Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 1
Jul 1, 2025
Visit Reason
The inspection was conducted as an unannounced on-site complaint investigation related to allegations that the facility failed to comply with fire codes following a recent Fire Marshal visit.
Findings
The facility was found to have failed to comply with fire codes, specifically related to fire marshal ordinances. The failure was substantiated and citations were written. Issues included hanging decorations on fire doors and failure to maintain fire-resistance-rated construction.
Complaint Details
The complaint investigation was substantiated. The facility failed to comply with fire codes following a recent Fire Marshal visit. The failed practice was confirmed through interviews, observations, and record reviews.
Deficiencies (1)
| Description |
|---|
| Facility failed to stay in compliance with local and state fire ordinances, placing residents at risk in the event of a fire. |
Report Facts
Total residents: 82
Resident sample size: 82
Fire doors with hanging items: 38
Fire doors observed with hanging decorations: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Clinton Fridley | Adult Family Home Nurse Field Manager | Investigator and author of the report |
| Yvonne Chitekwe | Department staff who did the on-site verification and investigation | |
| Staff A | Executive Director | Interviewed regarding facility handbook and compliance with fire marshal ordinance |
| Staff B | Maintenance Technician | Interviewed regarding compliance with fire marshal ordinance and facility handbook |
Inspection Report
Re-Inspection
Deficiencies: 15
May 21, 2025
Visit Reason
The Office of the State Fire Marshal conducted a re-inspection at the facility to verify correction of previously cited fire safety violations.
Findings
The facility was found to have multiple unresolved fire safety violations including holes in fire-resistance-rated walls, fire doors with items on them, and failure to provide required annual inspections and reports for fire resistance-rated construction and fire dampers.
Deficiencies (15)
| Description |
|---|
| Hole in fire wall found near activities in corridor wall at gas valve |
| Fire doors throughout found to have items on doors |
| Facility failed to provide annual inspection of fire resistance-rated construction |
| Facility failed to provide 4 year fire damper inspection report |
| Facility failed fire door inspection found to have 85 percent failure of fire doors |
| Facility failed to provide semi annual hood suppression testing |
| Facility failed to provide annual fire alarm inspection report |
| Facility failed to provide monthly carbon monoxide detector testing |
| Facility failed to provide monthly emergency light testing |
| Facility failed to provide annual emergency light testing |
| Facility failed to conduct fire drills once per shift per quarter |
| Floor 2 dryer cords found unsecured (missing strain protection) |
| Hole in ceiling of floor 2 activities |
| Upon inspection of fire doors multiple found to be non compliant due to excessive gaps and failed self closing devices |
| Fire alarm cover missing in laundry room floor 2 (strobe base) |
Report Facts
Failure rate: 85
Next inspection date: Jun 20, 2025
Next inspection date: Apr 18, 2025
Next inspection date: Oct 27, 2025
Next inspection date: Jun 7, 2025
Next inspection date: Aug 1, 2025
Next inspection date: Sep 5, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Hobbs | Maintenance Director | Signed as Owner or Authorized Representative on multiple pages |
| Nicholas Wolden | Deputy State Fire Marshal | Signed as Deputy State Fire Marshal on multiple pages |
| Carolyn Vanger | Executive Director | Signed as Owner or Authorized Representative on one page |
Inspection Report
Re-Inspection
Deficiencies: 3
Mar 19, 2025
Visit Reason
The Office of the State Fire Marshal conducted a re-inspection at the facility to verify correction of previous fire safety violations.
Findings
The facility failed to provide annual inspection of fire resistance-rated construction, fire door inspections, and a 4-year fire damper inspection report. Multiple fire safety deficiencies remain uncorrected.
Deficiencies (3)
| Description |
|---|
| Facility failed to provide annual inspection of fire resistance-rated construction |
| Fire doors throughout found to have items on doors |
| Facility failed to provide 4 year fire damper inspection report |
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 7, 2025
Visit Reason
The Department of Social and Health Services completed a Complaint Investigation at the assisted living facility Brookdale Fishers Landing on March 7, 2025, due to concerns about medication services.
Findings
The licensee failed to develop and implement systems that supported and promoted safe medication service when one resident had medications left and not observed ingested in a resident's room, placing residents at risk of harm due to inconsistent medication services. This was a recurring deficiency previously cited on November 21, 2024.
