Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Life Safety
Deficiencies: 13
Apr 30, 2025
Visit Reason
The Office of the State Fire Marshal conducted an inspection at the facility to assess fire protection and safety compliance.
Findings
The inspection identified multiple fire safety violations including malfunctioning kitchen fire extinguisher, blocked fire doors, improperly latched fire doors, missing hydraulic calculation plate, unavailable documentation for fire suppression service, missing fire alarm detectors, and issues with door locks and latches.
Deficiencies (13)
| Description |
|---|
| Primary Kitchen GFCI next to fire extinguisher blinking red represent malfunction and needs replaced. |
| Facility is unable to provide documentation for the semi-annual hood cleaning. |
| Main kitchen gas appliances on casters not tethered to wall. |
| Fire doors to dining area in country wing blocked. |
| Fire doors to living area in country wing blocked. |
| Door propped open with end table room 26. |
| Fire door not properly latching rooms 40, 42, 39. |
| Fire door not properly latching Boat House kitchen. |
| Hydraulic calculation plate not on riser. |
| Documentation unavailable for the semi annual kitchen suppression service. |
| Detector missing in sprinkler room. |
| Smoke detector covers hanging in rooms 43 and 47. |
| Memory care wander garden exterior gates system does not include instructions for exiting within six feet of the door. |
Report Facts
Next inspection scheduled: May 30, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Allan Reyes | Supervisor | Named as Owner or Authorized Representative signing the inspection report |
| Brandon G. Brown | Deputy State Fire Marshal | Conducted the inspection and signed the report |
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 12, 2024
Visit Reason
The Department of Social and Health Services conducted a Complaint Investigation at Brookdale Alderwood on November 12, 2024, due to concerns related to the facility's implementation of policies and procedures.
Findings
The investigation found that the licensee failed to implement their Change of Condition policy when a resident could no longer ambulate or transfer independently and was experiencing pain, resulting in delayed medical evaluation after a broken hip. This violation led to a civil fine.
Complaint Details
The complaint investigation substantiated a violation of WAC 388-78A-2600 (1)(b) related to policies and procedures, specifically the failure to implement the Change of Condition policy, resulting in resident harm. This was a recurring citation previously cited on January 9, 2023, and August 23, 2023.
Deficiencies (1)
| Description |
|---|
| Failure to implement Change of Condition policy resulting in delayed medical evaluation after a resident's broken hip |
Report Facts
Civil fine amount: 700
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the letter regarding the civil fine and complaint investigation |
| Jamie Singer | Field Manager | Contact person for plan of correction and appeals |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 1
Nov 12, 2024
Visit Reason
The inspection was conducted as a complaint investigation regarding a named resident who had a fracture of unknown origin at the Assisted Living Facility.
Findings
The investigation found that the facility staff failed to follow their policy to have the resident evaluated by a physician until the day after the resident reported difficulty walking and pain. This failure resulted in a delay in medical evaluation following a broken hip.
Complaint Details
The complaint involved a named resident with a fracture of unknown origin. The investigation concluded that a failed provider practice was identified and citations were written.
Deficiencies (1)
| Description |
|---|
| Failure to follow policy to have resident evaluated by a physician in a timely manner after a change in condition. |
Report Facts
Total residents: 36
Resident sample size: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Mcglon | Nursing Consultant Institutional | Investigator who conducted the complaint investigation |
| Jamie Singer | Field Manager | Signed official documents related to the inspection |
Inspection Report
Follow-Up
Census: 36
Deficiencies: 8
Aug 21, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies, indicating the facility met the Assisted Living Facility licensing requirements. The original inspection identified multiple deficiencies related to infection control, resident rights, medication storage and administration, safe storage of supplies, and ongoing assessments.
Deficiencies (8)
| Description |
|---|
| Failure to ensure infection control practices by a Medication Technician during medication pass, including improper glove use and lack of hand hygiene. |
| Failure to protect confidentiality and privacy of residents by storing resident information in public locations and unsecured medication records. |
| Failure to ensure required one-step tuberculosis skin test for one staff member. |
| Failure to secure medication cart in memory care neighborhood, risking ingestion of unsupervised medications by residents with dementia. |
| Failure to promote safe medication services, including failure to ensure staff assisted residents with medication as prescribed. |
| Failure to securely store hazardous chemicals and equipment, accessible to residents in memory care unit. |
| Failure to ensure wet mops were consistently hung up to dry, risking infection control issues. |
| Failure to complete ongoing assessment related to change of condition for one sampled resident. |
Report Facts
Residents at risk: 36
Sample size: 7
Medication cart failures: 1
Staff members without required TST: 1
Residents with dementia: 36
Residents requiring medication assistance: 11
Residents with cognitive diagnoses: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Faith Le | NCI | Department staff who conducted the on-site verification and inspection. |
| Erin Steinbrenner | Nursing Consultant Institutional | Department staff who conducted the on-site verification and inspection. |
| Staff C | Medication Technician | Named in multiple findings related to infection control, medication administration, and tuberculosis testing. |
| Staff H | Health and Wellness Director | Provided interview statements confirming training and unsafe practices. |
| Staff A | Executive Director | Provided interview statements and participated in environmental tours. |
| Staff G | Maintenance Director | Participated in environmental tours showing unsecured resident information. |
| Staff I | Dining Services Coordinator | Observed during environmental tour related to housekeeping deficiencies. |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 60
Deficiencies: 2
Jan 4, 2024
Visit Reason
The inspection was conducted due to complaints alleging that a resident sustained a significant injury during care and concerns that the staff member assisting the resident was not properly credentialed to provide care.
