Brookdale Yakima

This is an Informal Dispute Resolution (IDR) decision letter regarding a Statement of Deficiencies dated 12/01/2025. The facility disputed deficiency findings, but after reviewing all evidence, the department upheld all original deficiencies without changes. The facility is required to submit a Plan/Attestation Statement within 10 days and complete corrections within 45 days, indicating the dispute was unsuccessful and corrective action remains mandatory.

The facility failed to maintain adequate medication ordering systems, causing multiple residents to miss prescribed doses of pain and neurological medications over several days. Resident 1 missed 18 doses of critical medications (Lyrica and Divalproex) resulting in severe pain and hand tremors requiring emergency room visit. The facility acknowledged the systemic ordering failures and is implementing improved medication management systems. This is a recurring deficiency previously cited in 2024, indicating incomplete prior corrective action, though the administrator has committed to enhanced monitoring protocols.

This is an administrative scheduling letter confirming the facility's request for an Informal Dispute Resolution (IDR) meeting to contest a Statement of Deficiencies dated December 1, 2025 regarding WAC 388-78A-2240. The letter provides meeting logistics and documentation submission requirements but contains no information about the nature of the violation or the facility's response. Without access to the underlying Statement of Deficiencies, no assessment of event severity or response quality can be made.

The facility failed their first Fire Marshal re-inspection, indicating non-compliance with fire safety requirements under WAC 388-78A-2040(2). The specific fire safety deficiencies are not detailed in this summary report. No information is provided regarding the facility's corrective actions or response to the failed inspection. The investigation concluded with citation(s) written for failed provider practice.

Fire Marshal inspections from September to December 2025 identified multiple recurring fire safety violations at this residential care facility, most critically a fire alarm system in trouble status since June 13, 2025 without proper notification to authorities. The facility demonstrated moderate responsiveness by correcting most routine issues on-site during inspections (electrical hazards, egress obstructions, fire door closers, extinguisher maintenance, oxygen signage), but the persistent fire alarm impairment across three consecutive inspections represents a significant gap in life-safety system integrity. Follow-up compliance was achieved for sprinkler system deficiencies and most other items by the December inspection, though documentation gaps initially persisted. The pattern shows a facility that corrects identified issues but struggles with proactive maintenance of critical fire protection systems.

This inspection identified 13 code violations primarily involving electrical safety issues, fire protection system documentation gaps, and egress maintenance concerns. Most violations were routine maintenance items (unsecured electrical panels, missing extinguisher tags, blocked exits) corrected on-site during inspection. However, two documentation violations remain unresolved: the facility failed to notify authorities when the fire alarm system was out of service since June 2025, and could not demonstrate completion of prior inspection deficiency corrections. The facility demonstrated a good immediate response by correcting 11 of 13 violations on-site, though the prolonged fire alarm system issue and missing follow-up documentation indicate gaps in systematic compliance tracking.

Follow-up inspection completed on 10/31/2025 found zero deficiencies. The facility successfully corrected previous deficiencies related to WAC 388-78A-2650-2 and WAC 388-78A-2650-3 and now meets all Assisted Living Facility licensing requirements. The facility is in full compliance with state regulations.

The facility discharged a resident without providing required written notice after the resident fell outside the facility and was placed on one-to-one supervision that could not be maintained. The resident's representative reported feeling rushed to relocate with no preparation time or formal documentation. The facility acknowledged the failure, stating they believed verbal conversations and emails constituted agreement but confirmed no formal discharge letter was provided. A follow-up inspection on 08/05/2025 verified all deficiencies were corrected and the facility returned to compliance.

The facility failed to follow proper procedures for routine cleaning, documentation, and sanitization of their ice machine, though the machine itself was not found to be visibly unsanitary during inspection. The investigation resulted in a written consultation citing WAC 388-78A-2600(2n) regarding sanitation standards. The report does not document any corrective actions taken by the facility in response to these procedural deficiencies.

The facility failed to follow established procedures for routine cleaning, documentation, and sanitization of the ice machine, though the machine itself was not found to be unsanitary during inspection. The investigation resulted in written consultation under WAC 388-78A-2600(2n) for failure to maintain proper documentation and adherence to cleaning protocols. This represents a procedural compliance issue with minimal direct resident impact, as the ice machine condition was acceptable despite inadequate record-keeping.

The provided document appears to be only the header/seal of a Washington State form with no inspection report content or findings available for analysis. Without any substantive inspection details, violations, or facility response information, no assessment can be made regarding deficiencies, event severity, or response quality.

The facility failed to document food temperatures at mealtimes as required by policy, though observations showed food was served warm and residents were satisfied. This represents a procedural documentation violation with no actual impact on resident safety or care quality. No facility response or corrective action is documented in the report, as the facility is only required to begin correction immediately without submitting a formal plan.

This fire safety inspection identified multiple routine maintenance violations including blocked fire dampers, non-latching fire doors, missing documentation for required testing (fire drills, sprinkler systems, fire alarms, CO alarms, generator logs), improper electrical adapters, unsecured oxygen tanks, and minor equipment issues (undercharged extinguisher, removed smoke detector). The facility demonstrated an exemplary response by correcting the vast majority of issues on-site during the inspection, with remaining documentation gaps resolved immediately thereafter. The follow-up inspection confirmed full compliance with all 17 violation categories corrected between inspections, earning the facility an "Approved" status.

