20 Reports
Inspection Report — May 26, 2026
Follow-Up
Date: May 26, 2026
Visit Reason
The Department conducted a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to fire safety and licensing compliance.
Complaint Details
The complaint investigation (Complaint #219171) was triggered by the facility's failure to pass a Fire Marshal re-inspection. The investigation found three unresolved violations from a previous inspection and confirmed the facility was working on repairs. The Executive Director stated vendors were waiting for parts to complete repairs.
Findings
The follow-up inspection on 05/26/2026 found no deficiencies and confirmed that previous violations were corrected. The facility had failed a prior Fire Marshal re-inspection but was working on repairs at that time.
Deficiencies (4)
WAC 388-78A-2040 Other requirements. The assisted living facility failed to comply with all applicable statutes and must have its building approved by the Washington state fire marshal to be licensed. This deficiency was cited due to failure to comply with fire marshal requirements placing residents and staff at risk.
IFC 705.2.4 (2021) Swinging fire doors should close from the full-open position and latch automatically. The cross corridor door by room 226 did not latch when tested.
IFC 706.1 (2018) The facility was unable to provide documentation for the required four-year fire and smoke damper inspection. The last documented inspection occurred in September 2021.
IFC 907.8 (2021) The facility provided documentation for required smoke detector sensitivity testing, but the report showed a deficiency with the testing that occurred.
Report Facts
Total residents: 63
Resident sample size: 63
Deficiencies cited: 4
Inspection Report — Apr 15, 2026
Re-Inspection
Date: Apr 15, 2026
Visit Reason
The inspection was conducted as a follow-up to verify correction of previously cited fire safety deficiencies at the facility.
Findings
All violations noted during previous related inspections have been corrected, resulting in an approved status for this inspection.
Inspection Report — Jan 16, 2026
Complaint Investigation
Date: Jan 16, 2026
Visit Reason
The inspection was conducted as a complaint investigation following allegations regarding staff actions related to a resident's death, unauthorized apartment access, and the resident's hospital admission with a pressure ulcer.
Complaint Details
Complaint number 207535 involved allegations that staff reported a resident's death without medical verification, unauthorized entry into the resident's apartment during hospitalization, and the resident's hospital admission with a pressure ulcer. The first allegation was substantiated with citations written. The second was unsubstantiated with no failed practice identified. The third allegation found no failed practice.
Findings
The investigation found that the facility failed to call 911 before notifying the resident's family and provided incorrect information about the resident's status, indicating a failure to train staff on medical emergency policies. The allegation of unauthorized apartment access was unsubstantiated. No failed practice was identified regarding the resident's pressure ulcer. Citations were written for the failure to implement medical emergency policies.
Deficiencies (1)
WAC 388-78A-2600 Policies and procedures. The assisted living facility failed to ensure 3 of 3 staff were trained to implement the medical emergency policy to notify 911 immediately during a suspected medical emergency, placing 74 residents at risk of delayed emergency evaluation.
Report Facts
Total residents: 74
Resident sample size: 3
Closed records sample size: 1
Staff trained: 0
Inspection Report — Jan 12, 2026
Life Safety
Date: Jan 12, 2026
Visit Reason
The Office of the State Fire Marshal conducted a scheduled fire safety inspection at the facility.
Findings
No violations were observed during this inspection. The facility passed the fire safety inspection with no deficiencies noted.
Inspection Report — Nov 3, 2025
Life Safety
Date: Nov 3, 2025
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The Office of the State Fire Marshal conducted a scheduled fire safety inspection at the facility.
Findings
Several deficiencies were identified related to fire safety equipment and documentation. Some violations were corrected on site, while others remain uncorrected due to missing documentation and failed equipment tests.
Deficiencies (10)
IFC 315.2.3 (2021) - Combustible material shall not be stored in boiler rooms, mechanical rooms, electrical equipment rooms or in fire command centers as specified in Section 508.1.5.
IFC 404.2 (2021) - Fire safety, evacuation and lockdown plan contents shall be in accordance with Sections 404.2.1 through 404.2.3.2.
IFC 603.2 (2021) - Abatement of unsafe conditions and electrical hazards shall be completed to eliminate electrical shock or fire hazards.
