Inspection Report Summary
The most recent inspection on September 2, 2025, found multiple deficiencies related to staff background checks, training, and tuberculosis screenings. Earlier inspections showed a pattern of issues including housekeeping and maintenance deficiencies, medication administration problems, incomplete service agreements, and failures in emergency care procedures. Inspectors frequently cited problems with staff qualifications, training, resident care services, and maintaining a safe, sanitary environment. Several complaint investigations were substantiated, including concerns about missed medications, delayed care, and emergency response failures, but enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows ongoing challenges with staff compliance and environmental maintenance, with no clear improvement trend evident over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
6.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
3% worse than Washington average
Washington average: 6.3 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
80 residents
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 7
Date: Sep 2, 2025
Visit Reason
The department completed an unannounced on-site full inspection and complaint investigation of Brookdale Meadow Springs on 09/02/2025 through 09/05/2025, referencing complaint numbers 191518 and 189388.
Complaint Details
The inspection was triggered by complaints numbered 191518 and 189388. The investigation found multiple deficiencies related to staff background checks, training, and tuberculosis screening, placing residents at risk.
Findings
Multiple deficiencies were found including failure to complete required background checks, fingerprint checks, tuberculosis screenings, and required training for staff. These failures placed residents at risk of being cared for by disqualified or untrained staff. The facility also failed to submit background checks timely and maintain valid certifications for staff.
Deficiencies (7)
Failure to ensure national fingerprint background checks were completed for 2 of 5 staff (Staff D and G).
Failure to maintain a valid two-year Washington state name and date of birth background check for 1 of 2 staff (Staff F).
Failure to submit a name and date of birth background check within one business day of hire for 1 of 1 staff (Staff G).
Failure to ensure caregivers completed specialty mental health and dementia training for 2 of 4 staff (Staff A and D).
Failure to ensure caregivers met long-term care worker training requirements for 2 of 4 staff (Staff D and G).
Failure to ensure tuberculosis screening within three days of hire for 3 of 4 staff (Staff A, B, and D).
Failure to ensure staff completed required 70-hour long-term care worker training for Staff D and Staff G, who worked 390 and 331 days respectively without completion.
Report Facts
Number of residents reviewed: 9
Number of former residents reviewed: 1
Staff shifts worked: 22
Staff shifts worked: 17
Days worked without training: 390
Days worked without training: 331
Days after hire TB screening completed: 371
Days after hire TB screening completed: 243
Days worked without TB screening: 85
Days late for background check: 165
Days late for fingerprint background check: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Clapp | Assisted Living Facility Licensor | Conducted inspection and on-site verification |
| Anna Cairns | ALF Long Term Care Surveyor | Conducted inspection |
| Tracy Ramirez | Assisted Living Facility Licensor | Conducted inspection |
| Staff H | Business Office Manager | Acknowledged missing background checks, training, and TB screenings during interviews |
| Staff I | Administrator | Acknowledged lack of LTCW training completion and previous business office manager's role |
| Staff A | Health and Wellness Director | Found missing specialty mental health and dementia training and late TB screening |
| Staff D | Caregiver | Found missing fingerprint background check, specialty training, LTCW training, and late TB screening |
| Staff F | Activities Director | Missing valid Washington state background check |
| Staff G | Caregiver | Missing fingerprint background check, late background check submission, LTCW training not completed |
| Staff B | Caregiver | Missing timely TB screening |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 84
Deficiencies: 2
Date: Jul 22, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding housekeeping concerns, including failure to provide weekly housekeeping services, restrictions on visitors cleaning apartments, and failure to wash laundry and bedding weekly for residents.
Complaint Details
The complaint alleged that an identified resident was not receiving weekly housekeeping services, the facility would not allow visitors to clean the resident's apartment, and the resident's laundry and bedding were not washed weekly. The investigation substantiated these concerns with failed practices identified and citations written.
Findings
The investigation found multiple deficiencies related to maintenance and housekeeping, including unsafe and unsanitary conditions in common areas and resident rooms, failure to wash personal clothing and bedding weekly, and inadequate staffing for housekeeping duties. The facility lacked a housekeeping policy and had issues with cleanliness, odors, and maintenance of equipment and furnishings.
Deficiencies (2)
Failure to maintain a safe, sanitary and well-maintained environment in facility common areas and resident rooms, with potential risk of exposure to disease-producing bacteria and decreased quality of life.
Failure to wash personal clothing and bedding weekly as care planned for sampled residents.