Complaint Details
Complaint investigation conducted on March 7, 2025. The deficiency was substantiated and resulted in a civil fine.
Deficiencies (1)
| Description |
|---|
| Failure to develop and implement systems that supported and promoted safe medication service when medications were left and not observed ingested in a resident's room. |
Report Facts
Civil fine amount: 300
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Clinton Fridley | RN, Field Manager | Contact person for plan of correction and follow-up related to the complaint investigation. |
| Matt Hauser | Compliance Specialist | Signed the imposition of civil fine letter. |
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 27, 2025
Visit Reason
This document reports the results of the Informal Dispute Resolution (IDR) process related to disputed deficiencies from a Statement of Deficiencies (SOD) report dated December 30, 2024.
Findings
After review of all materials, oral statements, and records, the decision was made to not change the original SOD report dated December 30, 2024. The facility is instructed to begin correcting the disputed deficiencies immediately and submit a Plan/Attestation Statement within 10 calendar days.
Report Facts
Correction timeframe: 45
IDR letter response timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staci Dilg | IDR Program Manager | Author of the IDR results letter |
| Clinton Fridley | Field Manager | Contact for mailing Plan/Attestation Statement |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 1
Jan 29, 2025
Visit Reason
The investigation was conducted due to a complaint alleging that the facility was not following medication administration services correctly by not observing residents take their medications as ordered and agreed in the negotiated service agreement.
Findings
The investigation substantiated that the facility failed to follow medication administration service protocols by not observing residents take their medications as ordered, placing residents at risk of harm due to inconsistent medication services. This was a recurring deficiency previously cited.
Complaint Details
The complaint was substantiated based on interviews, observations, and record reviews. The facility failed to observe residents taking medications as ordered, violating medication administration service requirements.
Deficiencies (1)
| Description |
|---|
| Facility failed to develop and implement systems that support and promote safe medication service when one resident had medications left and not observed ingested in their room. |
Report Facts
Total residents: 83
Resident sample size: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Yvonne Chitekwe | Investigator | Conducted the on-site complaint investigation |
| Staff A | Medication Technician | Observed leaving medications without observing ingestion |
| Staff B | Health and Wellness Director | Stated expectation that medication technicians observe residents taking medications |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 30, 2024
Visit Reason
The Department of Social and Health Services completed a complaint investigation visit at the assisted living facility Brookdale Fishers Landing on December 30, 2024.
Findings
The licensee failed to include the resident's representative and department case manager in the development of the personal service plan for one resident, resulting in a recurring deficiency that led to a civil fine.
Complaint Details
Complaint investigation visit completed on December 30, 2024. The deficiency was substantiated and resulted in a civil fine.
Deficiencies (1)
| Description |
|---|
| Failure to include the resident's representative and department case manager in the development of the personal service plan (facility’s negotiated service agreement) for one resident. |
Report Facts
Civil fine amount: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Burdick | Field Manager | Contact person for submission of Plan of Correction and inquiries. |
| Matt Hauser | Compliance Specialist | Signed the letter imposing the civil fine. |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 2
Dec 20, 2024
Visit Reason
The inspection was conducted as an unannounced on-site complaint investigation triggered by allegations that a resident's care plan did not include required services and that the resident was not receiving care and services as prescribed.
Findings
The investigation found that the facility failed to provide care and services as agreed upon in the negotiated service agreement for one resident, resulting in risks to the resident's health and safety. The resident was found incontinent and not consistently assisted with toileting as required by their service plan. The facility also failed to involve the resident's representative and department case manager in the development of the service plan. Documentation of care provided was lacking, and follow-up on family concerns was inadequate.
Complaint Details
The complaint alleged that Resident 1's care plan did not include necessary services to maintain health and safety and that the resident was not receiving care as prescribed. The complaint was substantiated with findings of failed provider practice and citations issued.
