Empress Senior Living at Laurelhurst.

This document was prepared by Residential Care Services for the Locator website. STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEAL TH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20311 52nd Ave W, Suite 100, Lynnwood, WA 98036 Laurelhurst Tenant LLC Empress Senior Living at Laurelhurst 4020 NE 55th St Seattle, WA 98105 RE: Empress Senior Living at Laurelhurst License# 2613 Dear Administrator: This letter addresses Compliance Determination(s) 55681 (Completion Date 03/03/2025) and 52756 (Completion Date 01/17/2025). The Department completed a follow-up inspection of your Assisted Living Facility on 03/03/2025 and found no deficiencies. Your facility meets the Assisted Living Facility licensing requirements. The Department found that deficiencies for the following licensing laws and regulations were corrected: WAC 388-78A-2100-2-b-i, WAC 388-78A-2466-1-a, WAC 388-78A-2466-1-b, WAC 388-78A- 2466-1, WAC 388-78A-2462-3-b The Department staff who did the off-site verification: Sunny Kent, Licensor Scottie Sindora, ALF Licensor If you have any questions, please contact me at (253)312-1446. . s.. Sincerely, MT Jamie,S,r....i,,Ln,g"loe!~,, Field Region 2, Unit J Residential Care Services 1/21/2025 This document was prepared by Residential Care Services for the Locator website. ST ATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEAL TH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20311 52nd Ave W, Suite 100, Lynnwood, WA 98036 Statement of Deficiencies License#: 2613 Compliance Determination # 52756 Plan of Correction Empress Senior Living at Laurelhurst Completion Date Page 1 of 5 Licensee: Laurelhurst Tenant LLC 01/17/2025 You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for the unannounced on-site full inspection on 01/13/2025 and 01/15/2025 of: Empress Senior Living at Laurelhurst 4020 NE 55th St Seattle, WA 98105 The following sample was selected for review during the unannounced on-site visit: 7 of 39 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Sunny Kent, Licensor Scottie Sindora, ALF Licensor From: DSHS, Aging and Long-Term Support Administration Residential Care Services, Region 2 , Unit J 20311 52nd Ave W, Suite 100 Lynnwood, WA 98036 As a result of the on-site visit(s), the department found that you are not in compliance with the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. Date I understand that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. This document was prepared by Residential Care Services for the Locator website. JAN/22/2025/WED 09:36 PM FAX No. P. 002 ~1 .11..:'.lfl:> 11 :'l:>:01 state of washtngton 5/16 Statement or Deficiencies License#: 2613 Compliance Determination# 52756 Plan of Correction Empress Senior Living al Laurelhurst Co1T1pletlon Date Page 2 of 5 Licensee: Laurelhurst Tenant LLC 01/17/2025 WAC 8-78A-2100 Ongoing assessments. (2) The assisted living facility must (b) Complete an assessment specifically focused on a resident's identified problems and related issues: (i) Consistent with the resident's change of condition as specified in WAC 388-?BA-2120 ; This requirement was not met as evidenced by: Based on observation, interview and record review, the Assisted Living Facility (ALF) failed to develop and implement a syst~m to ensure 1 of 7 sampled residents (Resident 6) provided the ALF with details about a recent surgical procedure to support their outpatient kidney dialysis (hemodialysis~treatment to filter wastes and water from the blood after kidney failure) treatrnents. Ti1is lack of information prevented the ALF from developing a safety plan for staff to follow if the surgical site showed signs of infection, bleeding or other complications that could place Resident e at risk for serious risk t1arrn. Findings included ... NOTE: WAC 388-78A-2090 Full assessment topics. The assisted living facility must obtain sufficient information to be able to assess the capabilities. needs, and preferences for each resident, and must complete a fL1II assessment addressing the following, witt)in fourteen days of the resident's move-in da1e, unless extended by the department for good cause: (1) Individual's recent medical history, including, but not limited to: {a) A licensed medical or health professional's diagnosis, lmless the resident objects for religious reasons; (b) Chronic, current, and potential skin conditions; or Record review of a face sheet, dated 01 /1312025, showed the ALF admitted Resident 6 on /2024 with disabling diagnoses including and . Record review of 8 move-in Progress Note (PN), dated /2024 and signed by Staff B (Health and Wellness Director). showed Resident 6 moved into the ALF with a hemodialysis catheter port (HCP). The port was installed on the right upper chest and managed by the kidney center. Review of tne pre-admission LC (Leisure Care) Assessment/Evaluation and Service Plan This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License#: 2613 Compliance Determination # 52756 Plan of Correction Empress Senior Living at