IFC 701.6 (2021) - The owner shall maintain an inventory of all required fire-resistance-rated construction and ensure annual visual inspections and proper repairs. The facility was unable to provide documentation that the annual fire wall inspection has been completed.
IFC 705.2.4 (2021) - Swinging fire doors shall close from the full-open position and latch automatically. The cross corridor by room 226 did not latch when tested.
IFC 706.1 (2018) - Dampers protecting ducts and air transfer openings shall be inspected and maintained per NFPA 80 and NFPA 105. The facility was unable to provide documentation for the required 4-year fire and smoke damper inspection; the last documented inspection was in September 2021.
IFC 903.5 (2021) - Sprinkler systems shall be tested and maintained in accordance with Section 901.
IFC 907.8 (2021) - Maintenance and testing schedules for fire alarm and detection systems shall be maintained. Facility provided documentation for required smoke detector sensitivity testing but reported a deficiency with the testing.
IFC 915.1 (2021) WAC 51-54A - Carbon monoxide detection shall be installed in new and existing buildings per code requirements.
IFC 1005.4 (2021) - The minimum width or required capacity of means of egress shall not be reduced along the path of travel until arrival at the public way.
Report Facts
Next inspection scheduled: Dec 3, 2025
Inspection Report — Oct 21, 2024
Follow-Up
Date: Oct 21, 2024
Visit Reason
The Department conducted a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. The original deficiencies related to food sanitation, safe storage, coordination of health care services, water supply, medication services, and background checks were corrected.
Deficiencies (6)
WAC 388-78A-2305 Food sanitation. The assisted living facility failed to ensure proper sanitation and labeling of ready-to-eat food, placing 55 of 55 residents at risk for foodborne illnesses.
WAC 388-78A-3100 Safe storage of supplies and equipment. The facility failed to secure sharp objects and personal care supplies in the memory care unit, placing 11 dementia residents at risk of harm.
WAC 388-78A-2350 Coordination of health care services. The facility failed to coordinate care with a physician for one resident on high and low blood sugar readings, placing the resident at risk.
WAC 388-78A-2950 Water supply. The facility failed to maintain water temperatures between 105°F and 120°F, placing 55 residents at risk for burns and injury.
WAC 388-78A-2210 Medication services. The facility failed to ensure medication was administered as ordered for one resident, placing the resident at risk for compromised health.
WAC 388-78A-2466 Background checks. The facility failed to ensure background inquiry renewal for one staff member, placing 53 residents at risk for care from staff with unknown criminal history.
Report Facts
Residents at risk for foodborne illness: 55
Residents at risk from unsecured hazardous supplies: 11
Residents at risk from water temperature issues: 55
Sampled residents: 7
Total current residents: 55
Residents at risk from medication service failure: 1
Residents at risk from background check failure: 53
Inspection Report — Sep 26, 2024
Life Safety
Date: Sep 26, 2024
Visit Reason
The Office of the State Fire Marshal conducted a scheduled fire safety inspection at the facility.
Findings
All violations noted during previous related inspections have been corrected. The facility was approved following this inspection.
Inspection Report — Aug 5, 2024
Life Safety
Date: Aug 5, 2024
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The Office of the State Fire Marshal conducted a scheduled fire safety inspection at the Brookdale Monroe residential care facility.
Findings
The inspection identified multiple fire and life safety code violations including electrical hazards, missing ceiling tiles, malfunctioning fire doors, lack of required inspection documentation, and issues with fire alarm and suppression systems. The facility was disapproved due to these unresolved deficiencies.
Deficiencies (9)
IFC 603.2 2021 - There is an electrical outlet in room 306 missing a faceplate, creating an electrical shock or fire hazard that must be abated.
IFC 701.3 2021 - There are missing ceiling tiles throughout the facility; an assessment and replacement of all missing tiles is required to maintain fire-resistance and smoke-resistant barriers.
IFC 705.2.4 2021 - The hallway door by 236, dining room fire door, and fire door by 307 did not operate properly and must close and latch automatically from the full-open position.
IFC 706.1 2018 - The facility is unable to provide documentation for the 4-year fire and smoke damper inspection required by NFPA 80.
IFC 903.5 2021 - The facility lacks documentation for the annual backflow forward flow test and has an escutcheon hanging off a sprinkler head in the kitchen dry goods storage.
