Inspection Reports for
Heritage Court
4230 Colby Ave, Everett, WA 98203, WA, 98203
Back to Facility Profile18 Reports
Inspection Report — Jan 5, 2026
Follow-Up
Date: Jan 5, 2026
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to safety and elopement prevention.
Complaint Details
The complaint investigation was triggered by an allegation that a Named Resident went missing after exiting through an unlocked secured exit door. The investigation found the facility failed to ensure the resident's safety and did not conduct regular elopement drills as required. Multiple staff interviews and record reviews confirmed the door was unlocked and alarms did not activate. The resident was found by police after being missing for nearly two hours. Citations were issued for noncompliance with WAC 388-78A-2170 (1).
Findings
The follow-up inspection found no deficiencies and confirmed that previously cited violations related to elopement prevention were corrected. The facility now meets Assisted Living Facility licensing requirements.
Deficiencies (1)
WAC 388-78A-2170 (1) The facility failed to ensure the safety and well-being of a resident who left the facility unsupervised through an unlocked secured exit door, resulting in the resident going missing and being at risk of harm. The facility also failed to conduct regular elopement drills as required by policy.
Report Facts
Total residents: 45
Resident sample size: 2
Inspection Report — Dec 1, 2025
Follow-Up
Date: Dec 1, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility on 12/01/2025 to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies; all previously cited licensing law violations were corrected.
Deficiencies (4)
WAC 388-78A-2466 Background checks Washington state name and date of birth background check Valid for two years National fingerprint background check Valid indefinitely. The facility failed to ensure valid background checks were completed every two years for all staff, placing residents at risk.
WAC 388-78A-2468 Background checks Employment Conditional hire Pending results of Washington state name and date of birth background check. The facility failed to submit background authorization forms within one business day after hire for some staff.
WAC 388-78A-2485 Tuberculosis Positive test result. The facility failed to ensure staff with positive TB blood tests received a chest X-ray within seven days.
WAC 388-78A-2480 Tuberculosis Testing Required. The facility failed to ensure staff were screened for tuberculosis within three days of employment.
Report Facts
Sampled residents: 7
Staff with late background check: 2
Days late for Staff E background check: 67
Days late for Staff F background check: 336
Staff with late background submission: 1
Staff without chest X-ray after positive TB test: 1
Staff without TB testing within three days of hire: 2
Inspection Report — Jul 16, 2025
Follow-Up
Date: Jul 16, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Complaint Details
The complaint investigation found that a resident's bathroom lights were not working and the emergency pull cord string was missing. Staff failed to respond to the resident's call light because the pager was left in the medication cart. The facility acknowledged and corrected the issue during the visit. A citation was issued for noncompliance with WAC 388-78A-3090 (1) (c).
Findings
The follow-up inspection found no deficiencies and confirmed that previously cited deficiencies were corrected.
Deficiencies (1)
WAC 388-78A-3090-1-c - The Assisted Living Facility failed to keep facilities, equipment, and furnishings clean and in good repair, resulting in a resident's emergency call light system being nonfunctional and bathroom lighting not working.
Report Facts
Total residents: 42
Resident sample size: 7
Closed records sample size: 3
Inspection Report — Jun 12, 2025
Complaint Investigation
Date: Jun 12, 2025
Visit Reason
The inspection was a complaint investigation triggered by multiple allegations including failure to respond to emergency call lights, failure to involve resident representatives and case managers in service agreement planning, and failure to investigate and document incidents such as a resident eloping from the facility.
Complaint Details
The complaint investigation involved allegations that a resident did not have a working call light for three days, staff failed to respond to emergency calls, a resident was moved without informing about delayed egress, and failure to contact case manager and POA during service assessment changes. Another allegation involved a resident eloping from the facility and failure to investigate the incident properly. The investigation confirmed these allegations and issued citations accordingly.
Findings
The investigation found multiple deficiencies including failure to involve the resident, their representative, and case manager in service agreement planning; failure to respond to emergency call lights placing residents at risk; and failure to thoroughly investigate and document an incident where a resident left the facility unnoticed. Citations were issued for these violations.
