Inspection Reports for
The Terrace at Beverly Lake

The complaint investigation (Complaint #220586) alleged insufficient staffing, failure to follow offloading education, and inadequate skin care for chairfast residents. The investigation substantiated the failure to assess and manage a pressure injury for one resident, resulting in citations. Staffing and offloading education allegations were not substantiated.

The investigation found that the facility followed staffing requirements but failed to conduct an assessment and provide proper wound care for one resident with a pressure injury. Citations were issued for these deficiencies.

The original complaint investigation (08/13/2025 through 08/19/2025) alleged multiple issues including insufficient PPE supplies, damaged housekeeping carts, lack of door stoppers, residents walking barefoot on wet floors, unsanitary resident rooms, and inadequate hygiene. The investigation substantiated a failed practice related to housekeeping and cleanliness but found no issues with PPE, housekeeping carts, door stoppers, barefoot residents, or hygiene. The follow-up inspection on 10/10/2025 found all deficiencies corrected.

The follow-up inspection found no deficiencies; previously cited issues with housekeeping and facility cleanliness were corrected. The facility now provides a safe, clean, and comfortable environment for residents as required.

The facility was cited for uncorrected deficiencies related to staff training and failure to notify the Department of Health Construction Review Services prior to renovations. These violations placed residents and others at risk and resulted in civil fines totaling $1,800.

This was a complaint investigation triggered by allegations related to fall prevention. The investigation confirmed the violation leading to a civil fine.

The facility was fined $400 for failing to investigate and document appropriate measures to prevent future falls after three residents experienced falls. This violation was recurring from previous citations.

All violations noted during previous related inspections have been corrected. The facility was disapproved on 08/27/2025 but the latest inspection on 09/09/2025 shows all prior violations corrected and the approval status is Approved.

The facility was cited for uncorrected deficiencies including failure to ensure staff completed required First Aid training and failure to notify the Department of Health Construction Review Services prior to renovations. These violations placed residents and others at risk and resulted in civil fines totaling $1,000.

The complaint investigation (Compliance Determination #60867) was triggered by an allegation that the facility failed to refund a deceased resident's payment in a timely manner. The investigation confirmed the failure and issued a citation. The follow-up inspection found the deficiency corrected.

The follow-up inspection on 08/15/2025 found no deficiencies and confirmed that the previously cited deficiency regarding failure to refund a resident's payment was corrected.

The complaint investigation from 08/21/2024 through 11/21/2024 involved two residents testing positive for COVID-19. The facility failed to have a respiratory protection program and failed to complete new and yearly N95 fit testing, resulting in citations for infection control violations.

The follow-up inspection on 08/07/2025 found no deficiencies and confirmed that the previously cited infection control deficiencies were corrected.

The facility was cited for three uncorrected deficiencies related to staff training, service agreement signing, and failure to notify the Department of Health prior to renovations. These violations resulted in civil fines totaling $800.

The complaint investigation referenced multiple complaint numbers and found that the facility failed to notify the Department case managers upon the death of residents, causing overpayments. The issue was corrected on site and payments were reverted. A protocol was created to prevent recurrence.

The Assisted Living Facility failed to notify the Home and Community Services case manager as required upon the death of residents, resulting in overpayments. The facility corrected the issue at the time of the visit and reverted the payments back, and created a protocol to ensure timely notification in the future.

The facility failed to ensure 53 staff were fit tested for N-95 respirators, violating their Respiratory Protection Program and placing 45 residents, staff, and visitors at risk. This deficiency is recurring and uncorrected despite previous citations.

The complaint involved allegations of poor hygiene and care for a named resident, including dirty hands and nails, sleeping on a wet mattress, unclean clothes, weight loss, long toenails, and self-inflicted hair cutting. The investigation found these allegations unsubstantiated with no citations issued.

The investigation found that the named resident and sampled residents were generally clean and well cared for, with no failed provider practices identified. A consultation was written for housekeeping due to dirty rooms that were cleaned immediately. No citations were issued.

The facility failed to implement required infection control measures by not having a written Respiratory Protection Program and not ensuring all 57 staff were fit tested for N-95 respirators. This deficiency was recurring and uncorrected, resulting in a $600 civil fine.

The inspection found multiple deficiencies related to fire safety equipment testing, maintenance, and documentation. Several violations were corrected on site, but key documentation for testing and maintenance of fire alarm, sprinkler, smoke detector, and carbon monoxide systems was not provided, resulting in a disapproved status.

The complaint investigation involved an allegation that a staff member laid in bed with a resident to help them sleep. The facility suspended the staff member temporarily but failed to conduct or document a thorough investigation and did not provide requested records to the department. The allegation was determined by the facility to be unsubstantiated and the staff member was reinstated. The resident involved moved to a different care facility.

The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies were corrected.

The inspection found multiple deficiencies related to fire safety equipment maintenance, documentation, and fire drills. Several violations remain uncorrected, resulting in a disapproved status.

All violations noted during previous related inspections have been corrected. The facility is currently approved with no open violations.

Complaint investigation regarding named residents testing positive with COVID-19 and failure to follow infection control practices including lack of PPE outside isolation rooms and lack of N95 fit testing for staff.

The follow-up inspection on 04/24/2023 found no deficiencies; all previously cited infection control deficiencies were corrected.

The complaint investigation (Compliance Determination #19874) involved ten named residents with symptoms of nausea, vomiting, and diarrhea. The facility did not investigate these symptoms or the death of one resident, resulting in a failed provider practice and citations.

The facility failed to investigate and document the circumstances surrounding the symptoms and death of a resident, placing all residents at risk of abuse, neglect, and diminished quality of life. Citations were written for these failures.

The complaint investigation (Complaint #63574) concerned an allegation that a resident was injured during a blood sugar test. The investigation found the facility failed to timely report the incident to law enforcement and the department, and failed to suspend the involved staff member during the investigation. Citations were issued for these failures.

The facility failed to report an incident of suspected physical abuse in a timely manner to the department and law enforcement, and failed to report the employee's certification status to the nursing assistants licensing board. The employee was allowed to continue working during the investigation. The department identified failed provider practices and issued citations.

The complaint investigation dated 07/26/2022 found that the facility failed to obtain approval a second time from the Fire Marshal, resulting in a citation under WAC 388-78A-2040 (2).

The follow-up inspection on 11/02/2022 found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies under WAC 388-78A-2040-2 were corrected.