IFC 904.13.5.2 2021 - The facility is unable to provide documentation for the semi-annual kitchen suppression system servicing.
IFC 907.8 2021 - The facility lacks documentation for monthly smoke alarm testing, has a smoke detector hanging from the ceiling in room 217, and a fire alarm DACT trouble that needs repair.
IFC 0915.1 2021 WAC 51-54A - The facility is unable to provide documentation for monthly carbon monoxide detector testing as required by NFPA 720.
IFC 1008.1 2021 - The exit stairway illumination throughout the building is not working and must be fixed to comply with means of egress illumination requirements.
Inspection Report — Mar 4, 2024
Follow-Up
Date: Mar 4, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to licensing laws and regulations.
Complaint Details
The complaint investigation concerned positive COVID residents and failure to ensure health care workers were fit-tested for respiratory protection. The investigation found the deficiency and citations were written.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies were corrected.
Deficiencies (1)
WAC 388-78A-2730 Licensee's responsibilities. The Assisted Living Facility failed to ensure staff were fit-tested for respiratory protection prior to a COVID outbreak, placing all residents at risk of exposure. This deficiency was corrected.
Report Facts
Total residents: 57
Resident sample size: 2
Inspection Report — Oct 18, 2023
Enforcement
Date: Oct 18, 2023
Visit Reason
The Department of Social and Health Services conducted a Complaint Investigation at the assisted living facility Brookdale Monroe, resulting in a civil fine due to failure to comply with fire and life safety regulations.
Complaint Details
The visit was complaint-related and resulted in a civil fine due to failure to comply with fire and life safety requirements. The deficiency was recurring and previously cited in 2021 and 2022.
Findings
The facility failed their second follow-up Fire and Life Safety Inspection, placing 58 residents, staff, and visitors at risk. This recurring deficiency led to a $1,000 civil fine.
Deficiencies (1)
WAC 388-78A-2040(1)(2) Other requirements. The licensee failed to ensure compliance with the Washington State Fire Marshal Office during the second follow-up Fire and Life Safety Inspection. This violation placed residents, staff, and visitors at risk.
Report Facts
Civil fine amount: 1000
Number of residents placed at risk: 58
Inspection Report — Oct 2, 2023
Complaint Investigation
Date: Oct 2, 2023
Visit Reason
The inspection was conducted as an unannounced on-site complaint investigation triggered by allegations including failure to provide care, harassment, and malfunctioning emergency pull cords, as well as a failed Fire Marshal re-inspection.
Complaint Details
The complaint investigation involved allegations that the facility charged a resident for care not provided, caused harassment and intimidation by increasing care charges, and had malfunctioning emergency pull cords. The investigation confirmed the failure to ensure all battery-operated call lights were functioning and failure to correct fire safety violations, resulting in citations.
Findings
The facility was found non-compliant with several licensing laws and regulations, including failure to correct fire and life safety violations and failure to maintain a functioning call light system on the Memory Care Unit. Deficiencies were cited and remain uncorrected as of the report date.
Deficiencies (2)
WAC 388-78A-2040 Other requirements. The assisted living facility failed to ensure compliance with the Washington State Fire Marshal Office by failing their second follow-up Fire and Life Safety Inspection, placing 58 residents, staff, and visitors at risk. Violations included broken electrical outlets, missing fire wall inspection documentation, missing kitchen hood signage, lack of semi-annual kitchen suppression system servicing documentation, and missing smoke alarm testing documentation.
WAC 388-78A-2930 Communication system. The assisted living facility failed to have a functioning call light/pull cord system on the Memory Care Unit for 1 of 2 sampled residents, placing the resident at risk for harm by not receiving staff assistance when needed.
Report Facts
Total residents: 58
Licensed beds: 82
Resident sample size: 4
Inspection Report — Sep 28, 2023
Follow-Up
Date: Sep 28, 2023
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to medication transcription errors.
Complaint Details
The complaint investigation found that the facility failed to properly transcribe physician's orders for one resident, resulting in missed medications. The allegation was substantiated with citations written.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies regarding medication transcription errors were corrected.
Deficiencies (1)
WAC 388-78A-2210 Medication services. The Assisted Living Facility failed to follow a physician's order correctly, resulting in a resident missing several doses of medication due to discontinuation in error.
