6 Reports
Inspection Report — Oct 2, 2025
Life Safety
Date: Oct 2, 2025
Visit Reason
The Office of the State Fire Marshal conducted a scheduled fire safety inspection at the facility.
Findings
No violations were observed during this inspection. The facility passed the fire safety inspection with no deficiencies noted.
Inspection Report — Aug 20, 2025
Annual Inspection
Date: Aug 20, 2025
Visit Reason
The Department of Social and Health Services conducted a full inspection of the Assisted Living Facility on 08/20/2025 to determine compliance with Assisted Living Facility requirements.
Findings
The inspection found that the facility did not meet Assisted Living Facility requirements related to tuberculosis testing. The deficiency was corrected prior to the survey.
Deficiencies (1)
WAC 388-78A-2480 Tuberculosis Testing Required. The assisted living facility must develop and implement a system to ensure each staff person is screened for tuberculosis within three days of employment.
Report Facts
Staff sampled: 6
Inspection Report — May 15, 2025
Complaint Investigation
Date: May 15, 2025
Visit Reason
A complaint investigation was conducted regarding a fire watch at Heron's Key Assisted Living Facility following a fire alarm system test during facility construction.
Complaint Details
Complaint #177073 alleged issues with fire watch during a fire alarm system test. The complaint was investigated and found unsubstantiated as no violations or fire incidents were observed.
Findings
The investigation found no sign of fire, the sprinkler system was not activated, no evacuations occurred, no injuries were reported, and the fire department did not respond. Fire watch documentation was provided and the facility was under construction with the fire alarm system in test mode.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| George Smith | Director of Facilities | Named as Owner or Authorized Representative in the report. |
Inspection Report — Feb 6, 2025
Complaint Investigation
Date: Feb 6, 2025
Visit Reason
An off-site investigation was conducted in response to complaint ID #165127 regarding heating units that were out of service, requiring the use of space heaters in several assisted living facility resident rooms.
Complaint Details
Complaint ID #165127 concerned space heaters used due to inoperable heating units. The investigation confirmed repairs were made to most units, one unit was pending repair, and space heaters were removed. No violations were found.
Findings
The investigation found that all inoperable heating units in multiple apartments have been repaired and restored to full functionality except one unit awaiting a coil part. All pre-approved space heaters have been removed, no residents were evacuated, no injuries occurred, and no fire department response was needed. No violations or IFC code breaches were detected.
Inspection Report — Mar 20, 2023
Follow-Up
Date: Mar 20, 2023
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 (Compliance Determination #17349) found that one resident was not administered blood thinner medication (Coumadin) from 11-7-22 to 12-9-22 due to staff error and lack of follow-up with the anticoagulation clinic and the resident's physician. The facility failed to follow up on medication orders and did not use the Coumadin Flow Sheet as required. No harm to the resident was reported. Citation was written for failed provider practice.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies were corrected.
Deficiencies (1)
WAC 388-78A-2210 (1b) Medication Services. The facility failed to ensure one resident received anticoagulant medication as ordered between 11/10/2022 and 12/09/2022, placing the resident at risk of significant physical harm.
Report Facts
Total residents: 30
Resident sample size: 1
Inspection Report — Nov 8, 2022
Life Safety
Date: Nov 8, 2022
Visit Reason
The Office of the State Fire Marshal conducted a scheduled fire safety inspection at the facility.
Findings
No violations were observed during this inspection. The facility was approved with no deficiencies noted.
4 CMS Surveys
Inspection Report — Nov 15, 2024
Routine
Date: Nov 15, 2024
Visit Reason
The inspection was a routine survey to assess compliance with resident rights, care planning, medication management, safety, staffing, food safety, and sanitary conditions at the nursing home.
Findings
The facility was found deficient in multiple areas including resident rights to room sharing, failure to provide periodic resident rights notices, incomplete advance directives, lack of written transfer and bed hold notices, incomplete care planning for PTSD, inconsistent bowel program implementation, unsafe environment hazards, failure to post accurate nurse staffing hours, use of unnecessary medications without prior non-pharmacological interventions, unsanitary food preparation and storage, and unclean wheelchair equipment. All deficiencies were cited with minimal or potential for minimal harm.
Deficiencies (12)
WAC 388-97-0580(1)(b)(i)(ii) - The facility failed to ensure married residents were provided the right to share a room for 2 of 2 sampled residents. Rooms were single occupancy and residents were not allowed to room together despite requests.
