Inspection Report
Follow-Up
Census: 47
Deficiencies: 3
Jul 18, 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 laws and regulations.
Findings
The follow-up inspection found no deficiencies, indicating the facility meets Assisted Living Facility licensing requirements. The prior deficiencies related to food sanitation and cleanliness in the kitchen were corrected.
Complaint Details
The inspection was triggered by complaint number 181513 and included an unannounced on-site full inspection and complaint investigation conducted on 06/02/2025, 06/03/2025, and 06/04/2025.
Deficiencies (3)
| Description |
|---|
| Failure to maintain overall cleanliness of the main kitchen, including grease and dust on exhaust fans, dirty knife holder, unclean steam table and lids, grime on refrigerators and freezer, dirty pantry refrigerator glass doors and shelves, dirty cabinet doors, garbage can covered with dirty towels, unswept floor with food debris, and unclean counters and prep areas. |
| Accumulated dust on a 220-volt extension cord tied to the ceiling and syrup dripping from wire shelves in the pantry room. |
| Black mats on the pantry floor were dirty and dirty towels were on top of the garbage can lid. |
Report Facts
Current residents: 47
Sample residents reviewed: 7
Compliance Determination Completion Dates: Completion dates for Compliance Determinations 62754 (07/18/2025) and 60404 (06/04/2025)
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cristina Gonzalez | Nursing Consultant Institutional | Department staff who did the on-site verification and inspection |
| Karen Glover | Nursing Consultant Institutional | Department staff who inspected the Assisted Living Facility |
| Melissa Phillips | Long Term Care Surveyor | Department staff who inspected the Assisted Living Facility |
| Anthony Devito | Field Services Administrator | Signed the follow-up inspection letter |
Inspection Report
Life Safety
Deficiencies: 6
Mar 5, 2025
Visit Reason
The Office of the State Fire Marshal conducted an inspection at the facility to assess compliance with fire protection and safety codes.
Findings
The inspection identified multiple violations including improper use of multi-plug adapters, use of extension cords as permanent wiring, lack of automatic door closure in the mechanical room, and missing documentation for sprinkler system testing and hydraulic calculation placard.
Deficiencies (6)
| Description |
|---|
| Multi-plug adapter without over current protection in the nurses office |
| Extension cords utilized as permanent wiring in the Wellness Center and Living Room |
| Mechanical room near room 21 lacks an automatic door closure |
| Facility unable to provide documentation for the annual forward flow test in accordance with NFPA 25 |
| Hydraulic calculation placard missing from the sprinkler system |
| Facility unable to provide documentation of the UL test results from the sprinkler head testing |
Report Facts
Next inspection scheduled date: Apr 4, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandon G. Brown | Deputy State Fire Marshal | Conducted the inspection and signed the report |
| Peter P. Day | Maintenance Director | Facility representative named on the report |
Inspection Report
Follow-Up
Deficiencies: 1
Nov 22, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to fire and life safety inspections.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. However, prior complaint investigations and statements of deficiencies documented uncorrected fire and life safety violations related to sprinkler system testing and smoke detector sensitivity.
Complaint Details
Complaint investigation conducted from 07/08/2024 through 08/06/2024 found the Assisted Living Facility failed their 3rd Fire and Life Safety Inspection. A citation was written for noncompliance with WAC 388-78A-2040 (2). The complaint was substantiated with failed provider practice identified and citation(s) written.
Deficiencies (1)
| Description |
|---|
| Failure to ensure violations for 3 Fire and Life Safety annual inspections (03/21/2024, 4/24/2024, and 5/29/2024) were corrected, including incomplete sprinkler head testing and failed smoke detectors not replaced. |
Report Facts
Residents: 44
Fire and Life Safety Inspections: 3
Sprinkler heads needing replacement: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Allison Nunn | Long Term Care Surveyor | Conducted off-site verification and follow-up inspection |
| Kimberley Ripley | Field Manager | Signed compliance determination letters |
| Jodi Condyles | ALF Licensor | Investigated complaint related to fire and life safety |
| Staff A | Executive Director | Interviewed regarding fire and life safety deficiencies and corrective actions |
Inspection Report
Life Safety
Deficiencies: 6
Oct 22, 2024
Visit Reason
The Office of the State Fire Marshal conducted an inspection at the facility to assess compliance with fire safety regulations.
Findings
All violations noted during previous related inspections have been corrected as of the latest inspection on 10/22/2024. Prior inspections from 03/21/2024 to 05/29/2024 documented multiple deficiencies related to door operation, sprinkler system maintenance, smoke detector sensitivity, and unlatching mechanisms, many of which were not corrected at the time.