Deficiencies (2)
| Description |
|---|
| Failure to provide care and services as agreed upon in the negotiated service agreement for Resident 1, including toileting assistance and care plan adherence. |
| Failure to include the resident's representative and department case manager in the development of the negotiated service agreement for Resident 1. |
Report Facts
Resident census: 83
Resident sample size: 3
Complaint number: 157018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Emily Boniface | Community Program Nurse Licensor | Investigator and on-site verifier of the complaint investigation |
| Megan Zerby | Community ALF/AFH Licensor | On-site verifier of the follow-up inspection |
| Jody Just | Field Services Administrator | Signed the follow-up inspection report letter |
| Staff C | Health and Wellness Director | Interviewed regarding care provision and documentation failures |
| Staff A | Executive Director | Acknowledged care and service deficiencies during interviews |
Inspection Report
Follow-Up
Deficiencies: 0
Nov 21, 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 found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies were corrected.
Inspection Report
Re-Inspection
Deficiencies: 13
Sep 27, 2024
Visit Reason
The Office of the State Fire Marshal conducted a re-inspection at the facility to verify correction of previous fire safety deficiencies.
Findings
The facility failed to provide annual inspections and reports for fire resistance-rated construction, fire doors, fire dampers, fire sprinkler systems, fire extinguishing systems, fire alarm systems, carbon monoxide detectors, emergency lighting, and fire drills. Multiple violations were noted including non-compliant fire doors, missing inspection reports, and failure to conduct required testing and maintenance.
Deficiencies (13)
| Description |
|---|
| Facility failed to provide annual inspection of fire resistance-rated construction |
| Facility failed fire door inspection found to have 85 percent failure of fire doors |
| Facility failed to provide 4 year fire damper inspection report |
| Facility failed to provide annual fire sprinkler inspection and related testing |
| Facility failed to provide semi annual hood suppression testing |
| Facility failed to provide annual fire alarm inspection report |
| Facility failed to provide monthly carbon monoxide detector testing |
| Facility failed to provide monthly emergency light testing |
| Facility failed to provide annual emergency light testing |
| Facility failed to conduct fire drills once per shift per quarter |
| Floor 2 dryer cords found unsecured (missing strain protection) |
| Hole in ceiling of floor 2 activities |
| Fire alarm cover missing in laundry room floor 2 (strobe base) |
Report Facts
Fire door failure rate: 85
Fire drills required: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Wolden | Deputy State Fire Marshal | Signed inspection reports and conducted re-inspection |
Inspection Report
Life Safety
Deficiencies: 7
Apr 25, 2023
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the Brookdale Fishers Landing residential care facility to assess compliance with fire protection codes and regulations.
Findings
The facility was found to have multiple violations including inadequate electrical clearance in the fire sprinkler riser room, missing electrical receptacle cover in the laundry room, failure to provide annual forward flow testing of the sprinkler system, failure to maintain carbon monoxide detector monthly test logs, failure to provide monthly emergency light testing logs, failure to conduct annual emergency light testing and repairs, and failure to conduct required fire drills once per shift per quarter.
Deficiencies (7)
| Description |
|---|
| Facility failed to maintain electrical clearance in fire sprinkler riser room |
| Electrical receptacle cover missing in laundry room floor 1 |
| Facility failed to provide annual forward flow testing of sprinkler system |
| Facility failed to provide carbon monoxide detector monthly test log |
| Facility failed to provide monthly emergency light testing log |
| Facility failed to provide annual emergency light testing/conduct repairs as needed |
| Facility failed to conduct fire drills once per shift per quarter |
Report Facts
Next inspection scheduled date: May 25, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Wolden | Deputy State Fire Marshal | Conducted the fire safety inspection and signed the report |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 28, 2023
Visit Reason
This document is a follow-up letter communicating the results of the Informal Dispute Resolution (IDR) process conducted on March 28, 2023, regarding disputed deficiencies from a prior Statement of Deficiencies dated January 31, 2023.
Findings
After review of all written materials, oral statements, and records, the decision was made not to change the previously issued Statement of Deficiencies dated January 31, 2023.
Report Facts
Date of IDR process: Mar 28, 2023
Date of Statement of Deficiencies: Jan 31, 2023
ALF License Number: 2261
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Fueston | IDR Program Manager | Author of the IDR results letter |
| Michael Burdick | Field Manager | Recipient for Plan/Attestation Statement submissions |
Inspection Report
Follow-Up
Census: 11
Deficiencies: 7
Feb 16, 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 confirmed that the facility meets Assisted Living Facility licensing requirements.