Findings
The investigation found that the resident received assistance from a staff member who was not credentialed to provide care, resulting in a significant injury. The facility failed to ensure sufficient trained and qualified staff were available to provide care, placing residents at risk.
Complaint Details
The complaint investigation was triggered by allegations that a named resident sustained a significant injury during care and that the staff member assisting the resident was not properly credentialed. The investigation substantiated deficient practice and failed provider practice was identified with citations written.
Deficiencies (2)
| Description |
|---|
| Failure to ensure residents who did not wear call light pendants had means to call for assistance in living and sleeping rooms. |
| Failure to ensure sufficient trained and qualified staff were available to provide care for one resident, resulting in unqualified staff providing care and causing injury. |
Report Facts
Total residents: 30
Resident sample size: 2
Total licensed capacity: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hayley Pinkham | ALF Licensor | Investigator who conducted the complaint investigation |
| Jamie Singer | Field Manager | Signed official correspondence related to the inspection |
Inspection Report
Follow-Up
Deficiencies: 1
Dec 22, 2023
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies related to electronic monitoring and resident privacy were corrected.
Complaint Details
The follow-up inspection was conducted after an unannounced complaint investigation on 09/27/2023 referencing complaint numbers 98275, 98935, 99873, and 100054. The investigation found noncompliance with licensing laws related to electronic monitoring and resident privacy.
Deficiencies (1)
| Description |
|---|
| Failure to conduct, document, and obtain resident or representative signatures for quarterly evaluations and time duration of electronic monitoring for 2 of 3 residents, placing residents at risk of privacy and rights violations. |
Report Facts
Complaint numbers referenced: 4
Residents sampled for review: 3
Completion dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Hauk | Complaint Investigator | Conducted the complaint investigation and follow-up inspection. |
| Jamie Singer | Field Manager | Signed the follow-up inspection letter and complaint investigation documents. |
| Staff A | Executive Director / Administrator | Interviewed regarding the SafelyYou Fall Detection System and facility compliance with electronic monitoring requirements. |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 3
Aug 23, 2023
Visit Reason
The investigation was conducted due to complaints alleging that a Named Resident had an untreated deep wound resulting in sepsis and death, and that the facility failed to notify the resident's family about the change of condition. Additionally, allegations included multiple pressure injuries and an unstageable wound on another resident.
Findings
The investigation found that the facility failed to update the Named Resident's Negotiated Service Agreement after a change in condition and wound development, failed to implement wound documentation policies, and failed to provide required care such as repositioning and incontinence care. These failures contributed to the development of pressure injuries and an unstageable wound. Citations were written for these deficiencies.
Complaint Details
The complaint investigation involved two complaint numbers (81480 and 82632) concerning two residents. Allegations included an untreated deep wound leading to sepsis and death, failure to notify family, and multiple pressure injuries with inadequate care. The investigation concluded with failed provider practices and citations issued.
Deficiencies (3)
| Description |
|---|
| Failure to update the Negotiated Service Agreement after a change in condition and wound development for Resident 1. |
| Failure to implement policy on wound documentation, including lack of documentation for an unstageable wound. |
| Failure to provide care as outlined in the personal service plan, including repositioning and incontinence care every two hours for Resident 2. |
Report Facts
Total residents: 36
Resident sample size: 2
Closed records sample size: 1
Pressure injury measurement: 3
Pressure injury measurement: 4.6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Mcglon | Nursing Consultant Institutional | Investigator who conducted the complaint investigation and on-site verification |
| Jamie Singer | Field Manager | Signed the compliance and deficiency reports |
Inspection Report
Follow-Up
Census: 35
Deficiencies: 7
Mar 9, 2023
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility on 03/09/2023 to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets the Assisted Living Facility licensing requirements. Previous deficiencies related to staff orientation, notification of administrator change, food sanitation, nursing services, negotiated service agreements, policies and procedures, and medication services were corrected.
Complaint Details
The inspection was triggered by a complaint investigation conducted on 12/27/2022 and 12/29/2022 referencing complaint numbers 63191 and 64949.
