Inspection Reports for Brookdale Torbett

The document confirms the scheduling of an Informal Dispute Resolution (IDR) meeting requested by the facility to dispute citations from a Statement of Deficiencies dated April 18, 2025.

The letter does not contain inspection findings but addresses the dispute process for a specific citation (WAC 388-78A-2650) and provides details about the IDR meeting.

This document addresses the Informal Dispute Resolution (IDR) process related to a dispute over the Statement of Deficiencies (SOD) report dated 2025-04-18 for an assisted living facility.

After review of materials, oral statements, and records, a change was made to the SOD by deleting WAC 388-78A-2650 (2)(3).

The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to infection control.

The follow-up inspection found no deficiencies and confirmed that previously cited infection control deficiencies were corrected. The prior complaint investigation found failures in infection control practices, staff training, and PPE use during a norovirus and COVID-19 outbreak, resulting in citations.

Complaint investigation triggered by an outbreak of norovirus causing nausea, vomiting, and diarrhea among residents and staff. The investigation found infection control failures, lack of staff training, and inadequate PPE use. The facility also experienced a COVID-19 outbreak during the investigation. The complaint was substantiated with citations issued.

The Department of Social and Health Services completed a Complaint Investigation at the assisted living facility Brookdale Torbett on February 19, 2025, due to concerns about medication availability.

The licensee failed to ensure medications were available for three residents, resulting in those residents not receiving medications, contributing to agitation in one resident, and placing residents at risk for decline in their chronic health conditions. This violation led to a civil fine.

The complaint investigation found that medications were not available for three residents, causing them to miss doses and contributing to one resident's agitation. This was a recurring citation previously noted on June 15, 2022, and December 15, 2023.

Follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies from complaint investigation and full inspection conducted in December 2024.

The follow-up inspection on 02/12/2025 found no deficiencies and confirmed correction of prior deficiencies related to investigations and monitoring residents' well-being. The complaint investigation identified failures in investigating incidents, medication administration errors, lack of nurse delegation, staff orientation, background checks, tuberculosis screening, and electronic monitoring consent and reevaluation. The facility was cited for multiple deficiencies including failure to investigate incidents, medication errors, lack of staff training, and privacy violations with electronic monitoring.

Complaint investigation conducted from 12/09/2024 through 12/23/2024 regarding HIPAA violation by a staff member and concerns about a dangerous resident. Investigation found failure to investigate incidents and other deficiencies.

The inspection was conducted as an unannounced complaint investigation regarding allegations that four named residents missed doses of medications.

The investigation found that three of the named residents missed multiple consecutive doses of various medications due to the facility's failure to ensure medications were available and administered as prescribed. This failure placed residents at risk for decline in their chronic health conditions and agitation.

Four named residents missed doses of medications. The complaint was substantiated with findings that three residents missed multiple consecutive doses, contributing to agitation and health risks.

The inspection was conducted as an unannounced on-site complaint investigation triggered by allegations that an identified resident was neglected, causing skin breakdown.

The investigation found that the facility failed to ensure a resident was treated with dignity and respect, resulting in the resident being left on a bare mattress for an extended period without sheets or proper clothing. Staff did not follow shift change procedures due to short staffing, leading to unmet care needs and risk of skin breakdown.

The complaint alleged neglect of a resident causing skin breakdown. The investigation substantiated the allegation with findings of failed provider practice and citations related to resident rights and quality of life.

The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to medication services.

The follow-up inspection on 08/12/2024 found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. The prior complaint investigation found a failed practice related to medication transcription errors resulting in a resident not receiving prescribed medication, which was corrected by the follow-up.

Complaint investigation conducted from 05/31/2024 through 06/13/2024 regarding medication services and residents helping others when staff was busy. The complaint was substantiated with a failed practice identified related to medication transcription errors causing a resident to miss medication and require hospitalization.

The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to complaint investigations.

The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previous deficiencies related to failure to report sexual abuse incidents were corrected.

The complaint investigation found that an identified resident was sexually abused by another resident and the facility staff failed to report the incident as required. The resident was cognitively unable to communicate, and the facility assigned one-on-one staff for safety. Failed provider practice was identified and citations were written.

The inspection was conducted as an unannounced on-site complaint investigation triggered by allegations that an identified resident was not receiving assistance with toileting and changing incontinence products and had fallen while trying to transfer themselves.

The investigation found failed provider practices related to failure to implement the care plan for an identified resident who was observed calling for help in the bathroom and had a history of falls. The facility staff were not always aware of call lights due to pager issues. Deficiencies were cited for failure to provide timely assistance as per the negotiated service agreement.

The complaint investigation was substantiated with findings of failed provider practice related to inadequate assistance with toileting and fall prevention. The identified resident was not getting assistance as required and had fallen while trying to transfer independently. The pager system for call lights was not effectively notifying staff.

The inspection was conducted as an unannounced on-site complaint investigation regarding allegations that identified residents were placed on one-to-one supervision for safety but the facility was not providing the staff, and that a resident missed their medications.

The investigation found deficient practices including failure to provide consistent one-to-one staffing as agreed in the negotiated service agreement, and failure to ensure medication availability resulting in a resident missing doses and having a seizure. Citations were issued for these deficiencies.

The complaint investigation was substantiated with failed provider practices identified and citations written. Allegations included failure to provide one-to-one staffing for safety and missed medications leading to a resident seizure.

The Department completed a complaint investigation of the Assisted Living Facility on 05/02/2023 based on complaint numbers 76972 and 75974 to determine compliance with Assisted Living Facility requirements.

The facility's call system was found not functioning at the time of the visit, specifically in bathrooms and resident rooms, due to batteries needing replacement and cords accessibility issues. The facility corrected the issue on site and provided staff education.

Complaint investigation referenced complaint numbers 76972 and 75974. The facility was found not to meet Assisted Living Facility requirements.

The Office of the State Fire Marshal conducted an inspection of the facility to assess compliance with fire safety codes and requirements.

The facility was found to be unable to provide documentation for the annual testing of the fire sprinkler system, semi-annual servicing of the kitchen hood suppression system, annual testing of the automatic fire alarm system, monthly testing of single station smoke detectors, and annual testing of the battery back-up emergency lights.

The Department completed a follow-up inspection of the Assisted Living Facility on 11/23/2022 to verify correction of previously cited deficiencies.

The follow-up inspection found no deficiencies and the facility met the Assisted Living Facility licensing requirements. Previous deficiencies related to licensing laws and regulations were corrected.