Everett Heritage Court.

WAC 388-78A-2170(1): The facility failed to ensure the safety and well-being of a resident with elopement risk and severe cognitive impairment who left the facility unsupervised through an unlocked memory care unit secured exit door on 09/25/2025, resulting in the resident going missing and being found by police at a nearby cemetery. The facility also failed to conduct regular elopement drills as required by their own policy.

WAC 388-78A-2466: The facility failed to ensure 2 of 2 staff (Staff E and F) had valid Washington State name and date of birth background checks completed every two years. Staff E's check was 67 days late and Staff F's was 336 days late, placing residents at risk of being cared for by staff with potentially disqualifying backgrounds. WAC 388-78A-2468: The facility failed to ensure 1 of 6 staff (Staff E) had a Washington State name and date of birth background check submitted within one business day after hire. Staff E's check was submitted 10 days after their hire date of 07/01/2023, placing residents at risk. WAC 388-78A-2485: The facility failed to ensure 1 of 1 staff (Staff C) completed a chest X-ray within seven days after a positive tuberculosis blood test result on 05/06/2025. This failure placed residents at risk of exposure to a communicable disease. WAC 388-78A-2480: The facility failed to ensure 2 of 4 staff (Staff B and Staff D) completed tuberculosis testing within three days of hire. Staff B was hired on 07/24/2025 and Staff D on 04/15/2025 with no documentation of TB testing, placing residents at risk of exposure to a communicable disease.

WAC 388-78A-3090(1)(c): The facility failed to keep equipment and furnishings in good repair. A resident's emergency pull cord string was missing for approximately one month, their bathroom light was not working, and staff did not respond to repair requests, placing the resident at risk for compromised safety.

WAC 388-78A-2090: The assisted living facility failed to assess whether residents were safe to use or have portable heaters in their rooms. The facility did not complete a full assessment addressing safety considerations that may pose a danger to residents, such as the use of medical devices or other safety hazards related to the portable heating equipment.

WAC 388-78A-2140(2): The facility failed to have a written policy and procedure documenting how residents of the bottom floor would have access to an outdoor area. The facility did not have a clear plan for bottom floor residents to access outdoor space for social interactions and activities, placing them at risk for unmet services and decreased quality of life.

WAC 388-78A-2410(9): The Assisted Living Facility failed to document in the Residents' records observations and assessments for 2 of 2 Residents with skin issues. The facility did not perform weekly assessments and documentation as required by their own Skin Care Management policy, which resulted in failure to monitor and assess the Residents' skin issues to determine and timely address potential complications or worsening conditions. WAC 388-78A-2600(1)(b): The Assisted Living Facility failed to ensure policies and procedures were implemented to provide necessary care and services for residents with special needs. Specifically, the facility failed to ensure weekly assessments, follow-up, and documentation for a resident with skin issues were completed as outlined in their Skin Care Management policy.

WAC 388-78A-2600: The facility failed to implement alert charting policy for residents with falls and changes in condition. Two sampled residents were not placed on alert charting after falls or hospital returns, placing them at risk for unrecognized complications. WAC 388-78A-2371: The facility failed to investigate, document investigative actions, and determine circumstances when staff found a bruise on a resident's left hip. The facility could not rule out abuse and neglect, and the resident was placed at risk for future incidents.

WAC 388-78A-2170: Facility failed to maintain secure premises. An unlocked kitchen door and an unalarmed gate door that was regularly left unlocked allowed a resident to leave the facility undetected, resulting in the resident being found 2 miles away by police. WAC 388-78A-2120: Facility failed to monitor resident well-being. A resident experienced a 15-pound weight loss over 4 months that was not identified by the facility, and the medical provider was not aware of the weight loss. WAC 388-78A-2120: Facility failed to monitor resident well-being. A resident lost 6 pounds over six months and was documented by hospital staff as 'thin and malnourished' with a BMI of 15.97 kg/m2, indicating inadequate nutritional monitoring and care. WAC 388-78A-2640: Facility failed to report significant change in resident's condition. A resident did not receive medications for 5 days and experienced severe diarrhea and dehydration requiring hospitalization, but the facility did not have an established medical provider for the resident at the time of the incident.

WAC 388-78A-2040: The Assisted Living Facility failed to comply with the annual Washington State Patrol Fire Protection Bureau inspection. The facility continued to have uncorrected violations from the second Fire Marshal visit on 08/01/2023.

WAC 388-78A-2371: Facility failed to complete an incident report and investigation for a reported fall on 03/25/2023. WAC 388-78A-2630: Facility failed to report a fall incident to the family and medical provider as required. WAC 388-78A-2600: Facility policies and procedures for incident reporting and investigation were not followed consistently.