Complaint Details
The inspection was triggered by complaint numbers 47385 and 51344. The department found the facility not in compliance with licensing laws and regulations as stated in the cited deficiencies.
Deficiencies (7)
| Description |
|---|
| Facility failed to complete tuberculosis (TB) testing for 1 of 5 sampled staff, placing residents and staff at risk of exposure to communicable disease. |
| Facility failed to have documentation for 1 of 1 residents' preadmission and 14 day assessments. |
| Facility failed to have an assessment completed for 1 of 12 residents at least annually. |
| Facility failed to have documentation for 1 of 12 residents' service plan and failed to have initial and 30 day negotiated service agreements signed by responsible parties. |
| Facility failed to notify the department in writing within 10 calendar days of change in administrator. |
| Facility failed to complete TB testing for 5 of 5 sampled staff, placing all staff and residents at risk for possible exposure and harm. |
| Facility failed to ensure a registered nurse delegated nursing tasks as required for 15 of 15 care staff and failed to supervise and evaluate delegated nursing tasks at least every 90 days, placing residents at risk of harm due to untrained and unsupervised care staff. |
Report Facts
Residents present during inspection: 11
Sample size for review: 11
Sample size for complaint investigation: 12
Staff sampled for TB testing: 5
Care staff requiring delegated nursing tasks: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kyle Gehlen | ALF Licensor - LTC | Department staff who inspected the Assisted Living Facility. |
| Jennifer Siharath | ALF Licensor | Department staff who inspected the Assisted Living Facility. |
| Cory Cisneros | Field Manager | Signed compliance determination and follow-up inspection letter. |
| Jody Just | Field Manager | Signed complaint and statement of deficiencies letters. |
| Staff A | Executive Director | Named in findings related to TB testing and nurse delegation deficiencies. |
| Staff B | Health and Wellness Director | Named in findings related to TB testing deficiencies. |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 5
Jan 31, 2023
Visit Reason
The complaint investigation was conducted due to allegations of quality of care/treatment concerns, including resident elopement and failure to provide agreed upon care services, coordinate care with external providers, and provide medications as prescribed.
Findings
The investigation found failed provider practices including failure to coordinate services with external health care providers, failure to implement negotiated service agreements, failure to monitor residents' well-being, failure to provide medications as prescribed, and failure to update negotiated service agreements in a timely manner. Specific issues included residents not receiving prescribed psoriasis creams, lack of communication with external providers, and a resident going without a bed without proper notification.
Complaint Details
The complaint investigation was initiated due to concerns about quality of care/treatment, including resident elopement and failure to coordinate care with external providers and provide medications as prescribed. The investigation concluded that failed provider practices were identified and citations were written.
Deficiencies (5)
| Description |
|---|
| Failed to coordinate services with external health care providers for 2 of 3 residents, placing residents at risk for unmet healthcare needs. |
| Failed to implement negotiated service agreements for 2 of 3 residents, resulting in unmet health needs due to not implementing residents' service plans. |
| Failed to monitor residents' well-being for 1 of 3 residents, risking healthcare needs not being recognized and met. |
| Failed to provide medication services as prescribed for 2 of 3 residents, risking health complications due to incorrect prescription management. |
| Failed to update negotiated service agreement within a reasonable time for 1 of 3 residents when the agreement no longer adequately addressed the resident's assessed needs. |
Report Facts
Total residents: 78
Resident sample size: 3
Monetary reimbursement: 647
Monetary reimbursement: 1294
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacob Ubl | Investigator | Conducted the complaint investigation |
| Michael Burdick | Field Manager | Signed follow-up inspection letter |
| Cory Cisneros | Field Manager | Signed complaint investigation letter |
| Staff A | District Director of Operations | Received complaint about failure to apply psoriasis creams |
| Staff B | Medication Technician | Reported Resident 1's inability to apply psoriasis creams and incontinence |
| Staff C | Health and Wellness Coordinator | Documented issues with Resident 1's bed and psoriasis cream application; educated staff |
| Staff D | Executive Director | Reported on failures to recognize and report Resident 1's lack of bed and medication issues |
| Staff E | Facility RN | Reported Resident 1 went without a bed and failure to report it |
| Collateral Contact 1 | Resident Representative | Reported concerns about Resident 1's care and medication |
| Collateral Contact 2 | Home Hospice Nurse | Reported Resident 1's lack of bed and incontinence issues |
| Collateral Contact 3 | Primary Care Provider | Attempted to coordinate care for Resident 2 |
| Collateral Contact 4 | Registered Nurse | Attempted to communicate with facility about Resident 2's care |
| Collateral Contact 5 | Resident Representative | Reported communication failures regarding Resident 2's care |
Inspection Report
Follow-Up
Deficiencies: 1
Dec 22, 2022
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 the facility meets Assisted Living Facility licensing requirements. Previous deficiencies related to medication nonavailability were corrected.