Deficiencies (3)
WAC 388-78A-2130 Service agreement planning. The assisted living facility failed to involve the resident, their representative, and case manager in developing and updating a negotiated service agreement for one resident with a change in condition.
WAC 388-78A-2930 Communication system. The facility failed to ensure staff responded to emergency call lights activated by two residents, placing them at risk for unmet care needs.
WAC 388-78A-2371 Investigations. The facility failed to document findings and actions from the investigation when one resident left the facility unnoticed and unsupervised, placing the resident at risk for harm and injury.
Report Facts
Total residents: 45
Resident sample size: 5
Duration of call light non-response: 36
Duration of call light non-response: 33
Inspection Report — Jun 10, 2025
Life Safety
Date: Jun 10, 2025
Visit Reason
The Office of the State Fire Marshal conducted a scheduled fire safety inspection at the facility.
Findings
The inspection identified multiple fire safety violations including improper use of power taps, missing grease filters, failure to provide required documentation for hood cleaning, fire extinguisher servicing, emergency lighting, generator testing, and fire drills. Several doors did not latch properly and exit signage was missing. The facility was disapproved due to these outstanding violations.
Deficiencies (11)
IFC 603.5.2 (2021) - Relocatable power taps and current taps must be connected to a permanently installed receptacle. The executive director's office, nurses office, and activities office had daisy chaining power strips.
IFC 606.3.1 (2021) - Kitchen hood system must have a grease filter in place. The kitchen hood system was missing a grease filter.
IFC 606.3.3 (2021) - Hoods and grease-removal devices must be cleaned at required intervals. Facility failed to provide documentation that the second semi-annual hood cleaning of 2024 was performed.
IFC 705.2.4 (2021) - Swinging fire doors must close and latch automatically from the full-open position. Doors to rooms 08, 10, 20, 31, and fire doors near room 23 did not latch from fully open position.
IFC 904.13.5.2 (2021) - Automatic fire-extinguishing systems must be serviced at least every six months with inspection certificates provided. Facility failed to provide documentation that the second semi-annual fire-extinguishing system service of 2024 was performed.
IFC 1003.6 (2021) - Means of egress must not be obstructed. A table was blocking the emergency exit near room 10.
IFC 1010.2.4 (2021) WAC 51-54A - Locking devices on doors must meet specific requirements for emergency egress. The rear exit gate did not have a legible code for emergency egress.
IFC 1013.1 (2021) - Exit signs must be marked by approved exit signs visible from any direction of egress travel. The kitchen did not have exit signs to the path of emergency exit.
IFC 1031.10.2 (2021) - Battery-powered emergency lighting equipment must be tested annually for at least 90 minutes. Facility failed to provide documentation that the annual 90-minute emergency lighting test was performed.
IFC 1203.4 (2021) - Emergency and standby power systems must be maintained and tested within required timeframes. Facility failed to provide documentation that the 3 year, 4 hour generator test was performed.
WAC 212-12-044 - Fire drills must be held at least twelve times per year with documentation maintained. Facility failed to provide documentation that two of the second quarter required fire drills were performed.
Inspection Report — May 16, 2025
Follow-Up
Date: May 16, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to full assessment topics and safety considerations for residents using portable heaters.
Complaint Details
The complaint investigation (Compliance Determination #54430) was triggered by the failure of the facility's boiler system, leading to use of portable heaters without assessing resident safety. The investigation found the facility did not assess residents' ability to safely use portable heaters, resulting in a citation for noncompliance with WAC 388-78A-2090.
Findings
The follow-up inspection on 05/16/2025 found no deficiencies and confirmed that previously cited deficiencies under WAC 388-78A-2090 were corrected. The facility had failed to assess residents' safety regarding portable heater use during the complaint investigation but has since corrected these issues.
Deficiencies (1)
WAC 388-78A-2090 Full assessment topics. The assisted living facility failed to assess the capabilities of residents using portable heaters after the boiler system failed, placing residents at risk of fire and injury.
Report Facts
Total residents: 47
Portable heaters in use: 12
Inspection Report — May 13, 2025
Complaint Investigation
Date: May 13, 2025
Visit Reason
The inspection was conducted as a follow-up to complaint investigations regarding a fall with injury, medication management concerns, rash and swollen limbs from medications, and a scabies outbreak at the Assisted Living Facility.
