Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 1
Jul 17, 2025
Visit Reason
The Department completed a complaint investigation of Brighton Court Assisted Living on 07/17/2025 due to a complaint regarding medication not being administered as ordered.
Findings
The investigation found that the facility was responsible for receiving the resident's medications but ran out of the medication, resulting in missed doses on a very infrequent basis. No harm was identified from the missed doses. A failed provider practice was identified and citations were written.
Complaint Details
Complaint number 184520 involved an allegation that medication was not being administered as ordered. The complaint was substantiated with a failed provider practice identified and citations written.
Deficiencies (1)
| Description |
|---|
| Nonavailability of medications resulting in missed medication doses. |
Report Facts
Total residents: 43
Resident sample size: 3
Compliance Determination number: 62595
Complaint number: 184520
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Wright | NCI Complaint Investigator | Investigator who conducted the complaint investigation |
Inspection Report
Follow-Up
Deficiencies: 7
Jun 16, 2025
Visit Reason
Follow-up inspection to verify correction of previously cited deficiencies at Brighton Court Assisted Living Facility.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies related to medication services, intermittent nursing services, training and certification, background checks, and food and nutrition services were corrected.
Deficiencies (7)
| Description |
|---|
| Failed to ensure a safe medication delivery system; medications were not given as prescribed for 3 of 11 residents, placing residents at risk of health complications. |
| Failed to ensure resident-specific nurse delegation training was completed for 7 of 10 staff, impacting residents receiving nurse delegated services. |
| Failed to ensure staff crushing medications for Resident 1 had individualized training; recurring deficiency. |
| Failed to ensure 1 of 4 staff had cardiopulmonary resuscitation, first aid training, and home-care aide certification. |
| Failed to ensure safe food holding temperatures were maintained in 2 kitchens and failed to record menu changes; staff lacked valid food worker card. |
| Failed to complete character, competence, and suitability review for 1 of 3 staff with a non-disqualifying crime. |
| Failed to complete a national fingerprint background check for 1 of 5 staff. |
Report Facts
Residents reviewed: 9
Residents with medication errors: 3
Staff without nurse delegation training: 7
Staff without CPR and first aid training: 1
Food temperature violations: 2
Staff without national fingerprint background check: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Director of Health Services/RN | Confirmed medication errors and lack of provider notification for missed medications. |
| Staff M | Resident Care Coordinator | Administered insulin without individualized nurse delegation training. |
| Staff O | Medical Technician | Administered insulin without individualized nurse delegation training. |
| Staff P | Medical Technician | Administered medications without individualized training for crushing medications. |
| Staff Q | Medical Technician | Administered medications without individualized training for crushing medications. |
| Staff R | Medical Technician | Administered medications without individualized training for crushing medications. |
| Staff S | Medical Technician | Administered medications without individualized training for crushing medications. |
| Staff T | Medical Technician | Administered medications without individualized training for crushing medications. |
| Staff C | Caregiver | Lacked CPR, first aid training, and home-care aide certification. |
| Staff D | Medical Technician | Lacked completed national fingerprint background check and character, competence, and suitability review. |
| Staff G | Cook | Did not have a valid food worker card. |
| Staff N | Cook | Observed serving food at unsafe temperatures. |
| Staff J | Memory Care Caregiver | Served food at unsafe temperatures and lacked training on food holding temperatures. |
Inspection Report
Life Safety
Deficiencies: 17
Mar 26, 2025
Visit Reason
The Office of the State Fire Marshal conducted a fire protection inspection at the Brighton Court residential care facility on 03/26/2025.
Findings
The inspection found several issues including missing documentation for sprinkler system inspections and tests, removed or corrected fire protection equipment, and maintenance deficiencies such as removed working space clearance and missing fire drills documentation. Some deficiencies were corrected during the inspection or scheduled for correction shortly after.
