Deficiencies per Year
20
15
10
5
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Enforcement
Census: 87
Deficiencies: 5
Feb 15, 2024
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to Brookdale Federal Way to assess compliance and impose civil fines based on uncorrected deficiencies previously cited.
Findings
Multiple uncorrected deficiencies were found, including failure to screen staff for tuberculosis, unqualified administrator staff, inadequate garbage disposal, poor ventilation maintenance, and insufficient housekeeping, all placing residents at risk.
Deficiencies (5)
| Description |
|---|
| Failed to ensure three staff were screened for tuberculosis within three days of employment. |
| Failed to ensure one staff met Washington State qualifications to be an assisted living facility administrator. |
| Failed to maintain one outdoor garbage container. |
| Failed to ensure window screens were appropriately placed and maintained on 17 operable exterior windows. |
| Failed to provide a clean, safe, and well-maintained environment. |
Report Facts
Civil fine amount: 300
Civil fine amount: 400
Civil fine amount: 200
Civil fine amount: 400
Civil fine amount: 400
Total civil fines: 1700
Resident census: 87
Number of windows with ventilation issues: 17
Number of staff not screened for TB: 3
Number of unqualified administrator staff: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter |
| Laurie Anderson | Field Manager | Contact person for the enforcement and plan of correction |
Inspection Report
Follow-Up
Deficiencies: 0
Feb 7, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to medication administration.
Findings
The follow-up inspection found no deficiencies, confirming that the facility meets Assisted Living Facility licensing requirements and that previously cited deficiencies were corrected.
Complaint Details
The complaint investigation was related to a medication management error involving failure to administer prescribed medication to a resident. The investigation found that the facility failed to administer Bupropion as ordered for one resident, resulting in a citation for failed provider practice.
Report Facts
Total residents: 93
Resident sample size: 3
Medication tablets received: 30
Medication doses administered: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly George | Nursing Consultant Institutional | Department staff who did the on-site verification during follow-up inspection |
| Kailash Sharma | ALF Licensor | Investigator who conducted the complaint investigation |
| Laurie Anderson | Field Manager | Signed the follow-up inspection letter |
Inspection Report
Life Safety
Deficiencies: 1
Jan 22, 2024
Visit Reason
The inspection was conducted due to a complaint regarding a power outage and lack of generator activation at the Brookdale Federal Way residential care facility.
Findings
The facility was found to be unable to provide documentation for weekly, monthly, and annual generator inspections, and the generator had not been serviced since February 2022. The facility's fire alarm panel was beeping every 15 minutes during the outage, and the generator was out of fuel and leaking.
Complaint Details
Complaint #114976 was regarding a power outage and no generator activation. The complaint was substantiated by observations during the inspection.
Deficiencies (1)
| Description |
|---|
| The facility was unable to provide documentation for their weekly, monthly, and annual generator inspection. The generator has not been serviced since February 2022. |
Report Facts
Complaint number: 114976
Time without power: 2
Next inspection date: Feb 21, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cozetta Christian | Deputy State Fire Marshal | Conducted the inspection and signed the report |
Inspection Report
Life Safety
Deficiencies: 20
Jul 13, 2023
Visit Reason
An unannounced Fire and Life Safety Code inspection was conducted at Brookdale Federal Way by a representative of the Washington State Patrol, State Fire Marshal's Office to determine compliance with all applicable codes.
Findings
Multiple fire and life safety code violations were observed, including unapproved multiplug adapters, power strips plugged into other power strips, extension cords in use, missing covers on electrical boxes, failure to provide documentation for annual and semi-annual hood cleaning, broken door closures, doors not closing properly, missing sprinkler escutcheon rings, fire alarm panel issues, lack of documentation for testing and maintenance of fire safety systems, and unsecured oxygen bottles.
Deficiencies (20)
| Description |
|---|
| Resident room 287 has an unapproved multi plug adapter plugged into an extension cord. |
| The Wellness Center has a power strip plugged into another power strip. |
| Power strips are dangling by their cords in the Wellness Center - 1st floor and Sales Manager's Office - 1st floor. |
| Extension cords in use in Resident room 287 and Activity room - by exit door; plugged into power strip. |
| The Wellness Center has a cable box without a cover on it. |
| The facility was unable to provide documentation for their annual and semi annual hood cleaning. |
| The facility was unable to provide record of their annual fire wall inspection and/or repairs for all fire-resistant-rated construction. |
| The Business Office's fire door has been modified with a bolt lock and different door handle. |
| The Activity Manager's office has a broken door closure. |
| Several doors did not close/latch properly when tested including kitchen door, elevator room door, storage room, housekeeping room, private dining room, and sprinkler riser room. |
| Sprinkler heads missing escutcheon rings in Resident room 265 (x2), Kitchen/Waiter station area, Treatment room in Activity room; multiple dirty sprinkler heads in Wellness Center; painted sprinkler head in Housekeeping closet by room 104. |
| Facility was put on fire watch due to their fire alarm not signaling out and failure to have NOC shift complete a fire watch. |
| Facility unable to provide documentation for quarterly sprinkler reports. |
| Facility unable to provide service reports showing kitchen suppression system serviced annually and semi-annually in past 12 months. |
| Required maintenance for fire extinguishers in elevator room and activity room has not been completed. |
| Fire alarm panel is yellow tagged due to monitoring not signaling out and smoke sensitivity being overdue; facility placed on fire watch. |
| Facility unable to provide documentation showing testing of CO detectors in past 12 months. |
| Emergency lights did not work when tested in room 257, laundry room, and hall by Health and Wellness Director's office. |
| Facility unable to provide documentation showing 90-minute annual testing of emergency lighting performed in last 12 months. |
| Resident room 271 has unsecured oxygen bottles. |
Report Facts
Inspection date: Jul 13, 2023
Next inspection scheduled: Aug 12, 2023
Number of sprinkler heads missing escutcheon rings: 3
Number of doors not closing properly: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cozetta Christian | Deputy State Fire Marshal | Signed as Deputy State Fire Marshal conducting the inspection |
| John Sletick | Maintenance Director | Named as Owner or Authorized Representative signing the report |
Report
File
R_Brookdale_Federal_Way_56555_60015-ew.pdf
Report
File
R_Brookdale_Federal_Way_Amended_Inspection_10-19-23-AM.pdf
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