Complaint Details
The complaint investigation involved three complaint numbers (164476, 165157, 168392) concerning a resident's fall with injury, medication management issues, rash and swollen limbs, and a scabies outbreak. The facility failed to report the scabies outbreak to the Local Health Jurisdiction despite multiple residents being diagnosed and treated. The outbreak involved at least 18 residents, with 10 showing signs consistent with scabies. The facility staff and administration were uncertain about the outbreak status and reporting requirements. Citations were issued for failure to report. The follow-up inspection found all deficiencies corrected.
Findings
The investigation found multiple deficiencies including failure to report a scabies outbreak to the Local Health Jurisdiction, resulting in citations for non-compliance with WAC 388-78A-2610 Infection Control. Other allegations related to medication management and falls were investigated with failed provider practices identified and citations written. A follow-up inspection on 05/13/2025 found no deficiencies and confirmed correction of the cited infection control violation.
Deficiencies (1)
WAC 388-78A-2610 Infection control. The Assisted Living Facility failed to report a scabies outbreak involving multiple residents to the Local Health Jurisdiction, preventing proper public health investigation and placing residents at risk of exposure.
Report Facts
Total residents: 44
Resident sample size: 4
Residents treated for scabies: 18
Residents with signs consistent with scabies: 10
Inspection Report — Mar 14, 2025
Follow-Up
Date: Mar 14, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to freedom of movement and exit door access.
Complaint Details
The complaint investigation found that the ALF bottom floor did not have an accessible outdoor area and that the ALF did not have a visible access code for visitors on secured exit doors. These findings resulted in citations for noncompliance with WAC 388-78A-2381 and WAC 388-78A-2080 (3).
Findings
The follow-up inspection on 03/14/2025 found no deficiencies and confirmed that the previously cited deficiency regarding the system to inform and permit visitors to exit without sounding the alarm was corrected.
Deficiencies (3)
WAC 388-78A-2380 Freedom of movement. An assisted living facility must ensure all of the following conditions are present before moving residents into units or buildings with exits that may restrict a resident's egress: The facility failed to have a system in place to inform and permit visitors to exit without assistance from staff, resulting in unnecessary wait times.
WAC 388-78A-2080 (3) Freedom of movement. The ALF did not have a visible access code for visitors on secured exit doors, requiring visitors to call staff to open doors.
WAC 388-78A-2381 General design requirements for memory care. The facility failed to have a written policy and procedure documenting how residents on the bottom floor would have access to an outdoor area on the top floor, placing residents at risk for unmet services and decreased quality of life.
Report Facts
Total residents: 42
Licensed beds: 47
Resident sample size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Executive Director | Stated that codes were not posted for secured doors and explained visitor access procedures |
| Staff B | Health and Service Director | Described visitor access and escort procedures for secured doors and outdoor areas |
| Staff C | Caregiver | Reported no visible code for visitors on secured exit doors and described visitor exit process |
| Staff D | Med Tech/Caregiver | Described locked emergency exit door on bottom floor and escorting residents to outdoor area |
| Staff E | Med Tech/Caregiver | Reported no posted code for top floor secured exit door and visitor exit procedures |
| Resident 1 | Reported lack of outdoor area access on bottom floor and need for staff assistance | |
| Resident 2 | Reported no knowledge of outdoor area on bottom floor and reliance on staff escort | |
| Collateral Contact 1 | Licensed Social Worker | Reported no visible exit codes and wait times for staff to open secured doors |
Inspection Report — Feb 13, 2025
Complaint Investigation
Date: Feb 13, 2025
Visit Reason
The inspection was conducted in response to a complaint regarding the use and safety of heaters at Everett Heritage Court.
Complaint Details
Complaint #166187 alleged concerns about heaters. The investigation found the boiler needs replacement and that portable electric heaters are used with proper safety measures. No violations were observed, indicating the complaint was unsubstantiated.
Findings
The facility has a boiler that needs replacement and uses separate heating on the second floor. The Executive Director was informed about the proper use of portable electric space heaters per the 2021 International Fire Code. No violations were observed during the inspection.
