Greenlake Emerald City

The facility failed to implement multiple suicide prevention and mental health crisis policies for a resident experiencing suicidal ideations, plans, and a suicide attempt. This systemic failure resulted in the resident not receiving necessary mental health interventions, directly contributing to a second suicide attempt requiring hospitalization. This is a recurring deficiency previously cited twice in 2025 (February and June), demonstrating a pattern of non-compliance. The facility's inadequate response to prior citations and continued failure to protect a vulnerable resident resulted in a $2,000 civil fine and represents severe risk to resident safety.

This follow-up inspection on August 7, 2025 found five uncorrected deficiencies from a previous June 5, 2025 inspection, indicating a pattern of systemic non-compliance. Critical violations included unsecured hazardous chemicals in the Memory Care Unit exposing 15 cognitively impaired residents to poisoning risk, unsafe medication storage and narcotic accountability failures affecting 32 residents, and incomplete staff orientation training. The facility's response was inadequate, as evidenced by repeated failures to correct previously cited deficiencies within the 60-day correction period, resulting in escalating civil fines totaling $1,700 and demonstrating insufficient corrective action despite multiple opportunities.

The facility had severe medication management failures affecting 10 residents total, including failure to administer medications as prescribed, missing narcotic verification signatures, and unavailable medications for six residents. These are recurring violations previously cited three times in the prior 10 months (August 2024, September 2024, November 2024, February 2025), demonstrating a pattern of systemic non-compliance. The facility's response has been inadequate, as evidenced by repeated citations for the same deficiencies, resulting in $1,600 in civil fines. No evidence of effective corrective action or systemic improvements is present in the report.

The facility failed to notify the physician or conduct an evaluation when a resident refused medication, placing the resident at risk for health decline. This is particularly concerning as it represents an uncorrected repeat violation previously cited on February 21, 2025. The facility's response was inadequate, as evidenced by the failure to correct the deficiency after the initial citation, resulting in a $400 civil fine at the follow-up visit. The repeat nature of this medication management violation indicates systemic issues with staff training or policy implementation.

A resident was found dead on the bathroom floor when breakfast was delivered, and the facility failed to conduct required four-times-per-shift safety checks as specified in the care plan. Additionally, the facility failed to implement its skin care management policy for residents with wounds, with a newly employed nurse admitting she was unaware of residents' care needs during training. The facility conducted investigations into allegations of abuse, neglect, and medication diversion but could not substantiate those claims; however, the failure to execute existing care plans for vulnerable residents, resulting in one death, demonstrates serious systemic gaps in care delivery and supervision.

The facility had serious medication management failures affecting at least two residents: one resident refused Parkinson's and dementia medications 181 times over three months without physician notification or nursing evaluation, and another resident missed scheduled monthly antipsychotic injections (administered only twice in five months instead of five times), resulting in increased behavioral symptoms. The facility acknowledged the violations and the Health Services Director was aware of the issues, but there was no evidence of proactive monitoring systems or timely corrective action until the investigation occurred. This represents a repeat violation previously cited in August 2024, indicating systemic failure in medication administration oversight.

This facility had recurring serious medication management failures, with residents missing multiple critical doses of blood pressure, heart failure, and anticoagulation medications over extended periods (up to 31 consecutive doses), creating substantial harm potential. The facility also failed to implement required Respiratory Protection Program standards during a COVID-19 outbreak, lacking written protocols and proper staff fit-testing/medical evaluations. The facility conducted investigations and implemented corrective actions including developing an RPP and establishing monitoring systems, but the medication deficiency remained uncorrected upon follow-up inspection, demonstrating incomplete systematic response despite stated plans of correction.

The facility failed to maintain a compliant Respiratory Protection Program exposing 82 residents to COVID-19 risk, and failed to ensure medication availability causing one resident to miss doses of three prescribed medications. Both violations were previously cited on September 24, 2024, and remained uncorrected at the November 26, 2024 follow-up visit, demonstrating a pattern of non-compliance. The facility's inadequate response to prior citations resulted in civil fines totaling $800, with the medication violation assessed at the higher $500 penalty due to direct resident harm. The repeated failures indicate insufficient corrective action and oversight despite prior regulatory intervention.

The facility failed to administer prescribed antibiotics for a UTI, resulting in 6 missed doses out of 10 (five consecutive missed doses from 06/28-07/01, plus one additional missed dose), which delayed treatment of an active infection for a vulnerable resident. The facility conducted an investigation and acknowledged the medication administration failure but demonstrated gaps in their pharmacy delivery verification and medication administration systems. While two allegations were unsubstantiated, the confirmed medication error represents a serious lapse in basic care protocols that could have led to worsening infection and complications.