Deficiencies (6)
| Description |
|---|
| Sprinkler system had deficiencies noted that were not corrected. |
| Failed smoke detectors have not been replaced; facility unable to provide required documentation for smoke detector sensitivity testing. |
| Fire rated door from dining room to corridor would not close and latch from a fully open position. |
| Sprinkler head in kitchen loaded with combustible materials (lint). |
| Two multi-plug adapters without over current protection in use in room 59. |
| Emergency exit door in kitchen has locking devices requiring double action to open. |
Report Facts
Failed smoke detectors: 70
Total smoke detectors: 83
Next inspection scheduled: Jun 28, 2024
Next inspection scheduled: May 24, 2024
Next inspection scheduled: Apr 20, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandon G. Brown | Deputy State Fire Marshal | Signed inspection reports and involved in inspection findings |
| Todd Margeson | Executive Director | Owner or Authorized Representative signing inspection documents |
Inspection Report
Enforcement
Deficiencies: 1
Sep 24, 2024
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to Brookdale Fairhaven to assess correction of previously cited violations related to Fire and Life Safety annual inspections.
Findings
The licensee failed to correct violations from three Fire and Life Safety annual inspections conducted on March 21, April 24, and May 29, 2024, resulting in a civil fine due to the risk posed to residents in the event of a fire.
Deficiencies (1)
| Description |
|---|
| Failure to ensure violations for three Fire and Life Safety annual inspections were corrected. |
Report Facts
Civil fine amount: 600
Number of Fire and Life Safety inspections with violations: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter |
| Kim Ripley | Field Manager | Contact person for plan of correction and appeals |
Inspection Report
Life Safety
Deficiencies: 5
Apr 24, 2024
Visit Reason
The Office of the State Fire Marshal conducted an inspection at the facility to evaluate compliance with fire safety and life safety code requirements.
Findings
The inspection identified several violations including fire doors not closing properly, sprinkler system deficiencies, and failure to provide documentation for required smoke detector sensitivity testing. Some issues were corrected, while others remain uncorrected with plans for replacement.
Deficiencies (5)
| Description |
|---|
| Relocatable power taps were not listed and labeled in accordance with UL 1363 and UL 498A. |
| The fire rated door from the dining room to the corridor would not close and latch from a fully open position. |
| Sprinkler system had deficiencies noted that have not been corrected; a sprinkler head in the kitchen was loaded with combustible materials (lint). |
| Facility unable to provide documentation for required smoke detector sensitivity testing; 70 of 83 detectors failed sensitivity test. |
| Emergency exit door in the kitchen has locking devices which require double action to open. |
Report Facts
Smoke detectors failed sensitivity test: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandon G. Brown | Deputy State Fire Marshal | Signed the inspection report |
| Todd Margeson | Authorized Representative | Signed the inspection report |
Inspection Report
Life Safety
Deficiencies: 4
Apr 24, 2023
Visit Reason
The Office of the State Fire Marshal conducted an inspection at the facility to evaluate compliance with fire protection and safety codes.
Findings
The inspection found multiple violations including failure to provide documentation for the 4-year fire and smoke damper inspection, missing escutcheon rings on five sprinkler heads in the laundry, failure to maintain documentation for monthly carbon monoxide detector testing, and an emergency egress light near room #59 that did not illuminate during testing.
Deficiencies (4)
| Description |
|---|
| Facility is unable to provide documentation for the 4 year fire and smoke damper inspection. |
| Five sprinkler heads in laundry were missing the escutcheon rings. |
| Facility failed to maintain documentation for the monthly carbon monoxide detector testing. Last testing documented was completed in August 2022. |
| The emergency egress light near room #59 would not illuminate when the test button was pressed. |
Report Facts
Number of sprinkler heads missing escutcheon rings: 5
Last documented carbon monoxide detector testing: 202208
Next inspection scheduled on or after: Apr 19, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandon G. Brown | Deputy State Fire Marshal | Conducted the inspection and signed the report |
| Paul Stueber | Manager Supervisor | Facility representative signing the report |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
Nov 9, 2022
Visit Reason
The inspection was conducted to investigate complaint reference #56998 regarding a fire and partial evacuation at Brookdale Fairhaven.
Findings
A fire started in a gas dryer in the laundry room, triggering the fire alarm and evacuation of all 39 residents. The sprinkler system did not activate, but the heat detector did. The fire department responded and extinguished the fire. No injuries were reported and no IFC violations were observed.
Complaint Details
Complaint ref #56998 involved a fire and partial evacuation. The fire was contained to the gas dryer, sprinklers did not activate, all 39 residents were evacuated, no injuries occurred, and the fire department responded.
Report Facts
Residents evacuated: 39
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandon G. Brown | Deputy State Fire Marshal | Conducted the inspection and investigation of the complaint |
| Facility Maintenance Director | Interviewed during the investigation |
Report
File
R_Brookdale_Fairhaven_Complaint_05-10-2022_-_EL.pdf
Report
File
R_Brookdale_Fairhaven_Complaint_09-28-2023_-_EL.pdf
Loading inspection reports...
