Inspection Report
Follow-Up
Census: 96
Deficiencies: 1
Jun 3, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to medication services.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. The prior deficiencies related to medication services were corrected.
Complaint Details
The complaint investigation was triggered by an allegation that the Named Resident did not have medications available. The investigation found failed practice in medication reconciliation and communication, resulting in a citation for non-compliance with WAC 388-78A-2210 (2)(a) Medication services.
Deficiencies (1)
| Description |
|---|
| The Assisted Living Facility failed to ensure one resident received medications according to the service plan, resulting in missed medications for January 2025 and risk of medical complications. |
Report Facts
Total residents: 96
Resident sample size: 3
Number of missed medications: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wesler Dumecquias | Community Complaint Investigator | Conducted the complaint investigation and follow-up inspection |
| Anthony Devito | Field Services Administrator | Signed the follow-up inspection letter |
| Staff G | Licensed Nurse | Provided statement regarding medication availability and communication |
| Staff H | Licensed Nurse | Informed Staff G about Resident 1 being out of medications |
| Staff A | Executive Director | Reported on medication consumption and missed medications |
| Staff B | Medication Technician | Reported pharmacy communication and Resident 1's behavior changes |
| Staff C | Medication Technician | Reported Resident 1's confusion and behavior changes after running out of medications |
| Staff F | Caregiver | Reported Resident 1's anxiety and frequent call button use |
Inspection Report
Life Safety
Deficiencies: 19
Apr 2, 2025
Visit Reason
The Office of the State Fire Marshal conducted an inspection at the residential care facility Brookdale Arbor Place to assess compliance with fire safety and life safety codes.
Findings
The facility was disapproved due to multiple fire and life safety violations including improper storage of fueled equipment, unprotected gas appliances, unauthorized power strips and extension cords, missing documentation for fire safety maintenance, unsealed penetrations, malfunctioning fire doors, obstructed sprinkler heads, missing sprinkler system documentation, and inadequate emergency power illumination.
Deficiencies (19)
| Description |
|---|
| There was a gas grill with propane tank stored in the main laundry room. |
| Three multi-plug adapters did not have over current protection in rooms 306, 111, and 112. |
| A power strip was plugged into a non-compliant multi-plug adapter in the maintenance office. |
| Extension cords were utilized as permanent wiring in room 306 and the business office manager's office. |
| Facility unable to provide documentation for semi-annual hood cleaning. |
| Gas appliances on casters in the kitchen were not limited by a restraining device. |
| Unsealed penetrations in corridor near room 211 and kitchen ceiling. |
| Facility unable to provide documentation that annual fire resistance rated construction material inspection has been completed. |
| Resident room 318 door had a deadbolt lock removed leaving a hole. |
| Resident rooms 324 and 329 had unauthorized magnet hold open devices not connected to fire alarm system. |
| Fire rated cross corridor doors near rooms 338, 328, 205, and 1st floor mechanical room would not close and latch from fully open position. |
| Facility unable to provide documentation for 4 year fire and smoke damper inspection. |
| Sprinkler head in walk-in freezer was obstructed by food boxes and flow pattern was blocked. |
| Annual sprinkler inspection from 8/24/2024 had deficiencies not corrected; mixed standard and quick response sprinkler heads found; hydraulic calculation placard missing. |
| Facility unable to provide documentation for monthly fire extinguisher maintenance. |
| Facility unable to provide documentation for monthly single station smoke alarm testing. |
| Multiple floor mats and trash blocked emergency exit in kitchen. |
| Emergency egress light in 2nd floor stairwell 2 did not illuminate when tested. |
| Emergency lighting in first floor stairwells 1, 2, 3, and 4 did not illuminate exit access. |
Report Facts
Multi-plug adapters without over current protection: 3
Date of previous annual sprinkler inspection: Aug 24, 2024
Next inspection scheduled on or after: May 2, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandon G. Brown | Deputy State Fire Marshal | Conducted the inspection |
| Angela Kind | Executive Director | Signed as authorized facility representative |
| Johnnie Both | Maint Supervisor | Signed as owner or owner's representative on page 1 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 13, 2025
Visit Reason
The Department completed a complaint investigation of the Assisted Living Facility based on complaint numbers 162921, 164468, and 165680.