Report Facts
Residents affected: 19
Inspection Report — Jan 15, 2025
Enforcement
Date: Jan 15, 2025
Visit Reason
This document is a follow-up visit resulting in the imposition of a civil fine due to an uncorrected violation at the assisted living facility Everett Heritage Court.
Findings
The licensee failed to ensure a system was in place to inform and permit visitors to exit the facility without staff assistance, resulting in unnecessary wait times. This violation was previously cited and remains uncorrected, leading to a $400 civil fine.
Deficiencies (1)
WAC 388-78A-2380(3) Freedom of movement. The licensee failed to ensure a system was in place to inform and permit visitors to exit the ALF without assistance from staff. This failure resulted in unnecessary wait time to leave the facility.
Report Facts
Civil fine amount: 400
Inspection Report — Jan 9, 2025
Follow-Up
Date: Jan 9, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Complaint Details
The complaint investigation (Complaint #141151) involved allegations of rough handling, inadequate wound care, and poor hygiene for a named resident. The investigation found failures in documentation and monitoring of skin issues and policies related to care. Citations were issued for noncompliance with WAC 388-78A-2410(9) and WAC 388-78A-2600(1)(b).
Findings
The follow-up inspection found no deficiencies and confirmed that previously cited deficiencies related to resident records and policies were corrected.
Deficiencies (2)
WAC 388-78A-2410 Content of resident records. The assisted living facility must organize and maintain resident records in a format that enables effective care. The facility failed to document weekly assessments and monitoring of residents' skin issues, placing residents at risk of complications.
WAC 388-78A-2600 Policies and procedures. The assisted living facility must develop and implement policies to provide necessary care and services. The facility failed to monitor food intake and place a resident on weekly weights as required, risking worsening pressure wounds.
Report Facts
Total residents: 45
Resident sample size: 4
Closed records sample size: 1
Inspection Report — Sep 18, 2024
Complaint Investigation
Date: Sep 18, 2024
Visit Reason
The inspection was a follow-up complaint investigation triggered by allegations concerning resident care, including wounds, neglect, and potential abuse at Everett Heritage Court Assisted Living Facility.
Complaint Details
Two complaint investigations were conducted regarding allegations of wounds, neglect, and abuse involving named residents. The investigations found failed provider practices including failure to investigate incidents, failure to implement alert charting, and failure to report suspected abuse. The allegations of inappropriate touching and neglect were unsubstantiated. Citations were issued for the failures identified.
Findings
The investigation found multiple failures in policy implementation related to resident investigations, alert charting, and reporting abuse and neglect. Citations were written for deficiencies in investigations, policies and procedures, and reporting. The follow-up inspection on 09/18/2024 found no deficiencies and confirmed all prior citations were corrected.
Deficiencies (3)
WAC 388-78A-2371 Investigations. The assisted living facility failed to investigate, document findings, determine circumstances, and protect a resident after a bruise was found, placing the resident at risk for abuse and neglect.
WAC 388-78A-2600 Policies and procedures. The assisted living facility failed to implement policy and place two residents on alert charting after multiple falls and changes of condition, risking unrecognized complications.
WAC 388-78A-2630 Reporting abuse and neglect. The assisted living facility failed to report one resident's bruise to the Department’s Complaint Resolution Unit hotline, preventing review of potential abuse and neglect.
Report Facts
Total residents: 47
Resident sample size: 4
Inspection Report — Aug 9, 2023
Complaint Investigation
Date: Aug 9, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the Assisted Living Facility's failure to comply with the annual Washington State Patrol Fire Protection Bureau inspection.
Complaint Details
The complaint investigation was based on allegations that the Assisted Living Facility failed to comply with the annual Washington State Patrol Fire Protection Bureau inspection. The investigation found uncorrected violations from fire and life safety inspections conducted on 06/27/2023 and 08/01/2023. The facility was cited for these violations and a follow-up visit was planned.
Findings
The facility was found to have uncorrected fire safety violations from previous inspections, including issues with fire doors, emergency exit gate, hood cleaning documentation, and fire drills. The facility was cited for noncompliance with WAC 388-78A-2040 (2) Other requirements.
Deficiencies (8)
WAC 388-78A-2040 Other requirements. The assisted living facility must have its building approved by the Washington state fire marshal to be licensed. The facility failed to meet this requirement due to uncorrected violations from fire and life safety inspections placing residents at risk.
