Empress Senior Living at Laurelhurst

A memory care resident with documented elopement risk and exit-seeking behaviors eloped from the locked unit after dietary and reception staff mistook her for a visitor and escorted her out. The resident was found 1.75 hours later half a mile away after falling on the sidewalk with injuries requiring emergency room treatment. The facility lacked policies to ensure non-memory-care staff could identify at-risk residents, but conducted a thorough investigation, identified root causes, implemented corrective policies, and achieved compliance at follow-up inspection with no deficiencies found.

The inspection identified three moderate violations: failure to assess and document a resident's dialysis fistula surgery creating potential for unrecognized complications, one staff member working 501 days with an expired background check, and another staff member working 2.5 years without any background check. The facility responded appropriately by immediately initiating corrective actions during the inspection, submitting background check applications on-site, and committing to systemic monitoring improvements. All deficiencies were corrected by the follow-up inspection, and the facility demonstrated good cooperation with inspectors throughout the process.

The facility had three moderate violations affecting resident quality of life and safety: failure to post weekly menus in advance, incomplete tuberculosis screening documentation for one staff member (exposing residents to communicable disease risk), and an improperly secured bed rail creating entrapment risk for one resident. The facility responded appropriately with timely corrective actions, completing all corrections by the target date of October 5, 2023, and successfully passing the follow-up inspection on October 17, 2023 with no deficiencies found.

The March 2023 inspection identified 11 violations, all related to missing documentation for required annual safety system inspections and testing (fire doors, sprinklers, fire alarms, smoke detectors, CO detectors, emergency lighting, generator). Additionally, two fire doors failed to close properly and three areas lacked required CO detectors. The facility responded appropriately, correcting all violations by the August 2023 follow-up inspection, demonstrating adequate commitment to compliance despite the initial documentation and maintenance gaps. These were primarily administrative and maintenance issues with no evidence of immediate resident harm, though the cumulative pattern of missed inspections across multiple critical safety systems elevates concern beyond minor non-compliance.

The facility experienced a COVID-19 outbreak affecting four residents and one staff member, which triggered an investigation revealing failures in respiratory protection program (RPP) implementation and staff fit testing requirements. These violations represent moderate systemic gaps in infection control protocols that could compromise resident safety during respiratory illness outbreaks. The facility's response was adequate but not comprehensive, as citations were issued indicating the problems were identified through investigation rather than proactive facility correction, though the investigation methods suggest cooperation with regulatory review.