Laurelhurst Completion Date Page 2 of 5 Licensee: Laurelhurst Tenant LLC 01/17/2025 ae WAC 388-78A-2100 Ongoing assessments. (2) The assisted living facility must: (b) Complete an assessment specifically focused on a resident's identified problems and related issues: (i) Consistent with the resident's change of condition as specified in WAC 388-78A-2120 ; This requirement was not met as evidenced by: Based on observation, interview and record review, the Assisted Living Facility (ALF) failed to develop and implement a system to ensure 1 of 7 sampled residents (Resident 6) provided the ALF with details about a recent surgical procedure to support their outpatient kidney dialysis (hemodialysis-treatment to filter wastes and water from the blood after kidney failure) treatments. This lack of information prevented the ALF from developing a safety plan for staff to follow if the surgical site showed signs of infection, bleeding or other complications that could place Resident 6 at risk for serious risk harm. Findings included ... NOTE: WAC 388-78A-2090 Full assessment topics. The assisted living facility must obtain sufficient information to be able to assess the capabilities, needs, and preferences for each resident, and must complete a full assessment addressing the following, within fourteen days of the resident's move-in date, unless extended by the department for good cause: (1) Individual's recent medical history, including, but not limited to: (a) A licensed medical or health professional's diagnosis, unless the resident objects for religious reasons; (b) Chronic, current, and potential skin conditions; or Record review of a face sheet, dated 01/13/2025, showed the ALF admitted Resident 6 on /2024 with disabling diagnoses including and . Record review of a move-in Progress Note (PN), dated /2024 and signed by Staff B (Health and Wellness Director), showed Resident 6 moved into the ALF with a hemodialysis catheter port (HCP). The port was installed on the right upper chest and managed by the kidney center. Review of the pre-admission LC (Leisure Care) Assessment/Evaluation and Service Plan This document was prepared by Residential Care Services for the Locator website. JAN/22/2025/WED 09:36 PM FAX No. P. 003 01.21.202:i 11 :lfJ:01 State of Washin9ton 6/16 Statement of Deficiencies License#: 2613 Compliance Deterrnination # 52756 Plan of Correction Empress Senior Living at Laurelhurst Completion Date Page 3 of 5 Ll<,?nsee: Laurelhur-.st Te.nant LLC 01 /17 /202[) {equivalent to Assessment}; completed on 01/01/2025. and the 30-~ay Assessment did not show any documentation addressing the HCP. Record review of two Negotiated Service Agreements (NSA), one completed on 12/07/2024 and a second on!:', completed on 01/03/2025, did not show any documentation or safety instructions for the HCP. During an interview, on 01/14/2025 at 3:45 PM, Resident 6 stated that tney recently had surgery to install a fistula (a surgical connection created between an artery and vein to allow access for a. kidney dialysis machine) on the inner aspect of their left arm. Observation. on 01/14/202-5 at 4:00 PM, showed an approximately 12-inch long, well-healed scar on the inner aspect of the upper part Re.sident 6's left arm. Resident 6 identified the scar as the fistula placement site. During an interview, on 01/14/2025 at 1:48 PM,. Staff B stated that Resident 6 was very independent and scheduled their own physician and treatment appointments, as well as transpo1iation for the appointments. Staff B also stated that Resident 6 was not always forthcoming with information after t11ey returned from their appointments. Staff B expressed understanding the ALF needed to develop a system to gather health information from residents who self-manage their appointments. During a second interview, on 01i14/2025 at 2:20 PM, Staff 8 stated that Resident 6 did not tell them about the fistula. The ALF t11ought Resident 6 was at a regularly scheduled dialysis treatment, but was having the surgery to install the fistula, "about ten days agoµ. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Empress Senior Living at Laurelhl!tst is.,.or)Nill be in compliance with this law and J or regulation on (Date) :>. /. if. J . In addition, I will implement a systetn to monitor and. ensure continued compliance with this req · me . WAC 388-78A-2466 Background checks Washington state name and date of birth backgrouna check Valid for two year$ National finge.rprint bapk.ground check Valid indefinitely. (1) A Washington state name and date of birth background check is valid for two years from the initial date it is conducted. The assisted living facility must ensure: (a) A new DSHS bac1<ground authorization form is submitted to the department's This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License#: 2613 Compliance Determination # 52756 Plan of Correction Empress Senior Living at Laurelhurst Completion Date Page 3 of 5 Licensee: Laurelhurst Tenant LLC 01/17/2025 (equivalent to Assessment), completed on 01/01/2025, and the 