Inspection Reports for Brookdale Allenmore

3615 S 23rd St, Tacoma, WA 98405, United States, WA, 98405

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Deficiencies per Year

8 6 4 2 0
2023
2024
2025
Unclassified

Census Over Time

45 50 55 60 65 70 Feb '23 Aug '23 Nov '23 Apr '24 Jan '25
Inspection Report Complaint Investigation Deficiencies: 1 Oct 13, 2025
Visit Reason
The Department of Social and Health Services completed a Full Inspection and Complaint Investigation at the assisted living facility Brookdale Allenmore AL (WA) on October 13, 2025, resulting in a civil fine due to medication service violations.
Findings
The licensee failed to implement safe medication services for three residents, resulting in two residents receiving medications against physicians’ orders and one resident receiving medications without any physician's orders, placing residents at risk for illness and health decline.
Complaint Details
The visit was complaint-related and included a full inspection and complaint investigation. The deficiency was substantiated, resulting in a civil fine.
Deficiencies (1)
Description
Failure to implement medication services for three residents that were safe and supported the needs of each resident, resulting in medication errors.
Report Facts
Civil fine amount: 600 Number of residents affected: 3
Employees Mentioned
NameTitleContext
Matt HauserCompliance SpecialistSigned the enforcement letter regarding the civil fine
Laurie AndersonField ManagerContact person for the plan of correction and enforcement actions
Inspection Report Complaint Investigation Census: 51 Deficiencies: 2 Jan 14, 2025
Visit Reason
The inspection was conducted as an unannounced on-site complaint investigation triggered by allegations related to medication administration and reporting errors at the Assisted Living Facility.
Findings
The Assisted Living Facility failed to ensure that one resident received their medication as ordered and failed to report a medication error to the department’s Complaint Resolution Unit. This failure placed residents at risk for poor health outcomes. Staff involved were written up and re-trained, and the facility committed to corrective actions.
Complaint Details
The complaint involved a resident (AV) who was sent to the hospital and later diagnosed with a condition (redacted). The investigation confirmed medication administration failures and failure to report the medication error, substantiating the complaint.
Deficiencies (2)
Description
Failed to ensure that 1 of 1 resident received their medication as ordered, specifically missed doses of insulin glargine on multiple dates.
Failed to report a medication error to the department’s Complaint Resolution Unit as required for 1 resident.
Report Facts
Total residents: 51 Resident sample size: 1 Missed insulin doses: 9
Employees Mentioned
NameTitleContext
Nareet BajwaNCI-ALF Complaint InvestigatorConducted the on-site complaint investigation
Staff BClinical Service SpecialistReported and investigated missed insulin doses and medication errors
Staff AAdministratorAcknowledged missed insulin doses and failure to report medication error; responsible for monitoring medication cart and staff re-training
Staff CMedication TechnicianDid not administer insulin medication; was written up
Staff DMedication TechnicianDid not administer insulin medication; was written up
Inspection Report Follow-Up Capacity: 47 Deficiencies: 0 Jun 12, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility on 06/12/2024 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.
Report Facts
Current residents sampled: 7 Total licensed capacity: 47
Employees Mentioned
NameTitleContext
Cathleen DavisALF LicensorDepartment staff who did the on-site verification
Cory MyersALF Complaint InvestigatorDepartment staff who did the on-site verification
Dawn KinneyAdministratorSigned Plan/Attestation Statements for deficiencies
Inspection Report Follow-Up Deficiencies: 0 May 1, 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 on 05/01/2024 found no deficiencies, indicating the facility meets the Assisted Living Facility licensing requirements and corrected prior deficiencies.
Report Facts
Compliance Determination Completion Dates: Compliance Determination #38872 completed on 05/01/2024 and #32528 completed on 11/17/2023
Employees Mentioned
NameTitleContext
Nareet BajwaNCI-ALF Complaint InvestigatorDepartment staff who did the on-site verification during follow-up inspection
Manfay ChanField ManagerSigned the follow-up inspection letter
Inspection Report Follow-Up Census: 56 Deficiencies: 1 Apr 25, 2024
Visit Reason
The visit was a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to failure to report suspected resident abuse.
Findings
The follow-up inspection on 04/25/2024 found no deficiencies, confirming that the facility meets Assisted Living Facility licensing requirements after correcting prior issues related to failure to report suspected sexual abuse.
Complaint Details
The complaint investigation was triggered by an allegation that resident AV was being abused by staff member AP. The investigation found the facility failed to report the incident as required, constituting a failed provider practice with citations written.
Deficiencies (1)
Description
Failure to call law enforcement and Complaint Resolution Unit hotline as a mandatory reporter for an incident of suspected sexual abuse.
Report Facts
Resident census at risk: 56 Resident sample size: 1 Investigation date range: 09/27/2023 through 11/09/2023
Employees Mentioned
NameTitleContext
Nareet BajwaNCI-ALF Complaint InvestigatorConducted the complaint investigation and on-site verification.
Ann Marie NataliAdministratorSigned the Plan/Attestation Statement agreeing to take corrective action.
Staff AAdministrator notified about the incident but call did not go through.
Staff BResident Care CoordinatorWitnessed incident and attempted to notify Administrator and hotline.
Staff CCaregiverInvolved in the incident with resident and was fired.
Staff DMedication TechnicianWitnessed incident with Staff C and resident.
Inspection Report Enforcement Census: 60 Deficiencies: 1 Nov 17, 2023
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to Brookdale Allenmore AL (WA) to assess compliance and impose a civil fine based on uncorrected deficiencies.
