Brookdale Fairhaven

Facility unable to provide documentation of twelve planned and unannounced fire drills in the previous 12 months.

Facility unable to provide documentation that the annual fire door inspection has been completed.

Facility unable to provide documentation for the annual fire alarm system testing.

Facility unable to provide documentation for the monthly carbon monoxide detector testing.

Facility unable to provide documentation for the required smoke detector sensitivity testing.

Facility unable to provide documentation that the annual fire resistance rated construction material inspection has been completed.

Missing documentation for annual sprinkler inspection, 5-year internal piping inspection, 3-year dry system trip test, and annual forward flow test. Also, a missing escutcheon plate in the laundry room.

Extinguishers in the lobby were blocked by boxes and in the kitchen were blocked by a cake rack.

Monthly maintenance logs missing for beauty shop (March/April) and maintenance office (April).

Facility unable to provide documentation for the 12 months of semi-annual hood cleanings.

Emergency exit near room 48 was blocked by a chair on the outside.

Facility unable to provide documentation for the monthly 30-second emergency light activation test.

Combustible/flammable storage found in the housekeeping room with gas equipment and mechanical furnace room near laundry.

Facility unable to provide documentation for the 4 year fire and smoke damper inspection.

Facility unable to provide documentation for the annual 90-minute power test for emergency lights.

The facility failed to maintain overall cleanliness in the main kitchen. Observed issues included greasy/dusty fans, grime on equipment (knife holder, steam table, refrigerators, cabinets), dirty floors, lack of proper cleaning documentation, and improper storage of cleaning towels.

The mechanical room near room 21 does not have an automatic door closure.

Multi-plug adapter without overcurrent protection was in use in the nurses office.

Facility could not provide documentation for the annual forward flow test (NFPA 25), was missing the hydraulic calculation placard, and could not provide documentation of UL test results for sprinkler head testing.

Extension cords were utilized as permanent wiring in the Wellness Center and the Living Room.

Deficiency previously cited was corrected.

Fire-rated door from dining room to corridor would not close and latch automatically.

Unable to provide documentation for required sensitivity testing; nuisance log not maintained; failed smoke detectors not replaced.

Use of multi-plug adapters without overcurrent protection.

Sprinkler system deficiencies not corrected; sprinkler head in kitchen loaded with lint; 10-year and 20-year head testing not completed.

Emergency exit door in kitchen required double action to open.

The licensee failed to ensure the violations for three Fire and Life Safety annual inspections (March 21, 2024, April 24, 2024, and May 29, 2024) were corrected.

Facility failed to provide documentation for required smoke detector testing; a nuisance log is not maintained; 70 of 83 detectors failed sensitivity tests on 4/9/24.

Emergency exit door in the kitchen required a double action to open.

Sprinkler system deficiencies remain uncorrected and a sprinkler head in the kitchen is loaded with lint.

Multi-plug adapters without overcurrent protection were in use in room 59.

The fire rated door from the dining room to the corridor would not close and latch from a fully open position.

The facility failed to report a COVID-19 outbreak involving 37 residents and 15 staff to the Department's Crisis Response Unit.