30-day Assessment did not show any documentation addressing the HCP. Record review of two Negotiated Service Agreements (NSA), one completed on 12/07/2024 and a second one, completed on 01/03/2025, did not show any documentation or safety instructions for the HCP. During an interview, on 01/14/2025 at 3:45 PM, Resident 6 stated that they recently had surgery to install a fistula (a surgical connection created between an artery and vein to allow access for a kidney dialysis machine) on the inner aspect of their left arm. Observation, on 01/14/2025 at 4:00 PM, showed an approximately 12-inch long, well-healed scar on the inner aspect of the upper part Resident 6's left arm. Resident 6 identified the scar as the fistula placement site. During an interview, on 01/14/2025 at 1: 48 PM, Staff B stated that Resident 6 was very independent and scheduled their own physician and treatment appointments, as well as transportation for the appointments. Staff B also stated that Resident 6 was not always forthcoming with information after they returned from their appointments. Staff B expressed understanding the ALF needed to develop a system to gather health information from residents who self-manage their appointments. During a second interview, on 01/14/2025 at 2:20 PM, Staff B stated that Resident 6 did not tell them about the fistula. The ALF thought Resident 6 was at a regularly scheduled dialysis treatment, but was having the surgery to install the fistula, "about ten days ago". Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Empress Senior Living at Laurelhurst is or will be in compliance with this law and / or regulation on (Date) _______ In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date WAC 388-78A-2466 Background checks Washington state name and date of birth background check Valid for two years National fingerprint background check Valid indefinitely. (1) A Washington state name and date of birth background check is valid for two years from the initial date it is conducted. The assisted living facility must ensure: (a) A new DSHS background authorization form is submitted to the department's This document was prepared by Residential Care Services for the Locator website. JAN/22/2025/WED 09:37 PM FAX No. P. 004 HI .11.ZHZ::> II ;q::,:UI !itate of Washington 7/16 Statement of Deficiencies License#: 2613 Compliance Determination# 52756 Plan of Correction Empress Senior Living at Laurelhurst C.ompletion Date Page4 of5 Uqrnsee: Laurelhur:st Te.nant LLC 01/17/202~ bB"ckground check central unit every two years for all administrators, caregivers, staff persons, volunteers and students; and (b) There is a valid Washington state name and date of birth background check for all administrators, caregivers, staff persons, volunteers and students. This requirement was not met as evidenced !:,y: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure 1 of 5 sampled staff (Staff B) renewed their name and date of birth background inquiry (BGI) every two years. This placed the ALF'S 38 residents at risk for receiving care and services from a staff person whose current background history was unknown secondary to an expired BGJ. Findings included ... Record review of an undated Characteristic Roster showed the ALF provided care and services for 38 residents, Ten of the residents resided on a locked Memory Care unit. Record review showed the ALF hired Staff 8 (Health and Wellness Director) on 09/01/2023. Staff B's file contained a BGI. T1'1e BGI expired 06/03/2022. Staff 8 worked tor 501 days (1 year, 4 months, 13 days) in t11e ALF without a valid BGI. During an interview, on 01/15/2025 at 3:25 PM, Staff B $tated that they completed an application to renew the BGI during the department visit. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Empress Senior Living at Laurelhurst i~ or wjll be in compliance with this law and / or regulation on '2• 1 (Date) I• or J . In addition, I will implement a system to monitor and ensure continued compliance with this require t .......... ,... ...... / .. 2.?.~. ..1 ~. ...... .. Date WAC 388·78A~2462 Background checks Who is required to have. (3) The assisted living facility must ensure that the following individuals have a Washington state name and date of birth background check: (b) Staff persons who are not caregivers or administrators; This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License#: 2613 Compliance Determination # 52756 Plan of Correction Empress Senior Living at Laurelhurst Completion Date Page 4 of 5 Licensee: Laurelhurst Tenant LLC 01/17/2025 background check central unit every two years for all administrators, caregivers, staff persons, volunteers and students; and (b) There is a valid Washington state name and date of birth background check for all administrators, caregivers, staff persons, volunteers and students. This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure 1 of 5 sampled staff (Staff B) renewed their name and date of birth background inquiry (BGI) every two years. This placed the ALF's 38 residents at risk for receiving care and services from a staff person whose current background history was unknown secondary to an expired BGI. Findings included ... Record review of an undated Characteristic Roster showed the ALF provided care and services for 38 residents. Ten of the residents resided on a locked Memory Care unit. Record review showed the ALF hired Staff B (Health and Wellness Director) on 09/01/2023. Staff B's file contained a BGI. The BGI expired 06/03/2022. Staff B worked for 501 days (1 year, 4 months, 13 days) in the ALF without a valid BGI. During an interview, on 01/15/2025 at 3:25 PM, Staff B stated that they completed an application to renew the BGI during the department visit. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Empress Senior Living at Laurelhurst is or will be in compliance with this law and / or regulation on (Date) _______ In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date WAC 388-78A-2462 Background checks Who is required to have. (3) The assisted living facility must ensure that the following individuals have a Washington state name and date of birth background check: (b) Staff persons who are not caregivers or administrators; This document was prepared by Residential Care Services for the Locator website. JAN/22/2025/WED 09:37 PM FAX No. P. 005 tll .LI .l'dL'J 11 :'l:l:'dl ~tate ot Washington 8/16 Statement of Deficiencies License#: 2613 Compliance Determination# 52756 Plan of Correction Empress Senior Living at Laurelhurst C.ompletlon Date Page5 ofS Licensee: Laurelhur:St Te.nan! LLC 01/17/202~ This requirement was not met as evidenced by: Based on i_nterview, and record review, the Assisted Living Facility {ALF) failed to ensure 1 of S sample staff (Staff E) completed a background check prior to working in the ALF. Thls failure placed 39 of 39 residents at risk of exposure to staff whose criminal background was unknown. Findings included ... Record review of Staff E's personnel file showed they were hired on 06/21/20.22 as a full time Sales Advisor for the ALF. Further review showed no evidence of a background check. being completed. In an interview, on 01/13/2025 at 2:43 PM, Staff F (Building Office Manager) stated that Staff E was a full-time employee for the past 2 years and was transferred fron1 another community. Staff F stated that the ALF's corporate offices would have the background check, she had contacted the corporate office and expected a reply soon. Record review of an email from Staff F, sent on 01/14/2025 at 10:21 AM, showed the corporate office replied: "We don't run background checks at the home office, that would need to be completed at the community (ALF].'' In an interview, on 01/15/2025 at 12:45 PM, Staff F confirmed that the background check was 11ot completed, and they would submit a new background check immediately. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Ernprass Senior Living at Laurelhur_j.t i~ or w__ill be in compliance with this law and / or regulation on (Dal~) -J,f, J 5 . In addi1ion, I wlll implement a system to monitor and ensure continued compliance with this requiren-u.,....--- Date This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License#: 2613 Compliance Determination # 52756 Plan of Correction Empress Senior Living at Laurelhurst Completion Date Page 5 of 5 Licensee: Laurelhurst Tenant LLC 01/17/2025 This requirement was not met as evidenced by: Based on interview, and record review, the Assisted Living Facility (ALF) failed to ensure 1 of 5 sample staff (Staff E) completed a background check prior to working in the ALF. This failure placed 39 of 39 residents at risk of exposure to staff whose criminal background was unknown. Findings included ... Record review of Staff E's personnel file showed they were hired on 06/21/2022 as a full time Sales Advisor for the ALF. Further review showed no evidence of a background check being completed. In an interview, on 01/13/2025 at 2:43 PM, Staff F (Building Office Manager) stated that Staff E was a full-time employee for the past 2 years and was transferred from another community. Staff F stated that the ALF's corporate offices would have the background check, she had contacted the corporate office and expected a reply soon. Record review of an email from Staff F, sent on 01/14/2025 at 10:21 AM, showed the corporate office replied: "We don't run background checks at the home office, that would need to be completed at the community [ALF]." In an interview, on 01/15/2025 at 12:45 PM, Staff F confirmed that the background check was not completed, and they would submit a new background check immediately. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Empress Senior Living at Laurelhurst is or will be in compliance with this law and I or regulation on (Date) ______ In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date

Failed Provider Practice Not Identified / No Citation Written N/A This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website.

This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website.