Deficiencies (17)
| Description |
|---|
| Facility is unable to provide documentation for the quarterly sprinkler system inspections; only document on site is from 12/30/24. |
| Facility is unable to provide documentation for the 5 year internal piping inspection. |
| Facility is unable to provide documentation for the annual trip test. |
| Facility is unable to provide documentation for the 3 year dry system full flow trip test; scheduled for 4/29/25. |
| Facility is unable to provide documentation for the annual backflow forward flow test; scheduled for 4/29/25. |
| Facility was unable to provide documentation that the Fire Department Connection has been hydrostatically tested in accordance with NFPA 25. |
| Manual fire alarm boxes were removed or not accessible; ready access required at all times. |
| Chains were removed from locks that are required to prevent operation of doors where authorized locks are needed. |
| Battery-powered emergency lighting annual power test documentation is missing; last report on file is from 1/15/24. |
| Facility unable to provide documentation for the 4 year fire and smoke damper inspection. |
| Facility cannot provide documentation for completion of twelve planned and unannounced fire drills in the previous 12 months; drills missing for quarters 1 and 2 of 2024. |
| Oxygen cylinders in room #12 are not secured to prevent falling. |
| Facility unable to provide documentation for monthly 30 second activation test for emergency lights; missed months May-November 2024. |
| Facility unable to provide documentation for monthly carbon monoxide detector maintenance for May-November 2024. |
| Facility unable to provide documentation for semi-annual kitchen suppression system servicing for 1/27/25 inspection. |
| Facility unable to provide documentation for annual fire alarm system testing and maintenance. |
| Facility unable to provide documentation on smoke detector sensitivity test report. |
Report Facts
Next inspection scheduled: Mar 31, 2026
Missed fire drills: 2
Fire drills required: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Barbara R. McMullen | Deputy State Fire Marshal | Signed and digitally signed inspection reports |
| Bethany King | Executive Director | Signed as Owner or Authorized Representative on 03/26/2025 inspection |
| John Harris | Signed as Owner or Authorized Representative on 02/19/2025 inspection | |
| John Brooks | Signed as Owner or Authorized Representative on 02/19/2025 inspection |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Oct 29, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on allegations that a resident exposed private parts to another resident and that staff was inappropriately hugging a resident.
Findings
The facility provided for resident safety, updated the alleged perpetrator's care plan, monitored the alleged victim, and terminated the staff member involved in inappropriate hugging. However, the facility failed to complete a character, competence, and suitability review for one staff member with a non-disqualifying criminal conviction, resulting in a citation.
Complaint Details
Allegations included a resident exposing private parts to another resident and staff inappropriately hugging a resident. The facility was found to have failed in completing a required background review for one staff member. The alleged perpetrator was terminated and safety measures were implemented.
Deficiencies (1)
| Description |
|---|
| Failed to complete a character, competence, and suitability review for one staff member with a non-disqualifying criminal conviction. |
Report Facts
Total residents: 40
Resident sample size: 6
Closed records sample size: 0
Staff sample size: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tethra Wales | Assisted Living Facility Licensor | Investigator who conducted the complaint investigation |
| Jessica Salquist | Field Manager | Signed follow-up inspection letter |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Jul 29, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation from 07/12/2024 through 07/29/2024 regarding allegations that care plans were not updated to address assistance with meals and that the facility did not provide medications as ordered.
Findings
The investigation found that the facility failed to include instructions in the negotiated service agreement related to a resident's food and fluid intake, placing the resident at risk for inconsistent feeding assistance and aspiration. However, the allegation that the facility did not provide medications as ordered was not supported.
Complaint Details
The complaint investigation was substantiated for failure to update care plans to address assistance with meals, specifically for Resident 3 who required feeding assistance and had declining ability to eat. The allegation that the facility did not provide medications as ordered was not substantiated.
Deficiencies (1)
| Description |
|---|
| Facility failed to include instructions in the negotiated service agreement related to a resident's food and fluid intake for 1 of 3 residents receiving hospice services. |
Report Facts
Total residents: 38
Resident sample size: 9
Compliance Determination Completion Date: Jul 29, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sylvia Shauvin | Complaint Investigator | Conducted the complaint investigation and on-site verification |
| Staff B | Director of Nursing | Mentioned in relation to failure to provide verbal or written instructions regarding Resident 3's food and fluid needs |
| Staff A | Medication Aide/Caregiver | Observed providing medication and feeding assistance to Resident 3 |
| Staff C | Caregiver | Provided information about Resident 3's meal assistance and swallowing difficulties |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 28, 2024
Visit Reason
The inspection was conducted in response to a complaint (#129328) regarding a fire exit being locked at the facility.