Report Facts
Total residents: 48
Resident sample size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Mcglon | Nursing Consultant Institutional | Department staff who conducted the on-site verification and investigation |
Inspection Report — Sep 21, 2023
Re-Inspection
Date: Sep 21, 2023
Visit Reason
The inspection was a required reinspection following an initial inspection that identified violations. The reinspection was conducted to verify correction of previously cited deficiencies, but some violations remained uncorrected.
Findings
The facility failed to correct multiple fire and life safety violations identified during the initial inspection. The report lists numerous deficiencies related to electrical hazards, fire system maintenance, record keeping, and equipment servicing, all marked as uncorrected. The overall status is Disapproved.
Deficiencies (14)
IFC 604.1 2018 - Throughout the building, there are a number of electrical outlets with broken, grounding sockets. There needs to be an assessment of how many broken units there are, and a plan to replace and repair them needs to be implemented.
IFC 701.6 2018 WAC 51-54A - Facility is unable to provide documentation that the annual fire wall inspection has been completed.
IFC 904.12 2015, 2018 - The Main in Kitchen commercial hood requires a sign listing kitchen lineup. The cascade kitchen hood need to sign noting kitchen lineup.
IFC 904.12.5.2 2018 - Facility is unable to provide documentation for the semi-annual kitchen suppression system servicing for the cascade kitchen system. Facility is unable to provide documentation for the semi-annual hood cleaning for the cascade kitchen hood.
IFC 907.8 2018 - Facility is unable to provide documentation for the monthly single station smoke alarm testing. Facility is unable to provide documentation for the required smoke detector sensitivity testing.
IFC 315.3.3 2018 - 1. All mechanical/electrical rooms need to have any storage in them removed or arranged so that there is at least 3 feet around any electrical units. 2. The cascade kitchen has an electrical service panel that is blocked.
IFC 0405.5 2018 - Facility cannot provide documentation for the completion of unannounced fire drills, one drill per shift, per quarter, in the previous 12 months.
IFC 604.4.2 2018 - There is an extension cord being used in housekeeping by room 203 that needs to be removed. The refrigerator repair room by 216 has multiple daisy chained extension cords and power strips. This needs to be corrected. The executive directors office has power strips daisy chained together.
IFC 705.2.4 2021 - The fire door by 306 in memory care did not close properly.
IFC 706.1 2018 - Facility is unable to provide documentation for the 4 year fire and smoke damper inspection. NFPA 80(2016) 19.5.1.1 Each damper shall be tested and inspected 1 year after acceptance testing. 19.5.1.2 The test and inspection frequency shall then be every 4 years, except in buildings containing a hospital, where the frequency shall be every 6 years.
IFC 903.5 2009, 2012, 2015, 2018 - 1. Facility is unable to provide documentation for the 5 year internal piping inspection. 2. Facility is unable to provide documentation for the 3 year dry system full flow trip test. 3. Facility was unable to provide documentation that the Fire Department Connection has been hydrostatically tested in accordance with NFPA 25. NFPA 25 (2017) - 13.8.5 The piping from the fire department connection to the fire department check valve shall be hydrostatically tested at 150 psi (10 bar) for 2 hours at least once every 5 years. 4. The sprinkler heads in the freezer and refrigerator in the kitchen are over five years old and need to be replaced due to the hazardous environment.
IFC 0915.1 2015, 2018 WAC 51-54A - The CO detector by room 210 did not work.
IFC 1031.10.2 2018 - Facility is unable to provide documentation for the monthly 30 second activation test for the emergency lights. Facility is unable to provide documentation for the annual 90 minute power test for the emergency lights.
IFC 1203.1.3 2018 - The memory care generator needs to have foliage cut back so that there is 3 feet of working space around the generator.
Report Facts
Next inspection scheduled: Jul 28, 2023
Inspection Report — Sep 12, 2023
Follow-Up
Date: Sep 12, 2023
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies and compliance with licensing requirements.
Findings
The follow-up inspection found no deficiencies and confirmed that all previously cited deficiencies were corrected. The facility meets the Assisted Living Facility licensing requirements.
Inspection Report — Sep 6, 2023
Follow-Up
Date: Sep 6, 2023
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to medication availability and notification of physician regarding high blood sugar.
