting for medications. The facility failed to securely store medications for 2 of 3 residents, placing them at risk of ingesting unprescribed medications and missed doses.
WAC 388-78A-2210 Medication services. The facility failed to maintain safe medication systems, including missing narcotic count signatures and unsecured medications, placing 16 Memory Care Unit and 17 Assisted Living residents at risk of medication errors.
WAC 388-78A-3090 Maintenance and housekeeping. The facility failed to maintain a safe, sanitary, and well-maintained environment for residents, including odors, overflowing garbage, insect infestations, and poor apartment conditions, placing residents at risk of harm and decreased quality of life.
WAC 388-78A-2610 Infection control. Medication technicians failed to perform hand hygiene and used bare hands during medication preparation, placing all residents at risk for illness.
WAC 388-78A-2210 Medication services. The facility failed to administer medications in a timely manner and as prescribed for multiple residents, and pre-poured medications were not properly labeled, placing residents at risk of medication errors.
WAC 388-78A-2150 Signing negotiated service agreement. The facility failed to obtain resident or representative signatures on negotiated service agreements at least annually for 5 of 12 sampled residents, placing them at risk for not receiving agreed care and services.
WAC 388-78A-2690 Electronic monitoring equipment Resident requested use. The facility failed to complete evaluation and obtain consent for electronic monitoring for 2 residents with video cameras in their apartments, placing them at risk of privacy violations.
WAC 388-78A-2240 Nonavailability of medications. The facility failed to ensure medications were available and administered as prescribed for 6 of 12 sampled residents, placing them at risk for medical complications.
WAC 388-78A-2060 Preadmission assessment. The facility failed to complete a pre-admission assessment for 1 of 2 sampled residents prior to admission, placing the resident at risk for unmet needs.
WAC 388-78A-2090 Full assessment topics. The facility failed to complete a full assessment within 14 days of admission for 1 of 2 sampled residents, placing the resident at risk for unmet needs and decreased quality of life.
Report Facts
Residents in facility: 90
Sampled residents: 19
Deficiencies cited: 12
Residents with cognitive disorders: 23
Residents in Memory Care Unit: 15
Residents with video cameras: 2
Residents with unsigned ND consent: 13
Residents with unsigned negotiated service agreements: 5
Residents with missed medications: 6
Staff without valid food worker cards: 3
Staff without CPR certification: 2
Staff without two-step tuberculosis testing: 3
Staff without national fingerprint background check: 1
Inspection Report — Aug 7, 2025
Enforcement
Date: Aug 7, 2025
Visit Reason
This document is a formal notice of civil fines imposed following a follow-up visit conducted on August 7, 2025, at the Greenlake Emerald City assisted living facility due to uncorrected deficiencies.
Findings
The report details multiple uncorrected deficiencies related to staff training, safe storage of hazardous chemicals, medication storage and management, and facility maintenance. These violations placed residents at risk and resulted in civil fines totaling $1,700.
Deficiencies (5)
WAC 388-78A-2474 (2)(d)(e)(3) Training and home care aide certification requirements. The licensee failed to ensure two staff completed the required facility orientation, placing residents at risk of harm from unfamiliar care staff.
WAC 388-78A-3100 (1)(2) Safe storage of supplies and equipment. The licensee failed to identify and secure hazardous chemicals in a housekeeping cart, common bathroom, and a resident room in the Memory Care Unit, placing 15 residents at risk of harm and poisoning.
WAC 388-78A-2260 (1)(2)(d) Storing, securing, and accounting for medications. The licensee failed to ensure two residents’ medications were securely stored, risking ingestion of unprescribed medications and missed or incorrect doses.
WAC 388-78A-2210 (1)(b)(2)(a) Medication services. Two narcotic books lacked change of shift signatures, risking incorrect narcotic management for 15 Memory Care Unit and 17 Assisted Living residents.
WAC 388-78A-3090 (1)(a)(b)(c)(d)(2)(c)(ii) Maintenance and housekeeping. The licensee failed to maintain sanitary, safe, and good repair conditions in the building and two residents’ apartments, placing residents at risk of harm and decreased quality of life.
Report Facts
Civil fine amount: 1700
Residents at risk: 15
Residents at risk: 17
Staff not trained: 2
Residents affected: 2
Residents affected: 1
Inspection Report — Jun 5, 2025
Enforcement
Date: Jun 5, 2025
Visit Reason
The Department of Social and Health Services conducted a full inspection at the assisted living facility to assess compliance with medication administration and availability regulations.
Findings
The inspection found recurring deficiencies related to medication services and nonavailability of medications, resulting in civil fines. Multiple residents did not receive medications as prescribed, and narcotic medication logs lacked required verification, placing residents at risk.