IFC 607.3.3 2018 Cleaning. The ALF was unable to provide documentation for the semi-annual hood cleaning.
IFC 705.2 2018 Inspection and Maintenance. The fire rated door to the laundry room was blocked by a baby gate.
IFC 705.2.4 2018 Door operation. The fire rated door for Room 8 would not close and latch from a fully open position.
IFC 901.6 2018 Inspection, Testing and maintenance. There was a missing escutcheon plate from the sprinkler located in the kitchen.
IFC 1010.1.9.7 2018 WAC 51-54A. The emergency exit gate on the main entry has the wrong code posted on the gate.
IFC 1203.4 2018. The facility was unable to provide documentation for the annual servicing of the emergency generator and weekly inspections including monthly 30-minute full load testing.
The facility could not provide documentation for the completion of twelve planned and unannounced fire drills in the previous 12 months, missing multiple quarters and shifts.
Report Facts
Total residents: 47
Resident sample size: 1
Inspection Report — Aug 1, 2023
Life Safety
Date: Aug 1, 2023
Visit Reason
The Office of the State Fire Marshal conducted a scheduled fire safety inspection at the facility.
Findings
The inspection identified multiple fire safety violations including blocked fire doors, missing documentation for required maintenance and testing, and improper signage on emergency exit gates. Several violations were corrected on site, but the overall status remains Disapproved due to outstanding issues.
Deficiencies (9)
IFC 607.3.3 (2018) - Facility is unable to provide documentation for the semi-annual hood cleaning.
IFC 705.2 (2018) - The fire rated door to laundry is blocked by a baby gate.
IFC 705.2.4 (2018) - The fire rated door on room 8 would not close and latch from a fully open position.
IFC 901.6 (2018) - There was a missing escutcheon plate from the sprinkler located in the kitchen.
IFC 904.12.5.2 (2018) - Automatic fire-extinguishing systems were serviced not less frequently than every six months and after activation of the system.
IFC 906.2 (2015, 2018) - Portable fire extinguishers were selected, installed and maintained in accordance with NFPA 10.
IFC 907.8 (2018) - Maintenance and testing schedules and procedures for fire alarm and detection systems were in accordance with NFPA 72 with records maintained.
IFC 915.6 (2018) - Carbon monoxide alarms and detection systems were maintained in accordance with NFPA 720 and replaced when inoperable or end-of-life signals were produced.
IFC 705.2 (2018) - The emergency exit gate on the main entry has the wrong code posted on the gate.
Report Facts
Missing fire drills: 9
Missing fire extinguisher maintenance documentation: 3
Inspection Report — Aug 1, 2023
Re-Inspection
Date: Aug 1, 2023
Visit Reason
The Office of the State Fire Marshal conducted an annual fire and life safety inspection of Everett Heritage Court, followed by a required reinspection to verify correction of violations identified during the initial inspection.
Findings
The initial inspection identified multiple fire and life safety violations requiring correction. The reinspection found some violations corrected but others remained uncorrected, resulting in a disapproved status and a required follow-up letter from the facility.
Deficiencies (11)
IFC 607.3.3 (2018) - Hoods, grease-removal devices, fans, ducts and other appurtenances shall be cleaned at required intervals. Facility is unable to provide documentation for the semi-annual hood cleaning.
IFC 705.2 (2018) - Opening protectives in fire-resistance-rated assemblies shall be inspected and maintained. The fire rated door to laundry is blocked by a baby gate.
IFC 705.2.4 (2018) - Swinging fire doors shall close from the full-open position and latch automatically. The fire rated door on room 8 would not close and latch from a fully open position.
IFC 901.6 (2018) - Fire detection and alarm systems shall be maintained in operative condition. There was a missing escutcheon plate from the sprinkler located in the kitchen.
IFC 904.12.5.2 (2018) - Automatic fire-extinguishing systems shall be serviced at least every six months. Inspection shall be by qualified individuals and a certificate forwarded to the fire code official upon completion.
IFC 906.2 (2015, 2018) - Portable fire extinguishers shall be selected, installed and maintained per NFPA 10. Facility provided required maintenance documentation.
