Greenlake Emerald City

The licensee failed to implement policies regarding accidents, incidents, unusual occurrences, emergency transport, major medical emergencies, mental health deterioration, psychiatric crisis, and suicide precautions for one resident, which contributed to a second suicide attempt.

Facility failed to implement policies for accidents, incidents, medical emergencies, mental health crises, and suicide precautions for a resident who had suicidal ideations and a suicide attempt. Facility staff did not call 911 or contact mental health professionals when aware of the danger.

Facility failed to document reasons for discharge or include required advocacy information in the medical record for a resident given a discharge notice.

The facility failed to record reasons for a resident's discharge in the resident's record. Furthermore, the discharge notice issued to the resident lacked the required contact information for the agency responsible for the protection and advocacy of individuals with mental illness.

The licensee failed to ensure two staff completed the required facility orientation.

The licensee failed to identify and secure hazardous chemicals in a housekeeping cart, common bathroom, and a resident room in the Memory Care Unit (MCU).

The licensee failed to ensure two resident's medications were securely and safely stored.

The licensee failed to ensure safe medication systems were maintained when two narcotic books were without change of shift signatures.

The licensee failed to ensure the building and two residents' apartments were sanitary, safe and in good repair.

Failed to ensure 2 of 6 staff members completed required facility orientation training.

Failed to identify and secure hazardous chemicals in housekeeping carts and resident rooms in the Memory Care Unit.

Failed to ensure medications were securely stored for 2 of 3 residents and failed to maintain proper sign-off sheets for narcotic counts.

Failed to ensure safe medication systems, specifically regarding controlled substance narcotic book change of shift signatures.

Failed to ensure the building and resident apartments remained in a sanitary and safe condition.

Confidential list of resident names displayed in a public binder in the lobby.

3 of 6 sampled staff members failed to complete the required two-step tuberculin skin test.

1 of 6 sampled staff members (the Administrator) failed to have a completed national fingerprint background check.

Failure to ensure staff had current CPR certification, 12 hours of annual continuing education, and required facility orientation.

Failed to document interventions for resident care needs in Service Plans for 5 of 12 sampled residents.

Hazardous chemicals identified, stove top in Memory Care Unit not disconnected, and housekeeping cart unsecured.

Facility failed to obtain written consent for nurse delegation for 13 residents receiving skilled medication administration.

Facility failed to maintain an emergency supply of food in preparation for disasters, leaving 109 residents at risk.

Failed to complete a preadmission assessment for Resident 9.

Facility failed to ensure medications were securely and safely stored for 3 of 3 residents (Resident 3, 14, and 15). Unsecured medications were found in residents' apartments.

Facility failed to implement policy for smoking; a resident was found smoking in their apartment.

Failure to ensure juice machine cleaning, proper handwashing sink usage, labeling/dating ready-to-eat foods, and lack of valid food worker cards for staff.

The facility failed to ensure a full assessment was completed within 14 days of moving into the ALF for Resident 9, as it was completed 35 days after admission.

Medication technicians (Staff O and Q) failed to perform proper hand hygiene and infection control practices while passing medications.

Facility failed to ensure negotiated service agreements were signed annually for 5 of 12 sampled residents.

Facility failed to complete evaluations and obtain informed consent for 2 residents (11 and 13) using video cameras in their apartments.

Facility failed to ensure medications were administered in a timely manner (Residents 5, 6, 9, 10), failed to maintain proper narcotic counts, and performed unauthorized pre-pouring of medications.

Facility failed to maintain safe/sanitary environments in resident quarters (7 of 12) and did not properly store wet mops.

Facility failed to ensure prescribed medications were available for 6 of 12 sampled residents, resulting in missed doses (DNA - Drug Not Available).

Failure to ensure safe, timely medication administration; lack of narcotic count verification; medications administered without proper ID; four residents did not receive medications as prescribed.

Failure to ensure medications were available for six residents, resulting in them not receiving medications as prescribed.

The licensee failed to notify the physician or conduct an evaluation when one resident refused their medication, placing the resident at risk for a decline in health status. This was an uncorrected deficiency from February 21, 2025.

Facility failed to ensure Resident 2 received prescribed monthly haloperidol injections as ordered, resulting in inconsistent administration intervals (51 days and 37 days between doses). Deficiency was previously cited on 08/09/2024.

Facility failed to notify the physician or conduct a licensed nurse evaluation for Resident 1, who had a consistent pattern of refusing Parkinson's and dementia medications from November 2024 through January 2025.

Facility failed to implement skin care management policy for 2 residents with skin breakdown; failed to document interventions, follow-ups, and weekly skin assessments.

Facility failed to implement the Negotiated Service Agreement and complete safety checks (4 times per shift) for 1 resident (Resident 9) who was later found deceased.

Resident 9 was found deceased in their bathroom. Investigation revealed that care staff failed to conduct required safety checks during the evening and night shifts, with staff citing a lack of knowledge regarding the care plan or reliance on call lights rather than proactive checks.