Deficiencies (7)
| Description |
|---|
| Failed to ensure new staff received facility orientation for expected duties, contributing to all 35 residents being cared for by unfamiliar staff. |
| Failed to notify the Department in writing within ten calendar days of a change in the assisted living facility administrator. |
| Failed to maintain safe refrigerator temperatures for 3 of 3 refrigerators in neighborhood kitchens, placing 35 residents at risk for food borne illness. |
| Failed to ensure nurse delegation was in place for 2 sampled residents who received blood sugar checks and insulin injections by unlicensed staff, placing residents at risk of health complications. |
| Failed to develop negotiated service agreements that clearly defined roles and responsibilities for 2 sampled residents and 1 sampled resident's family member, placing residents at risk for compromised nutritional status. |
| Failed to implement policies and procedures to notify physicians when residents refused to wear compression stockings, placing residents at risk for compromised health status. |
| Failed to implement systems to promote safe medication services for 1 sampled resident, placing the resident at risk for compromised health conditions when medications were not given as prescribed. |
Report Facts
Residents at risk due to staff orientation deficiency: 35
Refrigerators with unsafe temperatures: 3
Residents sampled for nurse delegation deficiency: 2
Residents sampled for negotiated service agreement deficiency: 2
Residents sampled for compression stocking policy deficiency: 2
Residents sampled for medication service deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alma Duran | Licensor | Conducted on-site verification during inspections. |
| Erin Steinbrenner | Nursing Consultant Institutional | Conducted on-site verification during inspections. |
| Jamie Singer | Field Manager | Signed inspection letters and correspondence related to findings and enforcement. |
| Staff F | Executive Director | Interviewed regarding facility orientation, administrator change, and refrigerator temperature monitoring. |
| Staff I | Maintenance Supervisor | Interviewed and observed refrigerator temperatures during environmental tour. |
| Staff K | Certified Nursing Assistant/Resident Care Coordinator | Documented blood sugar checks and insulin administration; involved in nurse delegation deficiency. |
| Staff H | Registered Nurse Delegator/Health and Wellness Director | Interviewed about nurse delegation and medication administration deficiencies. |
| Staff L | Medication Technician | Observed performing blood sugar checks on residents. |
Inspection Report
Life Safety
Deficiencies: 4
Mar 6, 2023
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the facility to assess compliance with fire protection and life safety codes.
Findings
The inspection identified violations including blocked electrical service panels and egress points, lack of documentation for annual fire wall inspection, missing documentation for monthly carbon monoxide detector testing, and missing documentation for the annual 90-minute emergency light power test.
Deficiencies (4)
| Description |
|---|
| Back door vestibule area of the kitchen was full of storage blocking multiple electrical service panels and the egress point for the high voltage electrical room. |
| Facility unable to provide documentation that the annual fire wall inspection has been completed. |
| Facility unable to provide documentation for the monthly carbon monoxide detector testing. |
| Facility unable to provide documentation for the annual 90 minute power test for the emergency lights. |
Report Facts
Inspection date: Mar 6, 2023
Next inspection scheduled: Apr 5, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Ward | Deputy State Fire Marshal | Signed the inspection report |
| Jeremy White | Maintenance Director | Signed as Authorized Facility Representative |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 1
Feb 27, 2023
Visit Reason
The inspection was conducted due to a complaint alleging that a caregiver at the Assisted Living Facility hit a resident, who was observed with blood on her lip.
Findings
The investigation found reasonable cause to believe the allegation of abuse occurred. The facility failed to ensure timely reporting of the alleged abuse to management and the Department, constituting a deficient practice. A citation was written for the failed provider practice.
Complaint Details
The Named Resident reported a caregiver hit her, resulting in blood on her lip. The allegation was substantiated with reasonable cause. Staff failed to report the allegation to management or the Department promptly, and the responsible party was not notified for several days.
Deficiencies (1)
| Description |
|---|
| Failure to ensure a mandatory reporter reported alleged physical abuse for one resident in a timely manner. |
Report Facts
Total residents: 37
Resident sample size: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hayley Pinkham | ALF Licensor | Department staff who conducted the investigation and off-site verification |
Inspection Report
Follow-Up
Census: 34
Deficiencies: 2
Dec 5, 2022
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets the Assisted Living Facility licensing requirements. Prior deficiencies related to signing negotiated service agreements and service agreement planning were corrected.
Complaint Details
The complaint investigation was triggered by an allegation that a named resident's apartment had an unpleasant odor before and after cleaning. The investigation found the resident was incontinent and voided on the floor causing the odor. The resident's Personal Service Plan failed to reflect current toileting needs. Provider practice was found deficient and citations were written.
Deficiencies (2)
| Description |
|---|
| Failure to ensure the negotiated service agreement was signed annually by the resident or authorized representative for 2 of 3 sampled residents. |
| Failure to update the negotiated service agreement for 1 of 3 sampled residents when the resident's needs changed. |
Report Facts
Total residents: 34
Resident sample size: 3
Compliance Determination numbers: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Mcglon | Nursing Consultant Institutional | Conducted on-site verification and investigation |
| Jamie Singer | Field Manager | Signed enforcement and compliance letters |
| Staff A | Health and Wellness Director/Registered Nurse | Interviewed regarding resident care and odor issue |
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