Heritage House Morton.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Statement of Deficiencies License #: 2010 Compliance Determination # 53036 Plan of Correction HERITAGE HOUSE MORTON Completion Date Administrator (or Representative) Date WAC 388-78A-2040 Other requirements. (1) The assisted living facility must comply with all other applicable federal, state, county and municipal statutes, rules, codes and ordinances, including without limitations those that prohibit discrimination. (2) The assisted living facility must have its building approved by the Washington state fire marshal in order to be licensed. This requirement was not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain fire safety per the state fire marshal regulations for 1 of 1 facility reviewed. These failures placed 30 of 30 residents, staff, and visitors' life and safety at risk in the event of a fire. Findings included… IFC (International Fire Code) 701.6 2021- “The owner shall maintain an inventory of all required fire- resistance-rated construction, construction installed to resist the passage of smoke, and the construction included in Sections 703 through 707 and Sections 602.4.1 and 602.4.2 of the International Building Code. Such construction shall be visually inspected by the owner annually and properly repaired, restored or replaced where damaged, altered, breached or penetrated. Records of inspections and repairs shall be maintained. Where concealed, such elements shall not be required to be visually inspected by the owner unless the concealed space is accessible by the removal or movement of a panel, access door, ceiling tile or similar movable entry to the space.” IFC 705.2 2021- “Opening protectives in fire-resistance-rated assemblies shall be inspected and maintained in accordance with NFPA 80. Opening protectives in smoke barriers shall be inspected and maintained in accordance with NFPA 80 and NFPA 105. Openings in smoke partitions shall be inspected and maintained in accordance with NFPA 105. Fire doors and smoke and draft control doors shall not be blocked, obstructed, or otherwise made inoperable. Fusible links shall be replaced promptly whenever fused or damaged. Opening protectives and smoke and draft control doors shall not be modified.” IFC 907.8 2021- “The maintenance and testing schedules and procedures for fire alarm and fire detection systems shall be in accordance with Sections 907.8.1 through 907.8.5 and NFPA 72. Records of inspection, testing and maintenance shall be maintained.” . Statement of Deficiencies License #: 2010 Compliance Determination # 53036 Plan of Correction HERITAGE HOUSE MORTON Completion Date IFC 1031.10.2 2021- “Battery-powered emergency lighting equipment shall annually by operating the equipment on battery power for not less than 90 minutes.” (WAC 212-12-044) “In all Group I, Group E, and Group R2 Occupancies licensed by the state and inspected by the state fire marshal's office, at least twelve planned and unannounced fire drills shall be held every year. (1) Drills shall be conducted quarterly on each shift in Group I and Group R2, Occupancies and monthly in Group E Occupancies to familiarize personnel with signals and emergency action required under varied conditions. (2) A detailed written record of all fire drills shall be maintained and available for inspection. (3) When drills are conducted between 9:00 p.m. and 6:00 a.m., a coded announcement may be used instead of audible alarms.” In an undated facility policy titled, “Fire Drill Policy and Procedure,” It stated, “Fire drills and trainings will be held monthly and be scheduled so that each community shift participates in a drill once every quarter (i.e. every 3 months) … A written fire drill record must be kept to document fire drills that include b. Hard copy filed onsite for inspection.” Record review of the Washington State Patrol Fire Protection Bureau report, dated 07/26/2024, showed the Fire Marshal conducted an inspection at the facility and found the facility was out of compliance. It stated, • “(IFC 701.6 2021): The facility failed to provide the following reports. Annual Inspection of fire- resistance rated construction. Holes found around piping in fire alarm panel room. • (IFC 705.2 2021): The facility failed provide the following reports. Annual fire door inspection report. Fire doors throughout the building found to excessive gaps. • (IFC 907.8 2021): Deficiencies found in the fire alarm report. Fire alarm panel breaker missing lock device. • (IFC 1031.10.2 2021): The facility failed to provide the following reports. • (WAC 212-12-044): The facility failed to provide the following reports. Night shift fire drills for 3rd and 4th quarter of 2024.” Record review of the Washington State Patrol Fire Protection Bureau report, dated 09/25/2024, showed the fire marshal conducted a re-inspection at the facility and found that the following violations had not been corrected… It stated, • “(IFC 701.6 2021): The facility failed to provide the following reports. Annual inspection of fire resistance-rated construction. Holes found around piping in fire alarm panel room. • (IFC 705.2 2021): The facility failed to provide the following reports. Annual fire door inspection report. Fire doors throughout the building found to excessive gaps.” • (IFC 907.8 2021): Deficiencies found in the fire alarm report. Fire alarm panel breaker missing lock device. • (IFC 1031.10.2 2021): The facility failed to provide the following reports.” Record review of the Washington State Patrol Fire Protection Bureau report, dated 11/08/2024, showed the fire marshal conducted a re-inspection at the facility and found that the following violations had not been corrected… It stated, . Statement of Deficiencies License #: 2010 Compliance Determination # 53036 Plan of Correction HERITAGE HOUSE MORTON Completion Date • “(IFC 701.6 2021): Holes in fire alarm panel room filled with non-rated material. • (IFC 705.2 2021): The facility failed to provide the following reports. Annual fire door inspection report. Fire doors throughout the building found to excessive gaps.” • (IFC 907.8 2021): Deficiencies found in the fire alarm report. Fire alarm panel breaker missing lock device.” In an interview on 01/14/2025 at 9:59AM, Staff A, Administrator, was asked to discuss any updates to the violations that occurred during the Fire Marshal’s visit. • (IFC 701.6 2021): Staff A was asked if they could discuss the holes in the wall near the piping near the fire alarm breaker panel. Staff A stated, “[When previously fixed] we used the wrong fire- retardant caulking.” Staff A stated that they spoke with the Fire Marshal to get clarification. Staff A stated “[They] told me the corrected one to use. I went out to [store] and purchased it right away, and we installed that right away.” • (IFC 705.2 2021): Staff A was asked to discuss the issues with gapping in the doors. Staff A stated, “There is this new tool where they check for the gapping. The maintenance guys went around with the tool, and we did not pass that. We ordered the shims and tried to fix them the way the [Fire Marshal] explained.” Staff A stated that they had to reach out to a fire door specialist for certain doors, and stated they were then notified on what was needed to be done in order to move forward with getting the doors in compliance. “We got a bid [from a door company] and we submitted it to the home office [for approval]. My maintenance guys did go ahead and fix what they could fix, but we are currently waiting on the doors that we could not fix.” She stated she was sent an estimate for the fixes. “There are like 6 doors that we could not fix on our own.” • (IFC 907.8 2021): Staff A was asked about the missing lock on the fire alarm panel breaker. Staff A stated that there was no lock on the breaker but stated it has since been ordered and installed. Staff A stated that once it was installed, they informed the Fire Marshal. • (IFC 1031.10.2 2021): Staff A was asked about the failure to provide reports for emergency power testing. Staff A stated that the maintenance had tested all of the emergency lights recently, and stated they failed. Staff A stated at that time all of the lights were replaced with new batteries. Staff A stated from this point, they will all be on the same cycle and changed regularly on the same date. • (WAC 212-12-044): Staff A was asked about the failure to provide night shift fire drill records to the Fire Marshal.

This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website.

This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website.