Deficiencies per Year
12
9
6
3
0
Unclassified
Inspection Report
Life Safety
Deficiencies: 11
Aug 5, 2025
Visit Reason
The Office of the State Fire Marshal conducted a fire protection inspection at the Brookdale Courtyard Puyallup residential care facility on August 5, 2025.
Findings
The inspection identified several deficiencies related to fire door operation, sprinkler system documentation, emergency lighting testing, and fire door clearances. Some issues were corrected on site, while others require further documentation or correction. The facility was disapproved due to these findings.
Deficiencies (11)
| Description |
|---|
| Fire doors to second floor cinema room failed to self-close and latch when retested. |
| Facility must provide documentation confirming that all deficiencies noted in the June 10, 2025 inspection have been corrected. |
| Facility did not include documentation for emergency lights and exit signs that failed the 90-minute battery test. |
| Unprotected openings observed in first floor electrical room, sprinkler riser room, and second floor storage room. |
| Unable to provide record showing that fire doors have been annually inspected, tested, and repaired in the past 12 months. |
| Facility failed to provide documentation of 2024 inspection, testing, and maintenance of fire/smoke dampers; no follow-up documentation showing corrections. |
| Unable to provide fire sprinkler system documentation for quarterly inspection reports, hydraulic calculation plate, and forward flow test documentation; missing fire sprinkler escutcheon ring in room 321 closet. |
| Unable to provide last smoke detector sensitivity test report. |
| Unable to provide documentation showing monthly inspection of carbon monoxide alarms in past 12 months. |
| Unable to provide documentation showing 90-minute annual battery testing of emergency lighting and exit signs in past 12 months; facility must conduct 90-minute annual test for compliance. |
| Corridor doors throughout the facility have a center door gap that exceeds the allowed 1/16 inch. |
Report Facts
Inspection date: Aug 5, 2025
Previous inspection date: Jun 10, 2025
Next inspection scheduled: Sep 4, 2025
Next inspection scheduled: Jun 13, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mike Schwartz | ED | Owner or Authorized Representative who signed the August 5, 2025 inspection report |
| Damon Roberson | Deputy State Fire Marshal | Signed the inspection report as Deputy State Fire Marshal |
| Joshua Wyche | Business Office Coordinator | Owner or Authorized Representative who signed the May 14, 2025 inspection report |
Inspection Report
Follow-Up
Deficiencies: 0
Jun 16, 2025
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 previously cited deficiencies related to implementation of negotiated service agreements were corrected.
Report Facts
Sample residents reviewed: 6
Sample residents reviewed: 9
Residents affected: 9
Residents with unsigned NSAs: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carol Gijima | Community Complaint Investigator (NCI) | Conducted follow-up inspection and complaint investigation. |
| Jody Just | Field Services Administrator | Signed follow-up inspection report letter. |
Inspection Report
Follow-Up
Census: 78
Deficiencies: 9
Jun 16, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies and compliance with licensing requirements.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previous deficiencies related to staffing, maintenance, housekeeping, food temperature, service agreements, and notification of resident status were corrected or addressed.
Complaint Details
The inspection was complaint-driven, investigating allegations including alleged safety issues, lack of AEDs, short staffing, residents being charged for standby assistance without staff showing up, delayed call light responses, bed bugs, unclean apartments, cold food, failure to follow bed hold reporting, and failure to provide service agreements for signature. The investigation found multiple failed provider practices and citations were written.
Deficiencies (9)
| Description |
|---|
| Failure to ensure adequate staff to complete maintenance requests and provide care and services for residents as agreed upon in negotiated service agreements. |
| Failure to provide assistance as agreed upon, including timely showers and dressing assistance. |
| Failure to maintain resident apartments and facility cleanliness, including weekly room cleaning. |
| Failure to ensure residents received food at appropriate temperatures, placing all residents at risk for foodborne illness. |
| Failure to follow bed hold reporting requirements and provide residents' service agreements for signature. |
| Failure to notify the department case manager timely when a resident was discharged to the hospital or passed away. |
| Failure to ensure negotiated service plans were signed by the department case manager. |
| Failure to maintain documentation filed in closed resident records and maintain signed negotiated service agreements on file. |
| Failure to maintain a safe, sanitary, and well-maintained environment for residents, including timely completion of maintenance work orders. |
Report Facts
Total residents: 78
Closed records sample size: 9
Number of deficiencies cited: 9
Temperature of meat during lunch service: 126
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carol Gijima | Community Complaint Investigator (NCI) | Conducted the on-site verification and investigation. |
| Jody Just | Field Services Administrator | Signed the follow-up inspection letter. |
| Staff A | Maintenance staff interviewed regarding work orders and staffing. | |
| Staff B | Health and Wellness Director | Interviewed regarding staffing and service agreements. |
| Staff C | Maintenance | Interviewed about maintenance requests and staffing. |
| Staff E | Cook | Observed serving meals and interviewed about food temperature controls. |
| Staff F | Interviewed about food temperature controls. | |
| Staff G | Chef | Interviewed about food holding temperatures. |
| Staff H | Business Office Manager | Interviewed about resident records and notifications. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 27, 2025
Visit Reason
The Department completed a full inspection of the Assisted Living Facility on 02/27/2025 after a complaint investigation and found that the facility did not meet Assisted Living Facility requirements.
Findings
One of four medication technicians failed to possess a valid Cardiopulmonary/First-Aid (CPR/FA) card. The deficiency was corrected on-site during the visit by enrolling the technician in an approved CPR/FA course.
Complaint Details
The visit was complaint-related. The deficiency regarding CPR/FA certification was found and corrected on-site. Substantiation status is not explicitly stated.
Deficiencies (1)
| Description |
|---|
| One of four medication technicians failed to possess a valid Cardiopulmonary/ First-Aid (CPR/FA) card. |
Report Facts
Medication technicians: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Grew | LTC Surveyor | Department staff who did the inspection and provided consultation |
| Kathy Heinz | Long Term Care Surveyor | Department staff who did the inspection and provided consultation |
| Cory Myers | ALF Complaint Investigator | Department staff who did the inspection and provided consultation |
| Manfay Chan | Allied Health Field Manager | Signed the report letter |
Inspection Report
Enforcement
Deficiencies: 1
Feb 20, 2025
Visit Reason
A follow-up visit was conducted to assess compliance with previously cited deficiencies, resulting in the imposition of a civil fine for failure to provide showers as agreed upon in the negotiated service agreement for four residents.
Findings
The facility failed to provide showers as agreed upon in the negotiated service agreement for four residents, placing them at risk for skin infections and decreased quality of life. This deficiency was previously cited and remained uncorrected, leading to a $600 civil fine.
Deficiencies (1)
| Description |
|---|
| Failure to provide showers as agreed upon in the negotiated service agreement for four residents. |
Report Facts
Civil fine amount: 600
Number of residents affected: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter. |
| Manfay Chan | Field Manager | Contact person for plan of correction and appeals. |
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