Complaint Details
The complaint investigation was related to financial exploitation, specifically the facility not refunding for services charged but not provided. The investigation found failed provider practice with citations written.
Deficiencies (1)
| Description |
|---|
| Failure to obtain prescribed medications in a correct and timely manner, resulting in medications not being given and residents being charged for services not provided. |
Report Facts
Total residents: 80
Medication not administered days: 20
Medication not administered days: 21
Medication not administered days: 22
Correction timeframe: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Clinton Fridley | NCI, ALF Complaint Investigator | Investigator who conducted complaint investigation |
| Jason Rose | Department staff who did the on-site verification during follow-up inspection | |
| Cory Cisneros | Field Manager | Field Manager who signed enforcement and correction letters |
| Staff B | Licensed Practical Nurse (LPN), Health and Services Coordinator (HSC) | Interviewed regarding medication documentation and corrective processes |
| Staff C | Medication Technician | Documented medication availability and resident spouse statements |
| Staff D | Medication Technician | Documented medication availability and refusals on multiple dates |
| Staff E | Medication Technician | Documented medication availability and refusals on multiple dates |
Inspection Report
Enforcement
Deficiencies: 1
Nov 22, 2022
Visit Reason
The Department of Social and Health Services completed an investigation at the assisted living facility Brookdale Fishers Landing, resulting in a civil fine due to regulatory violations.
Findings
The licensee failed to complete tuberculosis testing for one staff member, placing residents and staff at risk of exposure to a communicable disease. This was an uncorrected deficiency previously cited on September 23, 2022.
Deficiencies (1)
| Description |
|---|
| Failure to complete tuberculosis testing for one staff member |
Report Facts
Civil fine amount: 300
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter |
| Cory Cisneros | Field Manager | Contact person for plan of correction and inquiries |
Notice
Deficiencies: 0
Brookdale Fishers Landing 2261 IDR Scheduling Letter 0223
Visit Reason
The letter confirms the scheduling of an Informal Dispute Resolution (IDR) meeting requested by the facility administrator to dispute a citation from a Statement of Deficiencies dated January 31, 2023.
Findings
The document does not contain inspection findings but serves to schedule and provide instructions for the IDR meeting related to disputed citations.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Casandra Vargas | Executive Director | Named as participant representing the facility in the IDR process. |
| Amanda Kelly | Health and Wellness Director | Named as participant representing the facility in the IDR process. |
Notice
Deficiencies: 0
Brookdale Fishers Landing 2261 51844 123024 Sched Ltr 0225
Visit Reason
The letter confirms the scheduling of an Informal Dispute Resolution (IDR) meeting requested by the facility to dispute citations related to a Statement of Deficiencies dated December 30, 2024, and a Civil Fine dated January 9, 2025.
Findings
The document does not contain inspection findings but relates to the dispute of citations WAC 388-78A-2160 and WAC 388-78A-2130.
Report Facts
Citation dates: Statement of Deficiencies dated December 30, 2024, and Civil Fine dated January 9, 2025
IDR meeting date: Scheduled for February 25, 2025, at 1:30pm
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Casandra Vargas | Executive Director | Participant representing the facility in the IDR process |
| Amanda Kelly | Health and Wellness Director | Participant representing the facility in the IDR process |
| Laci Traulsen | Program Specialist 2/ Volunteer Coordinator | Author of the scheduling letter |
| Matt Hauser | Compliance Specialist | Mentioned in cc list |
Loading inspection reports...