Findings
The investigation found that the facility did not meet Assisted Living Facility requirements, specifically regarding medication storage and organization. One of three medication carts had a drawer that was not organized, with ointments, lotions, and inhalers from multiple residents not properly stored.
Complaint Details
Complaint investigation included complaint numbers 162921, 164468, and 165680. The facility was found non-compliant with medication storage requirements.
Deficiencies (1)
| Description |
|---|
| Medication cart drawer was not organized; medications from multiple residents were not properly stored in original packaging and some were inside plastic bags. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wesler Dumecquias | Community Complaint Investigator | Department staff who did the inspection and provided consultation. |
Inspection Report
Follow-Up
Census: 87
Deficiencies: 0
Jul 25, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility on 07/25/2024 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. Previously cited deficiencies related to maintenance, housekeeping, CPR/first-aid training, background checks, tuberculosis testing, pet vaccinations, ongoing assessments, medication availability, food temperature monitoring, and full resident assessments were corrected.
Report Facts
Residents present during inspection: 87
Sample size for review: 9
Meals monitored for temperature: 134
Meals without temperature documentation: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cristina Gonzalez | ALF Licensor | Department staff who did the on-site verification |
| Allison Nunn | Long Term Care Surveyor | Department staff who did the on-site verification |
| Roger Harrington | Assisted Living Facility Licensor | Department staff who inspected the facility |
| Staff B | Med Tech | Named in CPR/first-aid training deficiency |
| Staff C | Med Tech | Named in CPR/first-aid training and background check deficiencies |
| Staff E | Caregiver | Named in CPR/first-aid training deficiency |
| Staff F | Med Tech | Named in CPR/first-aid training and fingerprint background check deficiencies |
| Staff D | Caregiver | Named in fingerprint background check and tuberculosis testing deficiencies |
| Staff I | Business Office Coordinator | Provided statements regarding CPR/first-aid training and background check processes |
| Staff G | Health and Wellness Director | Provided statements regarding medication administration and resident assessments |
| Staff J | Cook | Observed during food temperature monitoring deficiency |
| Staff K | Dining Services Coordinator | Provided statements regarding food temperature monitoring |
| Staff A | Executive Director | Participated in facility tours and provided statements related to deficiencies |
| Staff F | Med Tech | Named in fingerprint background check deficiency |
Inspection Report
Follow-Up
Census: 62
Deficiencies: 2
Sep 11, 2023
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to licensing laws and regulations.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets the Assisted Living Facility licensing requirements. Previous deficiencies related to the implementation of negotiated service agreements were corrected.
Complaint Details
The visit was complaint-related involving allegations of a witnessed fall and failure to take portable oxygen during an activity, and an unexpected death of a resident. The investigation found failed provider practices and citations were written.
Deficiencies (2)
| Description |
|---|
| Failed to review, update and ensure the resident's negotiated service agreement identified increased needs after a fall and failed to follow through with daily vital checks. |
| Failed to provide services as agreed upon in the Temporary Service Plan for 2 residents, including monitoring vital signs and updating negotiated service agreements after a fall. |
Report Facts
Total residents: 62
Resident sample size: 5
Closed records sample size: 1
Compliance Determination Completion Dates: 07/06/2023 and 09/11/2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wesler Dumecquias | Community Complaint Investigator | Investigator for complaint investigation |
| Jodi Condyles | ALF Licensor | Department staff who did the on-site verification during follow-up inspection |
| Kimberley Ripley | Field Manager | Signed follow-up inspection letter and statement of deficiencies |
Inspection Report
Life Safety
Deficiencies: 17
Jun 13, 2023
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the Brookdale Arbor Place residential care facility to assess compliance with fire and life safety codes.
