Inspection Reports for Mountain Glen Retirement Community
1810 E Division St, Mount Vernon, WA, 982744633
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
10.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
71% worse than Washington average
Washington average: 6.3 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
59 residents
Based on a October 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Life Safety
Deficiencies: 0
Date: Oct 8, 2025
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at Mountain Glen Retirement Center on 10/08/2025.
Findings
All violations noted during previous related inspections have been corrected.
Inspection Report
Follow-Up
Capacity: 60
Deficiencies: 2
Date: Nov 8, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility on 11/08/2024 to verify correction of previous deficiencies.
Complaint Details
The complaint investigation referenced complaint number 142599 and was part of the full inspection conducted on 09/12/2024.
Findings
The follow-up inspection found no deficiencies. However, a prior full inspection and complaint investigation on 09/12/2024 found the facility did not meet licensing requirements due to staff not completing required specialty training in developmental disabilities, dementia, and mental health, as well as continuing education.
Deficiencies (2)
Failure to ensure 4 of 6 staff completed specialty developmental disabilities training, 3 of 6 staff completed specialty dementia training, and 1 of 6 staff completed specialty mental health training.
Failure to ensure 1 of 6 staff completed 12-hours of Department of Social and Health Services approved continuing education per year.
Report Facts
Residents reviewed during inspection: 7
Total current residents: 60
Former residents reviewed: 1
Staff not completing specialty developmental disabilities training: 4
Staff not completing specialty dementia training: 3
Staff not completing specialty mental health training: 5
Staff not completing continuing education: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Executive Director | Named in deficiency for not completing specialty developmental disabilities training |
| Staff B | Caregiver | Named in deficiencies for not completing specialty developmental disabilities and dementia training |
| Staff C | Caregiver | Named in deficiencies for not completing specialty developmental disabilities, dementia, and mental health training |
| Staff D | Caregiver | Named in deficiency for not completing specialty developmental disabilities training |
| Staff F | Medication Technician | Named in deficiency for not completing continuing education |
| Staff H | Business Office Manager | Provided statements regarding staff training and continuing education |
| Jodi Condyles | ALF Licensor | Department staff who inspected the facility |
| Cristina Gonzalez | ALF Licensor | Department staff who inspected the facility |
| Judith Mellon | RN, Licensor | Department staff who inspected the facility |
Inspection Report
Follow-Up
Census: 59
Deficiencies: 1
Date: Oct 25, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to the implementation of negotiated service agreements.
Complaint Details
Complaint investigation conducted from 2024-08-22 through 2024-08-29 regarding a Named Resident who had not received a proper shower in three months, was supposed to wear pressure stockings but did not, and had pressure sores. The investigation substantiated failure to provide showers as agreed, resulting in a citation. No failed practice was identified regarding pressure stockings or wound care.
Findings
The follow-up inspection found no deficiencies, confirming that the previously cited deficiency regarding failure to provide care as agreed in the negotiated service agreement was corrected. The complaint investigation found one failed practice related to failure to provide showers as agreed, resulting in a citation.
Deficiencies (1)
Failure to implement the care and services as agreed upon in the negotiated service agreement, specifically not providing showers twice per week in the spa bathroom as required.
Report Facts
Total residents: 59
Resident sample size: 3
Resident bed bath refusals: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Allison Nunn | Long Term Care Surveyor | Investigator conducting complaint and follow-up inspections |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 12, 2024
Visit Reason
The Office of the State Fire Marshal conducted an inspection at Mountain Glen Retirement Center on 09/12/2024 to verify correction of previous violations.
Findings
All violations noted during previous related inspections have been corrected.
Report Facts
Inspection date: Jul 16, 2024
Number of fire drills not documented: 12
Next inspection scheduled on or after: Aug 15, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandon G. Brown | Deputy State Fire Marshal | Conducted the inspection and signed the report |
| Mark Luschny | Plant Ops Director | Owner or Authorized Representative who signed the report |
Inspection Report
Life Safety
Deficiencies: 18
Date: Aug 16, 2023
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at Mountain Glen Retirement Center to assess compliance with fire protection codes and regulations.
Findings
The inspection identified multiple violations including combustible storage in mechanical rooms, improper use of multiplug adapters and extension cords, lack of documentation for cleaning and maintenance of fire safety systems, and malfunctioning fire doors. The facility was unable to provide required documentation for annual and periodic inspections and testing of fire safety equipment and systems.
Deficiencies (18)
Combustible storage within the mechanical room near the dining room.
Multi-plug adapter without over current protection in use in room #523.
Extension cords utilized as permanent wiring in the Wellness Director's office and room #523.
Facility unable to provide documentation for the semi-annual hood cleaning.
Facility unable to provide documentation that the annual fire resistance rated construction material inspection has been completed.
Facility unable to provide documentation that the annual fire door inspection has been completed.
Fire rated cross corridor door near room #525 would not close and latch from the fully open position.
Facility unable to provide documentation for the 4 year fire and smoke damper inspection.
Facility unable to provide documentation for the annual sprinkler system inspection, 5 year internal piping inspection, 3 year dry system full flow trip test, and quarterly sprinkler system inspections.
Facility unable to provide documentation for the semi-annual kitchen suppression system servicing.
Facility unable to provide documentation for the annual fire alarm system testing.