Report Facts
Total residents: 73
Resident sample size: 2
Closed records sample size: 1
Total capacity: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Krista Connelly | Community Nurse Consultant | Investigator who conducted the inspection and on-site verification |
| Staff A | Executive Director | Interviewed regarding housekeeping and maintenance issues |
| Staff B | Housekeeper | Interviewed regarding housekeeping staffing and cleaning practices |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 4, 2025
Visit Reason
This document addresses the results of the Informal Dispute Resolution (IDR) process related to a Statement of Deficiencies (SOD) report dated March 04, 2025, disputing deficiencies cited during a prior inspection.
Findings
After review of all materials, oral statements, and records, the decision was made not to change the original SOD report dated March 04, 2025. 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
Plan/Attestation Statement submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Williams-Davis | Field Manager | Contact for clarification related to the SOD report. |
| Staci Dilg | IDR Program Manager | Author of the IDR results letter. |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 1
Date: Jan 21, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding allegations involving a named resident's spouse's move-in agreement, billing issues, and the resident's falls.
Complaint Details
The complaint involved allegations that the named resident's spouse was to move into the facility but did not, the resident had multiple falls leading to relocation, the spouse had not received a refund, and the facility continued billing the spouse. The investigation substantiated a failed practice related to signing negotiated service agreements.
Findings
The investigation found that the facility failed to ensure negotiated service agreements were signed by residents or their representatives for 1 former resident and 1 current resident, placing residents at risk for not being part of decision making and care planning. Additionally, the facility was unable to rent out an apartment due to a signed rental agreement by a spouse who did not move in. The facility refunded the named resident's account and no other failed practices were identified.
Deficiencies (1)
Failure to ensure the negotiated service agreement was agreed to and signed by the resident or their representative for 1 former resident and 1 current resident.
Report Facts
Total residents: 79
Resident sample size: 5
Closed records sample size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elaine Lopez | Licensor | Department staff who conducted the inspection and investigation |
| Laura Williams-Davis | ALF Field Manager | Signed follow-up inspection letter |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 1
Date: Mar 12, 2024
Visit Reason
The inspection was conducted as a complaint investigation regarding allegations that two residents were not receiving their medications as ordered.
Complaint Details
The complaint alleged that two residents were not getting their medications as ordered. The investigation substantiated the allegation with findings of missed and delayed medications.
Findings
The investigation confirmed missed medications and delayed medication start times for two residents, resulting in deficient practice. Citations were issued for failure to ensure a safe medication system.
Deficiencies (1)
Failed to ensure a safe medication system for 2 of 3 residents reviewed, resulting in missed medications and delayed wound healing.
Report Facts
Total residents: 73
Resident sample size: 4
Compliance Determination Completion Date: Completion date of the cited deficiencies was 2024-04-03
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laurel Knight | Community Complaint Investigator | Conducted the on-site verification and investigation |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 13
Date: Nov 2, 2023
Visit Reason
The Department completed a full inspection of the Assisted Living Facility on 11/02/2023 following complaint investigations referencing complaint numbers 101673, 102290, and 102510.
Complaint Details
The inspection was complaint-driven referencing complaint numbers 101673, 102290, and 102510. The facility was found not in compliance with multiple regulatory requirements.
Findings
The facility was found not in compliance with Assisted Living Facility requirements, with multiple deficiencies including intermittent nursing services, background checks, tuberculosis testing, pet records, resident rights notifications, ventilation, laundry, maintenance, housekeeping, orientation training, CPR and safety training. The facility failed to meet regulatory requirements in these areas, placing residents at risk.
Deficiencies (13)
Failed to ensure a safe system for nurse delegation for 4 residents receiving delegated nursing tasks.
Failed to submit Washington State background checks every two years for 2 staff.
Failed to submit background check within one business day after hire for 1 staff and failed to obtain three positive references for 2 staff.
Failed to ensure fingerprint background check results were pending for 1 provisionally hired staff with unsupervised access.
Failed to ensure tuberculosis screening within three days of hire for 4 staff.
Failed to maintain pet records including vaccination and examination records for pets of 3 residents.
Failed to inform residents in writing at least every 24 months of service items, activities, and facility rules for 2 residents.
Failed to provide and maintain intact sixteen mesh screens on operable windows and openings in 4 areas of the facility.
Failed to provide a safe and sanitary laundry environment with accessible laundry rooms for residents.
Failed to provide a safe, sanitary, and well-maintained environment in hallways, common areas, and exterior grounds.
Failed to complete facility orientation training before staff had routine resident interaction for 3 staff and failed to complete two-hour orientation training before long-term care workers provided care for 2 staff.
Failed to ensure CPR certification for 2 of 4 staff required to have certification.
Failed to complete three-hour safety training before staff provided care for 2 of 3 long-term care workers.