Findings
The inspection identified multiple fire and life safety violations including electrical hazards, extension cord misuse, fire door malfunctions, missing fire drill documentation, emergency lighting failures, and deficiencies in fire alarm and suppression system maintenance. Several violations were corrected, but many documentation and maintenance deficiencies remain.
Deficiencies (17)
| Description |
|---|
| Power cord for copier running through doorway to medical office. |
| Extension cords utilized as permanent wiring in medical office and main lobby. |
| Facility unable to provide documentation for semi-annual hood cleaning. |
| Facility unable to provide documentation for annual fire resistance rated construction inspection. |
| Facility unable to provide documentation for annual fire door inspection. |
| Multiple fire doors would not close and latch from fully open position. |
| Facility unable to provide documentation for annual sprinkler system inspection, 5-year internal piping inspection, and 3-year dry system full flow trip test. |
| Facility unable to provide documentation for semi-annual kitchen suppression system servicing. |
| Required annual maintenance for fire extinguishers tagged December 2023 instead of 2022; missing monthly maintenance documentation for 3rd floor extinguishers. |
| Portable fire extinguisher in kitchen obstructed by dry goods delivery. |
| Power breaker for fire alarm missing locking device. |
| Facility unable to provide documentation for annual fire alarm system testing. |
| Facility unable to provide documentation for monthly carbon monoxide detector testing. |
| Emergency egress lights and exit signs in multiple locations would not illuminate when tested. |
| Internally illuminated exit signs in corridors near rooms 333, 107, and 125 did not illuminate in normal operation. |
| Facility unable to provide documentation for annual 90-minute power test for emergency lights. |
| Facility cannot provide documentation for completion of twelve planned and unannounced fire drills in the previous 12 months; multiple shifts and quarters missing. |
Report Facts
Inspection date: Jun 13, 2023
Inspection date: May 8, 2023
Inspection date: Apr 3, 2023
Missing fire drills: 5
Fire drill frequency: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandon G. Brown | Deputy State Fire Marshal | Signed inspection reports and conducted inspections |
| Wendy S. Rebec | Maintenance Supervisor | Signed inspection report on 2023-04-03 |
| Mike Cook | Maintenance Supervisor | Signed inspection report on 2023-05-08 |
| Lorena Amarillo | Executive Director | Signed inspection report on 2023-06-13 |
Inspection Report
Life Safety
Deficiencies: 9
May 8, 2023
Visit Reason
The Office of the State Fire Marshal conducted an inspection at the facility to assess compliance with fire safety and electrical hazard regulations.
Findings
Multiple violations were observed including electrical hazards such as power cords running through doorways, extension cords used as permanent wiring, missing locking devices on fire alarm power breakers, emergency lighting failures, and incomplete documentation of fire drills and maintenance inspections. Several issues were corrected during the inspection.
Deficiencies (9)
| Description |
|---|
| Found power cord for copier running through doorway to medical office. |
| There was an extension cord utilized as permanent wiring in medical office. |
| The required annual maintenance for the fire extinguisher located throughout have been tag December 2023 instead of 2022. |
| The power breaker for fire alarm is missing locking device. |
| The emergency egress light in staircase 1 level 3 would not illuminate when the test button was pressed. |
| The emergency egress light/exit sign combo in kitchen by mechanical would not illuminate when the test button was pressed. |
| The internally illuminated exit signs in the corridor near room 333 did not illuminate in normal operation. |
| The internally illuminated exit signs in the corridor near room 107 did not illuminate in normal operation. |
| Facility cannot provide documentation for the completion of twelve planned and unannounced fire drills in the previous 12 months. Missing drills: 1st Shift - Quarter 4, 2nd Shift - Quarter 1 and 3, 3rd Shift - Quarter 3 and 4. |
Report Facts
Next inspection scheduled: Jun 7, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mike Cook | Maintenance Supervisor | Owner or Authorized Representative signing the inspection report |
| Brandon G. Brown | Deputy State Fire Marshal | Signed the inspection report |
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