The facility had multiple medication administration violations: giving incorrect Furosemide doses over several months, leaving medication unobserved with a resident who did not take it (but staff marked it as given), and three instances of unaccounted narcotic tablets. These represent systemic medication safety concerns affecting multiple residents, though no actual harm occurred. The facility responded promptly, correcting all deficiencies by the April 2024 follow-up inspection within two months, demonstrating strong corrective action and commitment to compliance.

The facility failed to properly delegate nursing tasks for insulin administration and blood glucose monitoring, resulting in medication technicians administering insulin without required delegation credentials. Staff ignored multiple days of critically high blood sugar readings ("high" display indicating >400-1000+), failed to notify the physician per orders, and contributed to a resident's hospitalization for diabetic ketoacidosis with blood sugar exceeding 1000. The facility responded with comprehensive retraining on delegation requirements, blood glucose parameter reporting, and change-of-condition protocols, including quarterly delegation audits and daily monitoring systems. The follow-up inspection on 02/06/2024 found all deficiencies corrected and the facility in full compliance.

The facility failed to investigate or document a stage 4 pressure ulcer of unknown origin discovered on a resident's sacral area, representing a systemic failure in resident safety protocols. This is a recurring deficiency previously cited in 2022. The administrator and health director admitted no investigation was conducted to determine cause or rule out neglect, despite severe tissue damage requiring hospitalization. The facility eventually acknowledged the deficiency and committed to corrective action by the follow-up inspection on 12/06/2023, which found all deficiencies corrected and the facility back in compliance.

The facility failed to maintain proper food sanitation protocols, with kitchen staff not documenting sanitization solution testing for multiple days in April 2023 and dishwasher temperatures falling below the required 180°F final rinse on eleven occasions without corrective action. Staff members were unaware of proper procedures and monitoring requirements, creating risk of foodborne illness. The facility responded by hiring a new dietary manager who began re-educating kitchen staff on food sanitation requirements and developing monitoring systems. A follow-up inspection on June 20, 2023 confirmed all deficiencies were corrected and the facility met licensing requirements.

The facility failed to protect residents from verbal abuse by the Administrator who yelled at residents in a hostile, derogatory manner during a group meeting, calling them "children" and making threatening statements, causing residents to report feeling bullied, intimidated, and afraid of retaliation. Additionally, the Administrator recorded a resident with dementia on her phone in a mocking manner to provoke a reaction, and staff feared reporting due to retaliation concerns. The facility's investigation was inadequate, failing to interview all witnesses privately or separately as required by their own policies, though deficiencies were corrected by the follow-up inspection on 04/13/2023. The systemic failures in protecting residents from administrator abuse and conducting proper investigations represent serious violations of resident rights and safety protocols.

The facility failed multiple fire safety inspections over a six-month period (September 2022 through January 2023), with recurring violations including lack of annual fire alarm service documentation, expired smoke alarms, combustible storage in mechanical rooms, and elevator fire alarm programming errors. These systemic failures in maintaining fire safety systems posed serious risk to all residents, staff, and visitors. The facility acknowledged the violations and worked toward corrections, but the prolonged timeline (requiring three failed inspections before achieving compliance in April 2023) and inability to promptly resolve critical fire safety issues demonstrates a moderate response with significant delays and gaps in urgency.

This series of fire safety inspections from September 2022 to March 2023 identified routine maintenance and documentation issues including missing fire extinguisher inspections, combustible storage in mechanical rooms, electrical hazards, door closure problems, and incomplete fire alarm/elevator/generator documentation. The facility demonstrated an exemplary response by systematically addressing all violations across three follow-up inspections, with the final March 2023 inspection confirming complete correction of all previously cited deficiencies.

The facility violated resident rights by failing to provide a written discharge notice when a resident could not return after skilled nursing care, and did not refund the resident's $4,197.54 deposit within the required 30-day timeframe, causing financial hardship to the family. The facility initially claimed no discharge notice was required and deflected responsibility for the delayed refund to corporate. A follow-up inspection on 03/14/2023 confirmed all deficiencies were corrected, demonstrating adequate but delayed corrective action.

The provided input contains only a Washington state seal graphic with no inspection report content. No violations, deficiencies, or facility response information is present to analyze. Unable to assess compliance status or facility performance without actual inspection documentation.

This inspection series identified routine fire safety maintenance issues including storage violations near sprinklers and in mechanical rooms, missing fire extinguisher monthly inspections, fire door maintenance needs, electrical hazards (missing outlet covers, daisy-chained power strips), and documentation gaps for annual fire alarm and elevator emergency operations testing. The facility responded exemplarily: most violations were corrected on-site during the November 2022 inspection, the fire alarm system deficiency was resolved by contractor service in late November, and all remaining issues were fully corrected by the March 2023 follow-up inspection which found zero violations.