WAC 388-97-0280(2), (3)(a-d) - The facility failed to periodically inform residents of their rights after admission for 8 of 8 sampled residents. Resident council meetings had no attendance and rights were not alternatively communicated.
WAC 388-97-0300(3)(b)(c) - The facility failed to determine if a resident had current advance directives and to update them annually for 1 of 4 sampled residents. Resident 9's advance directive was outdated and not reviewed after condition change.
WAC 388-91-0120(2) (a-d) - The facility failed to provide written notification of the reason for transfer to the hospital for 1 of 1 sampled residents. No documentation of transfer notice was found.
WAC 388-91-0120(4) - The facility failed to provide written bed hold notice at the time of hospital transfer for 1 of 1 sampled residents. No documentation of bed hold was found.
WAC 388-97-1020(1), (2)(a)(b) - The facility failed to develop a comprehensive care plan addressing PTSD for 1 of 8 sampled residents. Resident 6 had no PTSD focus area, goals, or interventions in the care plan.
WAC 388-97-1060(1) - The facility failed to consistently implement the bowel program when needed for 1 of 5 sampled residents. Resident 15 had no documented bowel movements for multiple days and delayed interventions.
WAC 388-97-1060 (3)(g) - The facility failed to ensure a safe environment related to a reclining chair for 1 resident and common area ovens for 2 common areas. Recliner chair lacked safety assessment and ovens were operable despite being out of order.
No Associated WAC - The facility failed to post actual nurse staffing hours daily for 11 of 11 months reviewed. Staffing sheets lacked recorded changes and were incomplete.
WAC 388-97-1060(3)(k)(i) - The facility failed to initiate non-pharmacological interventions prior to administering as needed pain medication for 1 of 5 sampled residents. Resident 14 received pain meds without documented non-drug interventions.
WAC 388-97-1100 (3), -2980 - The facility failed to sanitarily prepare food and monitor resident refrigerators. Cleaning supplies were stored near food, staff had improper hygiene, and resident refrigerators contained unlabeled and expired food including staff items.
WAC 388-97-3220(1) - The facility failed to ensure a sanitary piece of equipment was available for 1 resident. Resident 6's wheelchair armrests were covered with multiple layers of tape and were not cleanable surfaces.
Report Facts
Months missing nurse staffing postings: 11
Number of times Tramadol administered: 18
Number of times Tramadol administered: 6
Number of residents sampled for rights notice: 8
Number of residents sampled for room sharing: 2
Inspection Report — Jan 8, 2024
Complaint Investigation
Date: Jan 8, 2024
Visit Reason
The inspection was conducted based on complaints regarding medication monitoring, medication storage labeling, and food temperature safety at the facility.
Complaint Details
The investigation involved three main allegations: inadequate monitoring of anticoagulant medication side effects, improper labeling and dating of medication vials, and failure to serve meals at safe temperatures. All three allegations were substantiated with findings.
Findings
The facility was found deficient in monitoring residents for adverse effects of anticoagulant medications, labeling and dating of multiuse medication vials, and ensuring meals were served at appropriate temperatures. These deficiencies posed risks to resident safety and quality of life.
Deficiencies (3)
WAC 388-97--1060 (3)(k)(i) - The facility failed to adequately monitor for adverse side effects of anticoagulant medications for 2 of 5 sampled residents, placing them at risk for unidentified adverse effects.
WAC 388-97--1300 (2) - The facility failed to ensure drugs and biologicals were labeled, dated, or discarded according to professional standards for 2 medication carts, risking compromised or expired medications.
WAC 388-97-1100 (1), (2) - The facility failed to ensure residents were served meals at appropriate temperatures, risking foodborne illness and decreased satisfaction.
Report Facts
Sampled residents for medication monitoring: 5
Medication carts reviewed: 2
Residents affected by anticoagulant monitoring deficiency: 2
Residents affected by medication labeling deficiency: 2
Residents affected by food temperature deficiency: Some
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Resident Care Manager | Stated expectation for monitoring anticoagulant medication side effects |
| Staff G | Minimum Data Set Registered Nurse | Reported monitoring order for Resident 9 was not visible to nurses |
| Staff B | Director of Nursing Services | Stated expectation for monitoring anticoagulant medications and labeling of multiuse vials |
| Staff H | Registered Nurse | Stated multiuse vials should be labeled with resident name and date opened |
| Staff J | Licensed Practical Nurse | Reported Resident 18 had completed treatment and tube should have been dated and discarded |
| Staff D | Cook | Reported temperature taking responsibilities for soup and other hot items |
| Staff E | Dietary Aide | Observed temping soup during meal service |
| Staff C | Dietary Manager | Stated expectation for completion of temperature logs and proper food temperature monitoring |
Inspection Report — Aug 31, 2023
Complaint Investigation
Date: Aug 31, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to implement the required two-person assist during mechanical transfers, which resulted in harm to a resident.
