Brookdale Foundation House

Extinguisher in riser room missed annual servicing.

Unsecured compressed gas cylinders in kitchen (by exit door and food station) and by the generator (two propane tanks).

Facility provided only partial annual fire wall inspection report.

Missing documentation for various sprinkler system tests (5-year, 3-year, annual); uncorrected sprinkler pipe crack and painted head issues.

Missing documentation for smoke alarm testing; uncorrected battery failures in fire alarm system.

Missing documentation for kitchen hood cleaning; excess grease observed on hood.

Electrical panels obstructed in 1st floor laundry room and kitchen.

Extension cords used as permanent wiring in rooms 274, 259, 242, 251, 219, and outside dining patio door.

Excess lint observed behind dryer machines in 1st floor laundry room.

Kitchen egress door leading to beverage area lacks an exit sign.

Ceiling and wall penetrations observed in multiple locations including kitchen, dining office, walk-in freezer, and housekeeping storage.

Damper testing failed for two items; no documentation of correction provided.

Sprinkler riser was obstructed by excess of storage.

Multiple rated doors failed to close and latch when tested.

Evacuation plans were not available in the kitchen for employees to reference.

Egress door 8052 was obstructed (corrected).

Multi-plug adapter on power strip connected to kitchen appliance; refrigerator connected to power strip.

Unapproved multi-plug adaptors in use in rooms 376, 251, and 177.

Bent, dirty, or corroded sprinkler heads in kitchen and dining areas; uncapped sprinkler head on suppression system.

Broken outlet cover in laundry room; open junction boxes in dining patio area and maintenance room; exposed wires in 2nd floor dining area.

Facility unable to provide monthly 30-minute full load tests for emergency power systems from September 2024 through August 2025.

Facility unable to provide documentation for carbon monoxide testing and maintenance.

Fire extinguisher in riser room was obstructed.

Broken hardware/magnetic hold on kitchen door.

Door 8013 missing rating tag; Door 8051 had broken hardware.

205 smoke detectors failed sensitivity testing.

Memory care egress doors lack proper signage; staff could not unlock doors when requested.

Two unsecured fire extinguishers in maintenance director's office.

Facility not conducting fire drills for Assisted Living side; missing documentation for Memory Care fire drills for several quarters/shifts.

205 smoke detectors failed sensitivity test; facility placed on fire watch.

Penetrations on fire doors/frames; incomplete inspection report for rated doors; door obstructions in memory care and resident rooms.

Facility failed to ensure mechanical air exchange vents were functional in laundry rooms, janitor closets, and common bathrooms, and failed to maintain exterior benches.

Facility failed to ensure first-aid supplies were unlocked, clearly marked, and readily available.

Facility failed to ensure staff completed required orientation and basic training.

Facility failed to complete and submit DSHS background authorization forms prior to employment for staff.

Facility failed to complete full assessment components for 6 of 6 sampled residents regarding bedside mobility devices, medical equipment, and self-administration of medication.

Facility failed to ensure 4 of 11 residents or their representatives agreed to and signed their Personal Service Plan at least annually.

The facility failed to document in 4 of 11 residents (Resident 2, 3, 4, and 5) service agreements that included plans to monitor and address interventions required to meet their current clinical needs regarding their specific medical diagnoses and treatments.

Facility failed to conduct background checks for 4 staff members and 2 private caregivers.

Facility failed to ensure staff was screened for TB within three days of employment.

Facility failed to ensure 4 of 11 residents had a written plan for family assistance with medication management.

The facility failed to implement a safe nursing services system when non-licensed staff administered medications without a nurse delegation program to 3 of 3 residents (Resident 1, 2, and 3), and lacked documentation of nurse delegation training, consents, and RND supervision.

Facility license was not posted in a conspicuous location.

First-aid supplies were not readily available, clearly marked, or locations identified.

Staff E and F failed to complete all required basic training and continuing education hours.

Staff A, B, and D were not screened for Tuberculosis within three days of employment as required.

Facility hired Staff F without verifying required credentials for a long-term care worker prior to providing direct care.

Facility unable to provide documentation of CO detector testing in past 12 months.

Facility unable to provide documentation for annual generator inspection, load bank tests, and weekly checks.

Facility unable to provide documentation for last fire/smoke damper testing.

Facility unable to provide quarterly sprinkler inspections.

Facility unable to provide documentation for monthly 30-second emergency lighting testing.

Resident room 329 has two open cable boxes. Laundry room on 1st floor has a broken cover plate.

Fire extinguisher in 2nd floor little kitchen mounted above 5 foot requirement.

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

Painted sprinkler heads in 3rd floor storage 8203 and 2nd floor electrical room 8167.

Facility unable to provide record of annual fire-resistant-rated construction inspection/repairs.

Resident room 170 has excessive non-fire-retardant pictures on her door/walls.

Activities room has an extension cord plugged into a power strip.

Facility unable to provide service reports for kitchen suppression system.

Facility unable to provide documentation for 90-minute annual emergency lighting testing.

Facility unable to provide inventory record of annual inspection/repairs for fire-resistant-rated doors.

Club room 316, PPE storage room 8169, and cross corridor 8018 did not close/latch properly.