Deficiencies (2)
WAC 388-78A-2210 (1)(b)(2)(a) Medication services. The licensee failed to ensure safe medication systems were implemented, resulting in medications not administered timely or as prescribed, missing narcotic count verification signatures, and medications given without necessary identifications. Four residents did not receive medications as prescribed.
WAC 388-78A-2240 Nonavailability of medications. The licensee failed to ensure medications were available for six residents, resulting in them not receiving medications as prescribed and placing them at risk for medical complications.
Report Facts
Civil fine amount: 600
Civil fine amount: 1000
Total civil fines: 1600
Residents affected: 4
Residents affected: 6
Inspection Report — May 28, 2025
Follow-Up
Date: May 28, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets the Assisted Living Facility licensing requirements. Previously cited deficiencies related to medication refusal were corrected.
Deficiencies (1)
WAC 388-78A-2230 Medication refusal. The Assisted Living Facility failed to notify the physician or conduct an evaluation when a resident refused medication, placing the resident at risk for health decline. This deficiency was previously cited and remains uncorrected as of the earlier report dated 04/17/2025.
Report Facts
Resident sample size: 4
Resident sample size: 7
Total residents: 85
Medication refusals: 12
Medication refusals: 28
Medication refusals: 87
Medication refusals: 70
Medication refusals: 16
Medication refusals: 25
Haloperidol injection interval: 51
Haloperidol injection interval: 37
Inspection Report — Apr 17, 2025
Enforcement
Date: Apr 17, 2025
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to the assisted living facility to address previously cited deficiencies and enforce compliance, resulting in the imposition of a civil fine.
Findings
The facility was fined $400 for failing to notify the physician or conduct an evaluation when a resident refused medication. This deficiency was uncorrected from a prior citation dated February 21, 2025.
Deficiencies (1)
WAC 388-78A-2230 (1)(c)(i)(ii) Medication refusal. The licensee failed to notify the physician or conduct an evaluation when one resident refused their medication, placing the resident at risk for a decline in health status.
Report Facts
Civil fine amount: 400
Inspection Report — Feb 12, 2025
Complaint Investigation
Date: Feb 12, 2025
Visit Reason
The inspection was conducted as a complaint investigation triggered by multiple allegations including neglect, failure to implement care plans, medication diversion, abuse, and environmental concerns at the Assisted Living Facility Greenlake Emerald City.
Complaint Details
Multiple allegations were investigated including neglect resulting in skin breakdown, failure to notify family or physician, abuse and neglect, medication diversion, environmental concerns, and failure to provide showers. Some allegations were substantiated with citations written for failure to implement care plans and safety checks. Other allegations such as medication diversion, abuse, and environmental neglect were not substantiated.
Findings
The investigation found that the facility failed to implement care plans and skin care management policies for certain residents, resulting in risk of harm. Several allegations such as medication diversion, abuse, and environmental neglect were not substantiated. Citations were written for failure to implement care plans and safety checks.
Deficiencies (2)
WAC 388-78A-2600 Policies and procedures. The assisted living facility failed to develop and implement policies and procedures to provide necessary care and services for residents, including those with special needs. This deficiency was corrected as noted in the follow-up inspection.
WAC 388-78A-2160 Implementation of negotiated service agreement. The assisted living facility failed to implement the negotiated service agreement and complete safety checks for 1 of 20 residents, preventing needed interventions before the resident was found deceased.
Report Facts
Total residents: 91
Resident sample size: 20
Closed records sample size: 6
Inspection Report — Feb 11, 2025
Complaint Investigation
Date: Feb 11, 2025
Visit Reason
The inspection was conducted as an unannounced on-site complaint investigation triggered by multiple complaints regarding medication administration and refusal issues at the assisted living facility.
Complaint Details
This investigation involved multiple complaints (numbers 166061, 164925, 161273, 167650) concerning medication refusals and missed injections. The allegations included a resident refusing medications leading to medical deterioration and a missed prescribed injection causing increased anxiety. The investigation substantiated failures in medication administration and notification to physicians.
Findings
The facility was found to have failed in administering prescribed injectable medication on time and failed to notify the physician or evaluate outcomes when a resident refused medications. Citations were written for these deficiencies.
Deficiencies (2)
WAC 388-78A-2230 Medication refusal. The facility failed to notify the physician or conduct an evaluation when a resident refused medications consistently from November 2024 through January 2025, placing the resident at risk of health decline.