Complaint Details
The complaint investigation found that Resident 1 was injured on 08/09/2023 due to being transferred alone with a sit-to-stand lift despite requiring two-person assistance. Staff interviews confirmed the incident and failure to follow policy. The allegation was substantiated with actual harm to the resident.
Findings
The facility failed to follow its Safe Resident Handling Transfers Policy by transferring Resident 1 with only one person instead of two, resulting in a left humeral neck fracture. The investigation confirmed the failure caused actual harm and placed other residents at risk.
Deficiencies (1)
WAC 388-97-1060(3)(g) - The facility failed to ensure two-person assistance during mechanical transfers as required by policy, resulting in a resident sustaining a left humeral neck fracture. This failure caused actual harm and risk to other residents.
Report Facts
Residents Affected: 1
Inspection Report — Sep 20, 2022
Routine
Date: Sep 20, 2022
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including resident care, medication administration, infection control, and facility operations.
Findings
The facility was found to have multiple deficiencies including failure to inform residents of medication changes, failure to provide timely assessments, inaccurate resident assessments, incomplete and inaccurate care plans, medication administration errors, inadequate infection control practices, failure to provide necessary treatments and monitoring, and deficiencies in staff training on abuse reporting. Several residents were affected by these issues, but harm was generally minimal.
Deficiencies (15)
WAC 388-97-0300(3)(a)(b) - The facility failed to inform Resident 1 of changes to their Parkinson's medication administration time and did not obtain consent prior to the change.
WAC 388-97-0300 (1)(e) - The facility failed to provide a Notification of Medicare Non-Coverage to Resident 75 at least two calendar days before Medicare services ended.
WAC 388-97-1000(4)(a) - The facility failed to complete Resident 1's Quarterly Minimum Data Set assessment within 14 days of the Assessment Reference Date.
WAC 388-97-1000 (1)(b) - The facility failed to accurately assess five residents (3, 4, 10, 19, 21) in areas including behaviors, diagnoses, immunizations, falls, and activities.
WAC 388-97-1000 (1)(b) - The facility failed to ensure Resident 19's Activity section of the MDS was completed.
WAC 388-97-1020 (5)(b) - The facility failed to include Resident 21's right knee brace in the care plan and provide related instructions.
WAC 388-97-1620 (2)(b)(ii) - The facility failed to perform timely neurological checks on Resident 11 after a head injury and allowed the resident to fall asleep without monitoring.
WAC 388-97-1060 - The facility failed to provide appropriate care and services including bowel management, skin/wound care, and range of motion services for multiple residents (1, 4, 8, 10, 16, 73).
WAC 388-97-1060(3)(g) - The facility failed to assess Resident 1's environment for accident hazards and implement interventions to prevent re-occurrence of injuries.
WAC 388-97-1060(3)(c) - The facility failed to provide catheter care per orders for Resident 1 including weekly diluted vinegar bladder flushes and use of correct catheter size.
WAC 388-97-1100 (3) - The facility failed to ensure food safety practices including discarding expired food, proper labeling of seasonings, and appropriate hand hygiene and glove use by dietary staff.
WAC 388-97-1320 (2)(b) - The facility failed to follow infection control practices for quarantining Resident 123, including improper use and removal of PPE by staff.
No Associated WAC - The facility failed to implement an antibiotic stewardship program to monitor antibiotic use and resistance.
WAC 388-97-1340 (1), (2), (3) - The facility failed to ensure influenza and pneumococcal vaccines were offered or provided to Residents 8, 10, and 21.
WAC 388-97-0640 (2)(b), 388-97-1680 (2)(b) - The facility failed to provide effective training for staff on how to report abuse allegations.
Report Facts
Days without bowel movement: 10
Days without bowel movement: 5
Days without bowel movement: 4
Days without bowel movement: 4
Days without bowel movement: 5
Days without bowel movement: 5
Medication held: 3
Oxygen saturation readings: 60
Oxygen saturation below 93%: 2
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