Complaint Details
The investigation involved three complaint numbers (79003, 80954, 81937) concerning failure to follow physician's orders, bullying, medication availability, rent increase notification, and apartment cleanliness. Some allegations were substantiated, including failure to notify physician and medication availability issues, while others such as bullying and apartment cleanliness were not substantiated.
Findings
The follow-up inspection found no deficiencies and confirmed that previously cited deficiencies were corrected. The facility meets Assisted Living Facility licensing requirements.
Deficiencies (2)
WAC 388-78A-2240 Nonavailability of medications. The facility failed to ensure medications were available for one of two sampled residents, placing the resident at risk for health complications.
WAC 388-78A-2350 Coordination of health care services. The facility failed to notify a resident's physician about a high blood sugar result, placing the resident at risk for health complications.
Report Facts
Total residents: 54
Resident sample size: 4
Blood sugar reading: 353
Inspection Report — Jul 12, 2023
Enforcement
Date: Jul 12, 2023
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to Brookdale Monroe to assess compliance with nurse delegation criteria and other regulatory requirements, resulting in a civil fine.
Findings
The licensee failed to follow nurse delegation criteria for one resident requiring blood sugar checks and insulin administration, resulting in unqualified staff performing delegated nursing tasks. This violation was uncorrected from previous citations and led to a $600 civil fine.
Deficiencies (1)
WAC 388-78A-2320 (1)(b)(2)(b) Intermittent nursing services systems. The licensee failed to follow nurse delegation criteria for one resident requiring blood sugar checks and insulin administration, resulting in unqualified staff performing delegated nursing tasks. This placed the resident at risk for compromised health.
Report Facts
Civil fine amount: 600
Inspection Report — May 8, 2023
Enforcement
Date: May 8, 2023
Visit Reason
This document is a formal notice of a civil fine imposed on Brookdale Monroe following a follow-up visit by the Department of Social and Health Services Residential Care Services on May 8, 2023.
Findings
The licensee failed to ensure that consent and Nurse Delegation services were in place for Medication Technicians to check one resident's blood sugar, placing the resident at risk of harm. This citation was previously cited on March 2, 2023, and remains uncorrected, resulting in a $300 civil fine.
Deficiencies (1)
WAC 388-78A-2320(1)(b)(2)(b) Intermittent nursing services systems. The licensee failed to ensure consent and Nurse Delegation services were in place for Medication Technicians to check one resident’s blood sugar, placing the resident at risk of harm from unlicensed and untrained staff.
Report Facts
Civil fine amount: 300
Inspection Report — Nov 17, 2022
Life Safety
Date: Nov 17, 2022
Visit Reason
The Office of the State Fire Marshal conducted a fire and life safety inspection at the facility to determine compliance with applicable codes.
Findings
All violations noted during previous related inspections have been corrected. The facility was approved following the inspection.
Deficiencies (14)
IFC 605.5 - Extension cords and flexible cords shall not be a substitute for permanent wiring and shall be used only with portable appliances.
IFC 605.6 - Open junction boxes and open-wiring splices shall be prohibited; approved covers shall be provided for all switch and electrical outlet boxes.
IFC 701.6 2018 WAC 51-54A - The owner shall maintain an inventory of all required fire-resistance-rated construction and visually inspect and repair annually.
IFC 705.2 2018 - Opening protectives in fire-resistance-rated assemblies shall be inspected and maintained; fire doors and smoke and draft control doors shall not be blocked or modified.
IFC 705.2.4 2018 - Swinging fire doors shall close from the full-open position and latch automatically.
IFC 706.1 2018 - Dampers protecting ducts and air transfer openings shall be inspected and maintained in accordance with NFPA 80 and NFPA 105.
IFC 901.6 2018 - Fire detection and alarm systems, emergency alarm systems, and related equipment shall be maintained in operative condition and repaired if defective.
IFC 0901.6.2 - Records of all system inspections, tests, and maintenance shall be maintained on premises for a minimum of three years and copied to the fire code official upon request.
IFC 906.2 2015, 2018 - Portable fire extinguishers shall be selected, installed, and maintained in accordance with NFPA 10; annual maintenance for the Class K extinguisher in the kitchen has not been completed.