IFC 907.8 (2018) - Maintenance and testing schedules for fire alarm and detection systems shall be maintained. Records of inspection, testing and maintenance shall be maintained.
IFC 915.6 (2018) - Carbon monoxide alarms and detectors shall be maintained and replaced when inoperable or end-of-life signals occur. Facility provided required maintenance documentation.
IFC 1010.1.9.7 (2018) WAC 51-54A - Electric locking systems shall be permitted in certain occupancies with conditions. The emergency exit gate on the main entry has the wrong code posted on the gate.
IFC 1203.4 (2018) - Emergency and standby power systems shall be maintained and capable of supplying service within the specified time. Facility is unable to provide documentation for annual servicing of the emergency generator and weekly inspections and monthly full load testing.
IFC 110 (2018) - Fire drills shall be conducted quarterly or monthly as required and records maintained. Facility cannot provide documentation for twelve planned and unannounced fire drills in the previous 12 months; several drills are missing by shift and quarter.
Report Facts
Missing fire drills: 12
Inspection Report — Jul 28, 2023
Complaint Investigation
Date: Jul 28, 2023
Visit Reason
The Department completed a full inspection and a complaint investigation of the Assisted Living Facility on 07/28/2023 due to a complaint, to determine compliance with licensing requirements.
Complaint Details
The complaint investigation referenced complaint number 84716. The department found multiple deficiencies placing residents at risk, including unsafe environment, smoking violations, inadequate negotiated service agreements, lack of tuberculosis testing, infection control failures, medication refusal and availability issues, and freedom of movement restrictions.
Findings
The facility was found not in compliance with multiple Assisted Living Facility licensing requirements, including maintenance and housekeeping, smoking prohibitions, negotiated service agreements, tuberculosis testing, infection control, medication refusal, medication availability, and freedom of movement. Deficiencies placed residents at risk and corrective plans were submitted.
Deficiencies (9)
WAC 388-78A-3090 Maintenance and housekeeping. The facility failed to provide a safe, sanitary, well-maintained environment for all 37 residents, with issues including debris near heating units, worn furniture fabric, mold-like odors, broken ceiling tiles, ants, unlocked fire panel, and feces in the courtyard.
WAC 388-78A-2040 Other requirements. The facility failed to prohibit smoking within 25 feet of doors or windows, exposing all residents to secondhand smoke, with observed smoking less than three feet from entrances and smoke odors in hallways.
WAC 388-78A-2140 Negotiated service agreement contents. The facility failed to develop negotiated service agreements addressing behavioral interventions for 2 of 6 sampled residents, placing those residents at risk for unmet mental health needs.
WAC 388-78A-2480 Tuberculosis Testing Required. The facility failed to ensure 4 of 6 sampled staff were screened for tuberculosis within three days of hire, placing residents at risk of communicable disease exposure.
WAC 388-78A-2610 Infection control. The facility failed to provide fit testing for N95 respirator masks for 6 of 6 sampled staff, placing residents at risk of contracting communicable diseases.
WAC 388-78A-2230 Medication refusal. The facility failed to notify the physician for 1 of 7 sampled residents who refused medications, placing the resident at risk for untreated health care needs.
WAC 388-78A-2240 Nonavailability of medications. The facility failed to obtain prescribed medications in a timely manner for 3 of 7 sampled residents, placing them at risk for medical complications.
WAC 388-78A-2210 Medication services. The facility failed to develop and implement systems to support safe medication services for 2 of 7 residents, placing them at risk for medication mismanagement and medical complications.
WAC 388-78A-2380 Freedom of movement. The facility failed to ensure visitors were able to exit on their own free will, causing unnecessary waiting for personnel assistance.
Report Facts
Residents living at facility: 37
Sampled residents: 7
Sampled staff: 6
Inspection Report — Jul 10, 2023
Complaint Investigation
Date: Jul 10, 2023
Visit Reason
The inspection was conducted as a complaint investigation regarding multiple allegations of resident neglect, including a resident being missing from the facility, extreme weight loss, failure to monitor residents' well-being, failure to provide medications and fluids, and failure to report significant changes in residents' conditions.