WAC 388-78A-2210 Medication services. The facility failed to administer a prescribed monthly haloperidol injection as ordered from November 2024 to February 2025, resulting in delayed or missed doses and increased risk of psychosis symptoms.
Report Facts
Total residents: 85
Resident sample size: 7
Medication refusals: 28
Medication refusals: 87
Medication refusals: 70
Medication refusals: 16
Medication refusals: 25
Days between injections: 51
Days between injections: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Health Services Director and Licensed Nurse | Provided statements regarding medication refusals and missed injections during interviews |
| Staff B | Administrator | Provided statements regarding lack of documentation of physician notification during interviews |
Inspection Report — Nov 26, 2024
Enforcement
Date: Nov 26, 2024
Visit Reason
This document is a formal notice of civil fines following a follow-up visit conducted on November 26, 2024, at the Greenlake Emerald City assisted living facility. The fines are imposed due to uncorrected deficiencies related to regulatory violations.
Findings
The report identifies two uncorrected deficiencies: failure to implement a Respiratory Protection Program placing 82 residents at risk of COVID-19 exposure, and failure to ensure availability of physician-ordered medications for one resident, resulting in missed doses and risk of harm. Civil fines totaling $800 were imposed.
Deficiencies (2)
WAC 388-78A-2730 (1)(b) Licensee's responsibilities. The licensee failed to implement a written Respiratory Protection Program, ensure three staff had medical evaluations, and four staff had respirator mask fit testing, placing 82 residents at risk of SARS-CoV-2 exposure.
WAC 388-78A-2240 Nonavailability of medications. The licensee failed to ensure physician’s ordered medication was available for one resident, resulting in missed doses of three medications and placing the resident at risk of harm.
Report Facts
Civil fine amount: 300
Civil fine amount: 500
Total civil fines: 800
Inspection Report — Aug 28, 2024
Complaint Investigation
Date: Aug 28, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by multiple allegations including verbal abuse, medication issues, and infection control concerns at Greenlake Emerald City Assisted Living Facility.
Complaint Details
The complaint investigation included allegations of verbal abuse, medication issues, and infection control concerns. The facility completed thorough investigations that ruled out abuse and neglect but confirmed medication availability failures and respiratory protection program deficiencies. The resident sample size was 9 out of 80 current residents. The complaint numbers referenced were 144044, 143961, 143166, 141538, 145169, 145731, 146569, and 147784.
Findings
The investigation found no substantiated abuse or neglect but identified failures in medication availability and respiratory protection program compliance. The facility failed to ensure physician-ordered medications were available for a resident, causing missed doses and risk of harm. The facility also lacked a written Respiratory Protection Program and had staff without required medical evaluations and fit-testing for respirators. The facility has taken or plans corrective actions.
Deficiencies (2)
WAC 388-78A-2730 Licensee's responsibilities. The facility failed to implement a written Respiratory Protection Program and ensure 4 of 5 staff had medical evaluations and respirator mask fit-testing, placing residents and staff at risk for COVID-19 exposure.
WAC 388-78A-2240 Nonavailability of medications. The facility failed to ensure physician-ordered medications were available for 1 of 2 residents, resulting in multiple missed doses of Carvedilol, Amlodipine, and Eliquis and placing the resident at risk of harm.
Report Facts
Resident count: 80
Resident sample size: 9
Missed Carvedilol doses: 31
Missed Amlodipine doses: 9
Missed Eliquis doses: 15
Resident sample size: 2
Staff without respirator medical evaluation or fit-test: 3
Staff with expired respirator fit-test: 2
Inspection Report — Aug 1, 2024
Complaint Investigation
Date: Aug 1, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding multiple allegations including miscommunication causing delay in antibiotic treatment for a UTI, delayed assessment for abdominal pain, and administration of diuretic medication not ordered by a physician.
Complaint Details
The complaint investigation involved allegations of miscommunication causing delay in antibiotic treatment for a UTI, delayed assessment for abdominal pain, and administration of diuretic medication not ordered by a physician. The antibiotic delay was substantiated with citations written, while the other allegations were not substantiated.
Findings
The investigation found that the facility failed to administer prescribed antibiotics timely, resulting in six missed doses for a resident, constituting a failed provider practice with citations written. No failed practice was identified regarding delayed assessment or diuretic medication administration.
Deficiencies (1)
WAC 388-78A-2210 Medication services. The assisted living facility failed to ensure one of three sampled residents received their prescribed medication as ordered, resulting in incomplete treatment of an infection.
Report Facts
Total residents: 53
Resident sample size: 3
Missed antibiotic doses: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cathy Prentice | Complaint Investigator | Named as the investigator who conducted the complaint investigation and on-site verification |
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