Inspection Reports for
Brookdale Fisher’s Landing

The licensee failed to implement systems supporting safe medication services, resulting in four residents not receiving medications as prescribed and failure to label opened nasal, optical, and topical medications and dispose of expired medications on one medication cart. These violations placed residents at risk and led to a $1,000 civil fine. This citation is recurring from previous inspections.

The inspection found multiple fire safety violations including holes in fire walls, unsecured dryer cords, failure to provide annual inspections of fire resistance-rated construction, and multiple failures in fire door inspections. The facility was disapproved due to these unresolved violations.

The visit was a complaint investigation completed on April 16, 2026. The complaint involved medication errors where an insulin pen was administered to the wrong resident. The deficiency was substantiated and resulted in a civil fine of $600.00.

The investigation found that the licensee failed to ensure medications were provided safely by administering an insulin pen belonging to one resident to a different resident, resulting in one resident not receiving medications as ordered and placing both residents at risk of harm. This deficiency is recurring and resulted in a civil fine.

The complaint investigation (Complaint #204425) alleged that the facility did not provide care according to a resident's negotiated service agreement. The investigation substantiated the allegation with findings that the facility failed to provide agreed care, resulting in harm to the resident.

The follow-up inspection found no deficiencies; the previously cited deficiency regarding the failure to provide care as agreed in the negotiated service agreement was corrected.

The complaint investigation (Complaint Number 213092) was substantiated. The allegation of neglect was confirmed as the facility failed to provide necessary skin checks and showers to Resident 1, leading to a large wound. Multiple staff and collateral contacts confirmed issues with documentation and care. The facility acknowledged the citation and planned corrective actions.

The facility was found to have failed to monitor residents' well-being, resulting in neglect. The investigation identified that the facility did not provide agreed-upon skin checks and showers to one resident, contributing to a large wound requiring hospitalization and surgery. Citations were written for failed provider practice.

The complaint investigation involved allegations that a caregiver took pictures of residents' private areas without consent and shared them in a staff group chat. The investigation substantiated a failure in resident rights but found no abuse. Three residents were affected. The caregiver admitted to taking and sharing the images. The facility's Associate Handbook prohibits texting of Protected Health Information via non-secure apps.

The follow-up inspection found no deficiencies and confirmed that previously cited violations regarding resident rights were corrected.

The complaint investigation involved four allegations: 1) medications not ordered on time, 2) staff using other residents' medications instead of re-ordering, 3) a resident given borrowed insulin from another resident, and 4) staff documenting medications as available when they were not. Only the third allegation was substantiated with citations written; the others were unsubstantiated.

The investigation substantiated a failed facility practice related to a resident being given a borrowed insulin pen from another resident, resulting in medication not being administered as ordered and risk of harm. Other allegations regarding medication ordering timeliness, misappropriation of medications, and falsification of medication records were not substantiated.

The visit was complaint-related, triggered by a complaint investigation completed on November 20, 2025. The deficiency cited was recurring and resulted in a civil fine.

The facility was fined $600 for failing to integrate annual assessment information from the resident's representative and department case manager into the personal service plan for one resident. This deficiency is recurring, having been cited previously in 2023, 2024, and earlier in 2025.

The complaint investigation involved allegations of neglect, quality of care, nursing services, physical environment, and administration personnel. Only the allegation related to quality of care was substantiated with citations written. Other allegations were found unsubstantiated.

The investigation substantiated a failure to provide care based on assessed care needs for one resident, resulting in citations. All other allegations including neglect, nursing services, physical environment, and administration personnel were not substantiated.

Complaint number 181798 was investigated from 07/01/2025 through 07/25/2025. The allegation that the facility failed to comply with fire codes following a recent Fire Marshal visit was substantiated. The investigation included interviews with staff and review of fire marshal re-inspection reports. Violations were confirmed regarding fire-resistance-rated construction and fire doors with hanging decorations.

The facility was found to have failed to comply with fire codes as substantiated by the investigation. Violations related to fire marshal ordinance were identified and citations were written.

