Brookdale Federal Way

Emergency light #22 by room 115 did not operate when tested.

NW fire door 2 b needed additional force to open.

Missing documentation for weekly generator testing for several dates in 2024 and 2025.

Unable to provide documentation for 5-year internal pipe testing, 5-year FDC hydro testing, and forward flow testing.

Facility missing hydraulic calculation plate for sprinkler riser.

Multiple doors missing closure or failing to latch when tested.

Fire extinguishers in the kitchen were obstructed.

Resident room 273 has two extension cords in use.

Multiple fire door deficiencies; unable to provide correction report; multiple doors propped open.

Riser room has penetrations on the side wall.

Appliances plugged into power strips in Wellness center/offices; power strip plugged into another power strip.

Resident room 131 has unsecured oxygen.

Unapproved multi plug adapter in the kitchen.

Four portable fire extinguishers in the riser room not housed or hanging.

Penetrations throughout the facility by exit signs where ceiling tile was cut.

Unable to provide annual and semi-annual report for kitchen hood cleaning.

Facility failed to complete annual and change of condition assessments for 13 of 13 sampled residents, missing documentation on health status, medications, and specific conditions like seizures, depression, and anxiety.

Facility failed to coordinate care for 2 of 14 residents. Staff did not notify physicians of abnormal blood pressure readings (Resident 2) or perform required heart rate checks for medication administration (Resident 13).

Facility failed to ensure 14 of 14 sampled residents or their representatives/case managers signed the Personal Service Plan annually.

Facility failed to document service agreements for 11 of 13 residents that met clinical needs, including monitoring instructions for medications, side effects, and management of mental health or seizure conditions.

Facility failed to notify the Department of a change in administrator within 10 days of hiring Staff A.

Facility failed to provide medication assistance as prescribed; discrepancies found between eMAR documentation and narcotic control logs for multiple residents.

Facility failed to implement policies on oxygen management and medication disposal, placing residents at risk.

Facility failed to securely store resident records; medication carts with resident information were left unattended in hallways, and a supply room containing resident records was found unlocked.

Facility failed to investigate unwitnessed falls resulting in injury for 2 residents and failed to investigate a hospitalization for 1 resident.

Facility failed to post the assisted living facility license in a conspicuous location accessible to residents and visitors.

Facility failed to develop an operational system for nurse delegation for 13 residents, including missing consents, lack of supervision/evaluation, and improper insulin administration techniques by non-licensed staff.

Facility failed to provide activities for 86 of 86 residents, had no activity director, no activity calendar, and no functioning van service for outings.

Facility failed to ensure 3 of 7 sampled staff were screened for tuberculosis within 3 days of employment.

Facility failed to maintain outdoor garbage and recycling containers; lids were damaged with large holes, allowing pest access.

Facility failed to implement medication/treatment regimens for 3 residents and failed to provide shower/bath assistance for 2 residents as specified in their Personal Service Plans.

Facility failed to maintain lighting fixtures in a stairwell and the dining room; Resident 1 had a flickering light in their apartment.

Facility left hazardous chemicals (disinfectants, cleaners) and medical equipment (insulin syringes) in unlocked rooms/carts accessible to residents with cognitive deficits.

Facility failed to ensure proper handwashing by dishwashing staff, failed to maintain required dishwasher temperatures, and did not properly clean/sanitize meal surfaces.

Facility failed to provide a reliable system for residents to call for assistance. The system malfunctioned frequently, and there was no policy for staff when the system was not operational.

12 window screens were missing from operable exterior windows throughout the facility.

Facility failed to treat 3 of 3 sampled residents with dignity and respect by administering insulin injections in the common dining room without offering a private area, and failing to address resident concerns regarding mattress discomfort.

Facility failed to maintain current veterinary records for 7 of 8 pets living on the premises.

Facility failed to complete required full assessments to evaluate capabilities, care needs, and preferences for 4 sampled residents (Residents 3, 8, 24, and 45) at admission or with a change of condition, placing them at risk.

Facility failed to provide, format correctly, or maintain signatures for Medicaid disclosure policies for multiple residents.

Facility failed to provide specialized diets for 21 residents, failed to follow dietary manuals, had poor food quality, inconsistent service, and locked kitchen/storage areas preventing access.

Facility failed to ensure the Administrator met the state qualifications and requirements for an assisted living facility administrator.

Facility failed to implement infection control, PPE, respiratory protection, COVID-19 screening, and safe dining procedures during an outbreak.

Facility failed to provide a clean, safe, and well-maintained environment. Findings included stained carpets, broken ceiling tiles with exposed insulation, loose handrails, furniture in disrepair, dirty common areas, and unsecured closet doors in resident apartments.

Facility failed to maintain a comprehensive disaster plan, emergency food/water supplies, and accessible first aid kits.

Facility failed to ensure 6 of 7 staff members completed all required training, including hands-on CPR and first aid proficiency.

Facility failed to provide maintenance documentation for the generator and the generator had not been serviced since February 2022.

Licensee failed to ensure one staff met the Washington State qualifications and requirements to be an assisted living facility administrator.

Licensee failed to maintain one outdoor garbage container.

Licensee failed to ensure window screens were appropriately placed and maintained on 17 exterior windows.

Licensee failed to provide a clean, safe, and well-maintained environment.

Licensee failed to ensure three staff were screened for tuberculosis within three days of employment.

Facility failed to administer medication as ordered for 1 of 3 residents. Medication was received by facility but not transcribed to the eMAR and remained in the medication cart unopened.

Business Office fire door has been modified with a bolt lock and different handle.

Facility unable to provide documentation of 90-minute annual emergency lighting test.

Facility unable to provide service reports for kitchen suppression system for the past 12 months.

Facility unable to provide documentation for quarterly sprinkler reports.

Wellness Center has a power strip plugged into another power strip.

Power strips in the Wellness Center (1st floor) and Sales Manager's Office (1st floor) are dangling by their cords.

Facility failed to have fire watch personnel on the NOC shift.

Facility unable to provide documentation for annual and semi-annual hood cleaning.

Facility unable to provide record of annual fire wall inspection and/or repairs.

Fire alarm panel yellow tagged; monitoring not signaling out and smoke sensitivity overdue.

No documentation showing CO detector testing in past 12 months.

Wellness Center has a cable box without a cover on it.

Activity Manager's office has a broken door closure.

Resident room 271 has unsecured oxygen bottles.

Emergency lights failed testing in room 257, laundry room, and Health/Wellness Director's office.

Extension cords in use in resident room 287 and the activity room (by exit door, plugged into power strip).

Resident room 287 has an unapproved multi plug adapter plugged into an extension cord.

Maintenance for fire extinguishers in elevator room and activity room not completed.

Six doors (Kitchen, Elevator, Storage, Housekeeping, Private Dining, Sprinkler room) failed to close/latch properly.

Missing escutcheon rings on sprinkler heads, dirty sprinkler heads, and painted sprinkler head found in various locations.