Report Facts
Residents reviewed: 9
Current residents: 68
Deficiencies cited: 13
Missing/damaged screens: 38
Days late: 14
Days late: 82
Days pending: 134
Days without nurse delegation assessment: 301
Days without nurse delegation assessment: 308
Days without nurse delegation assessment: 302
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gwin Kaercher | Field Manager | Named as Field Manager overseeing inspection and correspondence |
| Elaine Lopez | Licensor | Department staff who did on-site verification |
| Tracy Ramirez | Assisted Living Facility Licensor | Department staff who did on-site verification and named in findings |
| Anna Cairns | ALF Long Term Care Surveyor | Department staff who inspected the facility |
| Jessica Clapp | Assisted Living Facility Licensor | Department staff who inspected the facility |
| Robin Rainville | Assisted Living Facility Licensor | Department staff who inspected the facility |
| Bo Phillipy | Executive Director | Named as responsible for corrective actions in Plan of Correction |
| Staff A | Administrator | Named in findings related to background checks, TB screening, orientation |
| Staff B | Licensed Practical Nurse (LPN)/Health and Wellness Director | Named in multiple findings including nurse delegation, background checks, TB screening, CPR, orientation |
| Staff C | Maintenance Director | Named in findings related to TB screening, orientation, maintenance |
| Staff D | Caregiver | Named in findings related to fingerprint background, TB screening, safety training |
| Staff E | Medication Technician | Named in findings related to background checks, safety training, CPR |
| Staff F | Resident Care Coordinator | Named in background check findings |
| Staff G | Business Office Coordinator | Interviewed regarding staff records and deficiencies |
| Staff H | Registered Nurse Delegator (RND) | Named in nurse delegation findings |
| Staff I | Medication Technician | Named in nurse delegation findings |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 1
Date: May 12, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations that a resident was denied timely brief changes and care services, and that call lights were not answered promptly.
Complaint Details
The complaint investigation was substantiated with findings that the identified resident was told they could not have their briefs changed because it had not been long enough and experienced delays over 30 minutes in call light response. Facility staff interviews and record reviews confirmed these issues.
Findings
The investigation found deficient practices including failure to provide brief changes as requested by the resident and delays in responding to call lights, resulting in discomfort and skin issues for the resident. Citations were issued for failure to ensure resident care and services per resident choice.
Deficiencies (1)
Failure to ensure resident care and services were provided per resident choice, including timely brief changes and response to call lights.
Report Facts
Total residents: 56
Resident sample size: 3
Call light wait time: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laurel Knight | Community Complaint Investigator | Investigator who conducted the complaint investigation and on-site verification |
| Gwin Kaercher | Field Manager | Signed correspondence related to the inspection and findings |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 1
Date: Sep 8, 2022
Visit Reason
The inspection was conducted as a complaint investigation triggered by an allegation that a resident was found unresponsive in the hall and no lifesaving measures were performed despite a duty to act.
Complaint Details
The complaint alleged that a named resident was found unresponsive in the hall and no lifesaving measures were done despite a duty to act. The investigation confirmed that staff delayed responding to the resident's call for help, did not perform CPR or open the airway as directed by emergency dispatch, and the resident was found unresponsive and cold. Emergency personnel initiated CPR upon arrival but the resident was pronounced deceased. The facility policy was not followed and staff cited difficulty moving the resident and uncertainty about CPR procedures.
Findings
The investigation found that the facility failed to follow its policy regarding emergency care for an unresponsive resident, specifically failing to initiate CPR or lifesaving measures for a resident who was found unresponsive. The facility was cited for failed provider practice.
Deficiencies (1)
Failure to ensure staff followed policies related to care for an unresponsive resident, resulting in no lifesaving measures being initiated when needed.
Report Facts
Total residents: 70
Resident sample size: 5
Closed records sample size: 1
Investigation dates: 2022-07-15 to 2022-09-08
Complainant contact date: Jul 25, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laurel Knight | Community Complaint Investigator | Conducted the complaint investigation and on-site verification |
| Michelle Closner | Field Manager | Field Manager who signed enforcement and deficiency letters |
Notice
Deficiencies: 0
Date: Brookdale Meadow Springs 2311 5331 030425 IDR Sched Ltr 0425
Visit Reason
This letter confirms the facility's request for an Informal Dispute Resolution (IDR) meeting to dispute a citation from a Statement of Deficiencies dated March 4, 2025.
Findings
The document schedules the IDR review meeting and identifies the citation being disputed (WAC 388-78A-2150).
Report Facts
License number: 2311
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bo Phillipy | Executive Director | Named as participant representing the facility in the IDR process. |
| Laci Traulsen | Program Specialist 2/ Volunteer Coordinator | Author of the letter and contact for the IDR process. |
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