Multiple smoke detector heads installed within 36 inches of an air supply diffuser or return air opening, preventing proper operation.
Power breaker #2 in panel X for the fire alarm system is missing locking device.
Facility unable to provide documentation for the required smoke detector sensitivity testing.
Facility unable to provide documentation for the monthly carbon monoxide detector testing.
Facility unable to provide documentation for the annual 90 minute power test for the emergency lights.
Facility unable to provide documentation for the annual servicing of the emergency generator and weekly inspections and monthly 30 minute full load testing.
Facility cannot provide documentation for the completion of twelve planned and unannounced fire drills in the previous 12 months.
Report Facts
Inspection date: Aug 16, 2023
Next inspection scheduled: Sep 15, 2023
Provider Number: 2328
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandon G. Brown | Deputy State Fire Marshal | Conducted the fire safety inspection |
| Mark Liechty | Plant Ops Director | Owner or Authorized Representative signing inspection documents |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 21, 2023
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility on 04/21/2023 to verify correction of previous deficiencies.
Findings
The follow-up inspection found no deficiencies and the facility meets the Assisted Living Facility licensing requirements. Previously cited deficiencies were corrected.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberley Ripley | Assisted Living Facility Licensor | Named as department staff who did the off-site verification and inspection. |
Inspection Report
Enforcement
Deficiencies: 1
Date: Feb 10, 2023
Visit Reason
The Department of Social and Health Services completed an investigation at Mountain Glen Retirement Community on February 10, 2023, resulting in a civil fine due to failure to correct violations from four Fire and Life Safety annual inspections.
Findings
The licensee failed to correct violations from four Fire and Life Safety annual inspections conducted between August and December 2022, placing residents at risk of harm in the event of a fire. This deficiency was previously cited on December 7, 2022.
Deficiencies (1)
Failure to ensure violations from four Fire and Life Safety annual inspections were corrected.
Report Facts
Civil fine amount: 700
Number of fire and life safety inspections with violations: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jayne Hill | Field Manager | Contact person for plan of correction and appeals. |
| Matt Hauser | Compliance Specialist | Signed the enforcement letter. |
Inspection Report
Life Safety
Deficiencies: 9
Date: Feb 6, 2023
Visit Reason
The Office of the State Fire Marshal conducted an inspection at Mountain Glen Retirement Center to evaluate compliance with fire safety codes and regulations.
Findings
The inspection identified multiple fire safety violations including delaminating fire rated doors that would not close and latch properly, lack of documentation for required fire system inspections and testing, failed smoke detector sensitivity testing, and blocked emergency exits. Several deficiencies were corrected onsite, while others require further action.
Deficiencies (9)
The fire rated resident door to room #513 is delaminating and would not close and latch from a fully open position.
The fire rated resident door to room #412 is delaminating.
The latest annual sprinkler system inspection had multiple deficiencies not corrected.
Facility unable to provide documentation for the 3 year dry system full flow trip test.
The latest annual alarm system testing had multiple deficiencies not corrected.
Facility unable to provide documentation for the required smoke detector sensitivity testing.
Laundry bin blocking the emergency exit on the 1st floor exit #613.
Internally illuminated exit signs near stairwell exits #612 and #432 did not illuminate in normal operation.
Oxygen cylinders in room #414 are not secured to prevent cylinders from falling.
Report Facts
Inspection date: Feb 6, 2023
Next inspection scheduled: Mar 8, 2023
Failed smoke detectors: 167
Damper failures: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandon G. Brown | Deputy State Fire Marshal | Signed inspection report |
| Mark Liechty | Plant Operations Director | Facility representative who signed inspection report |
Inspection Report
Life Safety
Deficiencies: 12
Date: Nov 7, 2022
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at Mountain Glen Retirement Center.
Findings
The facility was disapproved due to multiple fire safety violations including lack of documentation for annual fire wall and fire door inspections, deficiencies in fire door operation, missing documentation for fire and smoke damper inspections, sprinkler system deficiencies, and incomplete testing and maintenance of fire alarm and detection systems.
Deficiencies (12)
Facility is unable to provide documentation that the annual fire wall inspection has been completed.
Facility is unable to provide documentation that the annual fire door inspection has been completed.
Fire rated doors on multiple floors and rooms would not close and latch from a fully open position or are delaminating.
Facility is unable to provide documentation for the 4 year fire and smoke damper inspection.
Latest annual sprinkler system inspection had multiple deficiencies not corrected; missing documentation for 5 year internal piping inspection and 3 year dry system full flow trip test.
Facility is unable to provide documentation for the semi-annual kitchen suppression system servicing.
Latest annual alarm system testing had multiple deficiencies not corrected.
Facility is unable to provide documentation for the required smoke detector sensitivity testing.
Laundry bin blocking the emergency exit on the 1st floor exit #613.
Path of egress travel was obstructed by a laundry bin blocking the emergency exit.
Internally illuminated exit signs in stairwells near exit #612 and room #432 did not illuminate in normal operation.
Oxygen cylinders in room #414 are not secured to prevent cylinders from falling.
Report Facts
Next inspection scheduled date: Dec 7, 2022
Next inspection scheduled date: Oct 22, 2022
Next inspection scheduled date: Sep 16, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandon G. Brown | Deputy State Fire Marshal | Signed inspection reports and enforcement documents |
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