7 Reports
Inspection Report — Sep 17, 2025
Life Safety
Date: Sep 17, 2025
Visit Reason
The Office of the State Fire Marshal conducted a fire protection inspection at the facility to assess compliance with fire safety codes and maintenance requirements.
Findings
The inspection found multiple deficiencies including lack of documentation for fire damper repairs, missing quarterly inspection reports for sprinkler systems, and uncorrected horn strobe deficiencies. Some items were corrected on site, but overall the facility was disapproved due to outstanding violations.
Deficiencies (5)
IFC 706.1 2018 Dampers protecting ducts and air transfer openings shall be inspected and maintained in accordance with NFPA 80 and NFPA 105. Facility was unable to provide documentation showing the 20 fire dampers that failed testing on January 2023 have been corrected and are now in compliance with NFPA 80.
IFC 903.5 2021 Sprinkler systems shall be tested and maintained in accordance with Section 901. Unable to produce quarterly inspection reports for Quarter 3 or Quarter 4 of 2024.
IFC 904.13.5.2 2021 Automatic fire-extinguishing systems shall be serviced not less frequently than every six months and after activation of the system. Inspection shall be by qualified individuals, and a certificate of inspection shall be forwarded to the fire code official upon completion.
IFC 907.8 2021 The maintenance and testing schedules and procedures for fire alarm and fire detection systems shall be in accordance with Sections 907.8.1 through 907.8.5 and NFPA 72. Records of inspection, testing and maintenance shall be maintained. Unable to provide documentation showing that horn strobe deficiencies identified in the September 20, 2024 annual service report have been corrected.
IFC 1013.1 2021 Exits and exit access doors shall be marked by an approved exit sign readily visible from any direction of egress travel. Exit sign in the kitchen found inoperable--replacement required.
Report Facts
Fire dampers failed testing: 20
Quarterly inspection reports missing: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| D'Auna Jones | Maintenance Director | Named in signature block as Authorized Representative |
Inspection Report — Aug 25, 2025
Complaint Investigation
Date: Aug 25, 2025
Visit Reason
A complaint investigation was conducted due to a fire alarm issue reported at Brookdale Puyallup South.
Complaint Details
Complaint #189695 involved a fire alarm issue caused by a resident damaging a pull station. The fire alarm was operational but the pull station and display panel were not functioning properly. No fire, injuries, or sprinkler activation occurred. Violations were cited for the faulty pull station and display panel.
Findings
The fire alarm pull station was found to be in trouble due to damage by a resident, and the fire alarm display panel at the entryway was not working. The fire alarm system is operational but requires repairs to the pull station and display panel.
Deficiencies (1)
IFC 907.8 (2021) - Fire alarm pull station shall be fixed. Fire alarm display panel in front entry way is not working and shall be fixed.
Inspection Report — Jul 29, 2025
Follow-Up
Date: Jul 29, 2025
Visit Reason
The Department of Social and Health Services conducted a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Findings
The follow-up inspection on 07/29/2025 found no deficiencies and confirmed that the facility meets the Assisted Living Facility licensing requirements. Previously cited deficiencies were corrected.
Deficiencies (1)
WAC 388-78A-2466 - The facility failed to ensure a Washington state name and date of birth background check was completed every two years for one of six sampled staff, placing all 42 residents at risk. The deficiency was corrected.
Report Facts
Sampled residents: 7
Current residents: 42
Sampled staff: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Care Partner, Home Care Aide (HCA) | Named in background check deficiency finding |
| Staff A | Executive Director | Interviewed regarding background check compliance |
Inspection Report — Jul 23, 2025
Plan of Correction
Date: Jul 23, 2025
Visit Reason
This document reports the results of an Informal Dispute Resolution (IDR) process regarding disputed deficiencies from a Statement of Deficiencies (SOD) report dated 2025-06-10 for an assisted living facility.
Findings
After review of all materials and statements presented during the IDR, the decision was made to not change the original SOD report dated 2025-06-10. The facility is instructed to begin correcting the disputed deficiencies immediately and submit a Plan/Attestation Statement within 10 calendar days.
Report Facts
Correction timeframe: 45
SOD report date: Jun 10, 2025
Notice — Jul 8, 2025
Date: Jul 8, 2025
Visit Reason
This letter confirms the facility's request to reschedule an Informal Dispute Resolution (IDR) telephone meeting concerning a Statement of Deficiencies dated June 10, 2025.
Findings
The letter outlines the rescheduled date and time for the IDR meeting and identifies the citation under dispute (WAC 388-78A-2466) and the facility representatives who will participate.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hattie Russell | Executive Director | Named as a participant representing the facility in the IDR process. |
| Glenna Wickett | District Director of Operations | Named as a participant representing the facility in the IDR process. |
Notice — Jun 10, 2025
Date: Jun 10, 2025
Visit Reason
The document confirms the scheduling of an Informal Dispute Resolution meeting by telephone to discuss disputed citation(s) from a Statement of Deficiencies dated June 10, 2025.
Findings
The letter does not contain inspection findings but addresses the dispute of citation WAC 388-78A-2466 and lists facility representatives participating in the IDR process.
Inspection Report — Mar 19, 2025
Complaint Investigation
Date: Mar 19, 2025
Visit Reason
The inspection was conducted as an unannounced on-site complaint investigation regarding a medication error allegation at the Assisted Living Facility.
Complaint Details
The complaint investigation (Complaint #170399) focused on a medication error allegation. The investigation confirmed that one resident did not receive medication at the prescribed time and documentation was incorrect. The allegation was substantiated and citations were issued.
Findings
The investigation found that the facility failed to ensure that one resident received medication at the prescribed time and failed to ensure correct documentation of the administration. A failed provider practice was identified and citations were written.
Deficiencies (1)
WAC 388-78A-2210 Medication services. The assisted living facility failed to ensure that one resident received their medication at the prescribed time and failed to ensure correct documentation of the administration, placing residents at risk for poor health outcomes.
Report Facts
Total residents: 45
Resident sample size: 1
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