The facility remains disapproved due to multiple uncorrected fire safety violations including failure to maintain fire-resistance-rated construction, fire door obstructions, and lack of required inspection reports. Violations have not been corrected as of the re-inspection date.

The facility remains disapproved due to multiple uncorrected fire safety violations including failure to provide annual inspections, fire door maintenance issues, and missing inspection reports. Violations have not been corrected since the prior inspection.

The visit was a complaint investigation conducted on March 7, 2025, triggered by concerns about medication services. The deficiency was substantiated and resulted in a civil fine.

The investigation found a violation of WAC 388-78A-2210 (1)(b) regarding medication services where medications were left unobserved in a resident's room, placing residents at risk. This recurring deficiency resulted in a civil fine of $300.

The complaint investigation (Complaint #157018) alleged that a resident's care plan did not include required services and that the resident was not receiving prescribed care. The investigation found substantiated failures in care provision and service agreement planning, including lack of toileting assistance and failure to involve the resident's representative and case manager. The facility acknowledged these deficiencies and planned corrective actions.

The follow-up inspection on 02/28/2025 found no deficiencies and confirmed that previously cited deficiencies related to negotiated service agreements and service agreement planning were corrected. The original complaint investigation found failures in providing care as agreed in the negotiated service agreement and failure to involve the resident's representative and case manager in service planning.

The IDR process reviewed all materials, statements, and records related to the disputed deficiencies and decided not to make any changes to the original Statement of Deficiencies report dated December 30, 2024.

The document does not contain inspection findings but relates to the dispute process for citations WAC 388-78A-2160 and WAC 388-78A-2130.

The complaint number 156972 alleged improper medication administration practices. The investigation found the allegation substantiated as the facility failed to observe residents taking medications as ordered. The deficiency was recurring from a prior citation.

The investigation substantiated the allegation that the facility failed to observe residents taking their medications as ordered, resulting in a failed provider practice and citations being written. The deficiency was recurring from a previous citation dated 11/21/2024.

The visit was a complaint investigation conducted on December 30, 2024. The deficiency cited involved failure to include the resident's representative and department case manager in the personal service plan development. This deficiency was recurring and resulted in a civil fine.

The licensee failed to include the resident's representative and department case manager in the development of the personal service plan for one resident. This recurring deficiency resulted in a $500 civil fine.

The follow-up inspection on 11/21/2024 found no deficiencies and confirmed that all previously cited deficiencies were corrected.

The facility failed to correct multiple fire safety violations including annual inspections of fire-resistance-rated construction, fire door inspections, fire damper inspections, and other fire protection system maintenance. The overall status remains Disapproved.

All violations noted during previous related inspections have been corrected. The facility was approved at this inspection.

After review of written materials, oral statements, and records, the decision was made not to change the previously issued Statement of Deficiencies dated January 31, 2023.

The document does not contain inspection findings but schedules a telephone/Teams IDR review meeting for March 28, 2023, to dispute citation WAC 388-78A-2120.

The follow-up inspection on 02/16/2023 found no deficiencies and confirmed the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies were corrected.

The complaint investigation involved allegations of quality of care including resident elopement and failure to provide agreed upon care services, coordinate care with external providers, and provide medications as prescribed. The investigation substantiated failed provider practices with citations written for these issues.

The investigation found multiple deficiencies including failure to coordinate health care services with external providers, failure to implement negotiated service agreements, failure to monitor residents' well-being, failure to provide medication services safely, and failure to update negotiated service agreements to reflect residents' changing needs. The facility failed to provide necessary psoriasis creams, failed to notify appropriate parties about resident needs such as lack of a bed, and failed to respond to external healthcare provider communications. Monetary reimbursements were issued for some failures. The facility did not meet assisted living licensing requirements at the time of inspection.

The complaint investigation (Complaint #42924) found financial exploitation due to failure to refund for services not provided and failure to obtain medications as agreed. The investigation concluded with a failed provider practice and citations written.

The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies were corrected.

The facility was fined $300 for failing to complete tuberculosis testing for one staff member, an uncorrected deficiency previously cited on September 23, 2022. This failure placed residents and staff at risk for exposure to a communicable disease.