IFC 915.1.4 2018 - Carbon monoxide detection shall be provided in dwelling units, sleeping units, and classrooms containing fuel-burning appliances or fireplaces.
IFC 915.6 2018 - Carbon monoxide alarms and detection systems shall be maintained in accordance with NFPA 720 and replaced when inoperable or end-of-life.
IFC 1013.5 2018 - Electrically powered, self-luminous, and photoluminescent exit signs shall be listed, labeled, installed per manufacturer instructions, and illuminated at all times.
IFC 1203.4 2018 - Emergency and standby power systems shall be maintained in accordance with NFPA 110 and NFPA 111 to supply service within required time.
WAC 212-12-044 - At least twelve planned and unannounced fire drills shall be held annually with detailed written records maintained and available for inspection.
Report Facts
Annual required maintenance date: 2021
Deficiencies cited: 14
Inspection Report — Oct 27, 2022
Complaint Investigation
Date: Oct 27, 2022
Visit Reason
The inspection was conducted as an unannounced on-site complaint investigation triggered by allegations that the Assisted Living Facility had two failed Fire Marshal Inspections.
Complaint Details
The complaint investigation referenced complaint number 54406. The facility failed to correct six violations from a previous inspection and failed their re-inspection. The Executive Director stated the maintenance director was attempting to obtain required documentation. The complaint was substantiated with citations written.
Findings
The investigation found that the facility failed to maintain compliance with fire safety regulations, including missing outlet cover plates, open junction boxes, lack of annual fire inspection records, and improper maintenance of fire extinguishers. These deficiencies were previously cited and remain uncorrected.
Deficiencies (1)
WAC 388-78A-2040 Other requirements. The Assisted Living Facility failed to maintain compliance with the Washington State Patrol Fire Protection Bureau requirements after failing their second Fire and Life Safety Inspection. Deficiencies included missing outlet cover plates, open junction boxes, lack of annual fire inspection documentation, and improper fire extinguisher maintenance.
Report Facts
Total residents: 65
Deficiencies cited: 6
Inspection Report — Sep 8, 2022
Re-Inspection
Date: Sep 8, 2022
Visit Reason
On 09/08/2022, the Office of the State Fire Marshal conducted an unannounced Fire and Life Safety Code inspection at Brookdale Monroe to determine compliance with applicable codes and to re-inspect previously cited deficiencies.
Findings
The facility was found to have multiple fire and life safety code violations including use of extension cords, open junction boxes, missing outlet cover plates, failure to provide inventory and inspection records for fire-resistant construction and doors, malfunctioning fire doors, missing escutcheon rings, lack of annual fire sprinkler inspection documentation, incomplete maintenance of fire extinguishers, absence of carbon monoxide alarms in required areas, burnt out exit signs, and failure to provide documentation for emergency power systems and fire drills. Some violations were corrected at the time of inspection, while others remained unresolved.
Deficiencies (11)
Use of extension cords in resident room 245 and salon on 2nd floor.
Open junction boxes and missing outlet cover plates in elevator/electrical room and mechanical room by room 306.
Failure to maintain inventory and records of annual inspection and repairs for fire-resistant-rated construction and doors.
Fire doors did not close or latch properly in cross corridor by room 104/105, elevator door by Maintenance Director's Office, and cross corridor by room 306.
Missing escutcheon rings in room 222 closet, room 248 closet, and kitchen near kitchen hood.
Facility failed to have annual fire sprinkler inspection documentation including 5 year internal pipe testing, 3 year dry system full flow trip test, and quarterly inspections.
Annual required maintenance for Class K fire extinguisher in kitchen not completed since 2/2021; failure to install required Class K placard.
No carbon monoxide alarms in laundry room or near gas-fed dryer in Memory Care; lack of documentation for CO detector testing in past 12 months.
Exit sign/light by room 244 is burnt out.
Failure to provide automatic backup generator inspection/service report and weekly/visual inspection documentation for last 12 months.
Failure to provide documentation for twelve planned and unannounced fire drills in previous 12 months.
Report Facts
Inspection date: Sep 8, 2022
Number of fire drills required: 12
Last maintenance date for Class K extinguisher: 202102
Fire sprinkler inspection intervals: 5
Fire sprinkler inspection intervals: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cozetta Christian | Deputy State Fire Marshal | Conducted the inspection and signed the report |
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