Findings
The licensee failed to implement their own policy on call system alerts for two residents, placing all 60 residents at risk for serious negative health outcomes and poor quality of care. This deficiency was previously cited and remains uncorrected.
Deficiencies (1)
Description
Failure to implement policy on call system alerts for two residents
Report Facts
Civil fine amount: 400 Residents at risk: 60
Employees Mentioned
NameTitleContext
Matt HauserCompliance SpecialistSigned the enforcement letter
Manfay ChanField ManagerContact person for plan of correction and inquiries
Inspection Report Complaint Investigation Census: 56 Deficiencies: 1 Aug 17, 2023
Visit Reason
The Department of Social and Health Services conducted a complaint investigation at the assisted living facility following allegations related to failure to respond to residents' calls for help.
Findings
The licensee failed to implement policies and procedures to respond timely to residents' calls for assistance for two residents, placing all 56 residents at risk for serious negative outcomes and poor quality of life. This was a recurring deficiency previously cited on October 22, 2022.
Complaint Details
Complaint investigation completed on August 17, 2023. The deficiency was substantiated and resulted in a civil fine.
Deficiencies (1)
Description
Failure to implement policies and procedures to respond to residents’ call for help for two residents, resulting in untimely response and risk to all residents.
Report Facts
Civil fine amount: 400 Resident census: 56
Employees Mentioned
NameTitleContext
Matt HauserCompliance SpecialistSigned the letter regarding the civil fine and inspection findings.
Manfay ChanField ManagerContact person for plan of correction and appeals.
Inspection Report Follow-Up Deficiencies: 2 Jun 2, 2023
Visit Reason
The Department completed a follow-up inspection and complaint investigation of the assisted living facility on June 2, 2023, to verify correction of deficiencies cited in the report dated July 20, 2021.
Findings
The follow-up inspection found no deficiencies. The prior complaint investigation identified a failure to notify a resident's representative of significant weight loss and failure to ensure a resident received all meals at regular intervals, resulting in citations.
Complaint Details
Complaint investigation included allegations that a named resident waited over 45 minutes for call light to be answered, residents not receiving meals, failure to inform resident representative of significant weight loss, and residents testing positive for COVID. The investigation substantiated failure to notify representative of significant weight loss and failure to ensure meal delivery; other allegations were unsubstantiated.
Deficiencies (2)
Description
The Assisted Living Facility failed to notify named resident's representative of a significant change in condition (significant weight loss).
The assisted living facility failed to ensure a resident received all three meals at regular intervals when the facility did not deliver the resident's meal to their room.
Report Facts
Sample residents reviewed: 4 Complaint numbers referenced: 4
Employees Mentioned
NameTitleContext
Woodetta MaulanaInvestigatorConducted the follow-up inspection and complaint investigation.
Manfay ChanField ManagerSigned the follow-up inspection letter.
Inspection Report Life Safety Deficiencies: 8 May 16, 2023
Visit Reason
The Office of the State Fire Marshal conducted an inspection of the Brookdale Allenmore AL facility on 05/16/2023 to assess compliance with fire safety codes and regulations.
Findings
The inspection identified multiple violations including failure to provide an inventory of fire-resistance-rated construction, fire doors failing to self-close and latch, inaccessible or improperly installed fire/smoke dampers, lack of documentation for sprinkler system inspections, carbon monoxide alarm inspections, emergency generator servicing, and fire extinguisher inspections. Additionally, a door to the RC Coordinator office had a penetration near the handle.
Deficiencies (8)
Description
Facility shall provide an inventory of all fire-resistance-rated construction.
Fire doors throughout the facility failed to self-close and latch in specified locations.
Six fire/smoke dampers were inaccessible and five failed to operate or were installed incorrectly.
Unable to provide documentation showing quarterly inspection of the automatic fire sprinkler system in the past 12 months.
Unable to provide documentation showing monthly inspection of carbon monoxide alarms in the past 12 months.
Unable to provide documentation showing annual servicing of the emergency backup generator in the past 12 months.
Several fire extinguishers have not received monthly inspections since March 2023.
Door to RC Coordinator office has a penetration near door handle.
Report Facts
Fire/smoke dampers inaccessible: 6 Fire/smoke dampers failed to operate or installed incorrectly: 5 Fire extinguishers not inspected monthly: Since March 2023
Employees Mentioned
NameTitleContext
Lysandra DavisDeputy State Fire MarshalConducted the inspection and signed the report
Inspection Report Follow-Up Census: 61 Deficiencies: 2 Feb 9, 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 the facility met the Assisted Living Facility licensing requirements. Previous deficiencies related to food labeling and medication services were corrected.
Deficiencies (2)
Description
Failure to implement food labeling policy and procedure when food was found to be undated or expired, placing all 61 residents at risk for food borne illnesses.
Failure to develop and implement a safe medication system for 6 of 8 sample residents, placing residents at risk for harm and potential medical decline.
Report Facts
Residents present during inspection: 61 Sample size for review: 8
Employees Mentioned
NameTitleContext
Nareet BajwaNCI-ALF Complaint InvestigatorDepartment staff who did the on-site verification
Cathleen DavisALF LicensorDepartment staff who did the on-site verification
Lisa MasonNCI ALF LicensorDepartment staff who did the on-site verification
Vivienne CampbellExecutive DirectorSigned Plan/Attestation Statement and authored a letter regarding correction of deficiencies

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