Complaint Details
The complaint investigation involved multiple allegations including a resident missing from the facility, extreme weight loss, neglectful care, failure to provide medications and fluids, and failure to report significant changes in condition. The investigation substantiated failed provider practices and citations were written for multiple violations. The resident who left the facility was found by police 2 miles away. Weight loss was documented and interventions were inadequate. Medication administration failures were documented. The facility was cited and plans of correction were signed.
Findings
The investigation found multiple failed provider practices including failure to monitor residents' weight loss, failure to secure exit doors leading to a resident leaving the facility, failure to provide medications and fluids, and failure to notify appropriate parties of significant changes in residents' conditions. Citations were written for violations of WAC 388-78A-2170, 2120, 2640, and others. The facility was under a plan of correction for some medication issues. The report documents detailed findings for multiple residents and includes plans of correction signed by the administrator.
Deficiencies (5)
WAC 388-78A-2170 Required assisted living facility services. The facility failed to keep 1 of 8 sampled residents safe in the secured memory care unit, resulting in a resident leaving through an unsecured door and ambulating 2 miles from the facility.
WAC 388-78A-2120 Monitoring residents well-being. The facility failed to identify, evaluate, and intervene for weight loss in 3 of 8 sampled residents, resulting in continued weight loss and malnutrition risk.
WAC 388-78A-2640 Reporting significant change in resident's condition. The facility failed to notify the case manager, resident representatives, and medical provider of significant changes in condition for 4 of 8 sampled residents, resulting in delayed care and hospitalization.
WAC 388-78A-2600 Policies and procedures. The facility failed to have a policy to guide staff when a resident does not have an established primary care physician, resulting in 1 of 8 sampled residents not receiving medications for 5 days and being hospitalized.
WAC 388-78A-2240 Nonavailability of medication. The facility was under a plan of correction for medication nonavailability but failed to provide medications for 5 days to a resident, though no citation was issued for this incident.
Report Facts
Total residents: 44
Resident sample size: 6
Closed records sample size: 2
Weight loss: 15
Weight loss: 9.5
Weight loss: 10
Medication missed doses: 5
Inspection Report — Feb 24, 2023
Complaint Investigation
Date: Feb 24, 2023
Visit Reason
The inspection was conducted as a complaint investigation regarding allegations that several falls of a named resident were not reported to the family.
Complaint Details
The complaint alleged that a named resident had several falls that were not reported to the family. The investigation confirmed failures in incident reporting and investigation for multiple residents, including the named resident. The facility did not complete incident reports or investigations for falls occurring on 03/25/2023 and other dates, and failed to notify families or the complaint resolution unit as required.
Findings
The investigation found failed practices related to noncompliance with Washington Administrative Codes concerning investigations, reporting abuse and neglect, and policies and procedures. Several residents had unwitnessed falls and bruising with no documented investigations or notifications. The facility failed to ensure proper incident investigations and reporting.
Deficiencies (4)
WAC 388-78A-2371 Investigations. The assisted living facility failed to investigate and document investigative actions and findings for alleged or suspected abuse, neglect, or incidents jeopardizing resident health or life. The facility failed to ensure falls and injuries were fully documented and investigated for 14 of 17 sampled residents.
WAC 388-78A-2630 Reporting abuse and neglect. The assisted living facility failed to report to the department's complaint resolution unit 10 of 17 sampled residents' incidents with no investigations, placing residents at risk for abuse, neglect, additional falls, injuries, and diminished quality of life.
WAC 388-78A-2600 Policies and procedures. The assisted living facility failed to have written policies for incident investigations and reporting to the complaint resolution unit and failed to implement falls response procedures for 14 of 17 sampled residents with unwitnessed falls or bruising, placing residents at risk for abuse, neglect, additional falls, and diminished quality of life.
WAC 388-78A-2260 Storing, securing, and accounting for medications. The assisted living facility failed to ensure medications were properly stored and secured for 1 of 17 sampled residents; inhalers were stored in an unsafe and unsecured area accessible to memory care residents.
Report Facts
Total residents: 45
Resident sample size: 17
Residents with falls not fully documented or investigated: 14
Residents with incidents not reported to complaint resolution unit: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Glover | Complaint Investigator | Named as the investigator conducting the complaint investigation |
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