Findings
The inspector found that the chain and lock had been removed from the gate, a key pad was installed with posted codes, and no violations were cited.
Complaint Details
Complaint #129328 alleged a fire exit was locked. The investigation found the issue corrected with no violations cited.
Report Facts
Complaint number: 129328
Inspection time: 1015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Barbara McMullen | Deputy State Fire Marshal | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 1
May 6, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation based on allegations including a resident fall, deception by the facility, denial of family preferred staff participation in care meetings, failure to update negotiated service agreements, missing resident items, and nurse delegation issues.
Findings
The investigation found no failed facility practices related to the fall, care meeting participation, service agreement updates, or missing items. However, a failed provider practice was identified regarding nurse delegation, where a medication technician performed delegated nursing tasks without proper credentials or training, placing residents at risk.
Complaint Details
Allegations included a resident fall, deception by the facility, denial of family preferred staff participation in care meetings, failure to update negotiated service agreements for 8 months, missing clothing items and dentures with refusal to reimburse or replace, and nurse delegation issues. The nurse delegation allegation was substantiated with failed provider practice identified.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure nurse delegation criteria was followed and staff were credentialed and qualified to provide nurse delegated services, resulting in unsafe medication administration. |
Report Facts
Total residents: 43
Resident sample size: 5
Dates of medication administration by unqualified staff: Staff C performed blood sugar checks and insulin administration on 04/21/2024, 04/22/2024, 04/28/2024, 04/29/2024, and 05/06/2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Fast | Community Complaint Investigator | Investigator who conducted the complaint investigation and on-site verification |
| Staff C | Medication Technician | Unqualified staff who performed nurse delegated tasks without proper credentials or training |
| Staff B | Business Office Manager | Reported that Staff C was not nurse delegated and lacked required training |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
Jan 2, 2024
Visit Reason
The inspection was conducted as an unannounced on-site complaint investigation regarding allegations of unqualified staff at Brighton Court Assisted Living.
Findings
The investigation found that a staff member had an incomplete background check requiring additional information, and the facility lacked a process to ensure completion of such background checks. The staff member worked over four months without a completed background check, constituting a failed provider practice.
Complaint Details
Allegation of unqualified staff was substantiated with failed provider practice identified and citation(s) written.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure staff had a valid Washington state name and date of birth background check for 1 of 5 staff, placing residents at risk. |
Report Facts
Total residents: 46
Staff with incomplete background check: 1
Staff sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joy Pipgras | LTC Surveyor | Investigator who conducted the complaint investigation |
| Laurie Hudson | Business Office Manager | Interviewed regarding personnel files and background check processes |
Inspection Report
Life Safety
Deficiencies: 10
Apr 11, 2023
Visit Reason
The Office of the State Fire Marshal conducted an inspection at the Brighton Court residential care facility to assess compliance with fire safety and life safety code requirements.
Findings
The inspection found that all identified fire safety deficiencies were corrected or completed, including storage of combustible materials, electrical junction boxes, fire door inspections, and carbon monoxide detection and maintenance. Documentation was provided or corrections made for all code requirements.
Deficiencies (10)
| Description |
|---|
| Combustible material shall not be stored in boiler rooms, mechanical rooms, electrical equipment rooms or in fire command centers. |
| Open junction boxes and open-wiring splices shall be prohibited; approved covers shall be provided for all switch and electrical outlet boxes. |
| Hoods, grease-removal devices, fans, ducts and other appurtenances shall be cleaned at required intervals. |
| Owner shall maintain inventory of fire-resistance-rated construction and inspect annually. |
| Materials and firestop systems used to protect membrane and through penetrations in fire-resistance-rated construction shall be maintained. |
| Opening protectives in fire-resistance-rated assemblies shall be inspected and maintained. |
| Swinging fire doors shall close from the full-open position and latch automatically. |
| Sprinkler systems shall be tested and maintained in accordance with Section 901. |
| Carbon monoxide detection shall be provided in specified occupancies. |
| Carbon monoxide alarms and detection systems shall be maintained in accordance with NFPA 720. |
Report Facts
Next inspection scheduled: Next inspection scheduled on or after 2024-03-31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Barbara McMullen | Deputy State Fire Marshal | Signed the inspection report |
| Doug Edington | MBA, HCM | Owner or Authorized Representative who signed the report |
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