Inspection Reports for
La Conner Retirement Inn

IFC 603.6 (2021) Extension cords shall not be used as permanent wiring and must be listed and labeled. Extension cords were found used as permanent wiring in the main laundry room and room 305.

IFC 705.2 (2021) Fire door opening protectives must be inspected and maintained per NFPA 80 and 105. Facility could not provide documentation of annual fire door inspection.

IFC 705.2.4 (2021) Swinging fire doors must close and latch automatically from the full-open position. The fire rated cross corridor door near room 314 would not close and latch from the fully open position.

IFC 903.3.3 (2021) Automatic sprinklers must not be obstructed. The sprinkler head in the walk-in refrigerator and freezer was obstructed by boxes and food.

IFC 903.5 (2021) Sprinkler systems must be tested and maintained per Section 901. Facility could not provide documentation for annual sprinkler system inspection and annual forward flow test.

IFC 906.6 (2021) Portable fire extinguishers must not be obstructed or obscured. Extinguishers in the 2nd and 3rd floor resident laundries were obstructed by trash cans.

IFC 907.8 (2021) Fire alarm and detection systems must be maintained and tested per NFPA 72. Facility could not provide documentation for monthly single station smoke alarm testing.

IFC 915.6 (2021 WAC) Carbon monoxide detectors must be maintained and tested. Facility could not provide documentation for monthly carbon monoxide detector testing.

IFC 1008.3.1 (2021) Emergency electrical systems must illuminate aisles, corridors, and exits during power failure. Emergency egress lights in the 3rd floor south stairwell and activity room would not illuminate when tested.

IFC 1013.5 (2021) Exit signs must be illuminated at all times. The internally illuminated exit sign in the 1st floor north stairwell was not illuminated on normal power.

IFC 1032.10.1 (2021) Emergency lighting must be tested monthly for at least 30 seconds. Facility could not provide documentation for monthly 30 second activation test of emergency lights.

IFC 1031.10.2 (2021) Battery-powered emergency lighting must be tested annually for 90 minutes. Facility could not provide documentation for annual 90 minute power test for emergency lights.

Fire Drills Facility must conduct twelve planned and unannounced fire drills annually. Facility could not provide documentation for completion of twelve planned and unannounced fire drills in the previous 12 months, with missing drills on 2nd Shift - Quarter 3 and 3rd Shift - Quarter 1 and 2.

WAC 388-78A-3090 Maintenance and housekeeping. The facility failed to maintain a safe, sanitary, and well-maintained environment on 3 floors, including issues with dust buildup, missing rubber baseboards, peeling wall coverings, missing light fixture covers, and insect presence.

WAC 388-78A-2484 Tuberculosis testing. The facility failed to ensure 3 of 5 staff were screened for tuberculosis within required timeframes, placing residents at risk of exposure.

WAC 388-78A-2466 Background checks. The facility failed to complete required two-step background checks for 2 of 5 staff, risking care by disqualified personnel.

WAC 388-78A-2474 Training and home care aide certification. The facility failed to ensure 2 of 6 staff met long-term care worker training requirements, risking inadequate care.

WAC 388-78A-2305 Food sanitation. The facility failed to keep food labeled and discarded appropriately in the main kitchen, placing residents at risk of foodborne illness.

WAC 388-78A-2950 Water supply. The facility failed to maintain hot water temperatures between 105°F and 120°F, with observed temperatures as high as 134.7°F, placing residents at risk of injury.

IFC 603.5.1 (2021) - There was a multi-plug adapter that does not have over current protection in use in the maintenance office.

IFC 705.2.4 (2021) - Resident room 306 fire door would not close and latch from the fully open position.

IFC 603.6 (2021) - There was an extension cord utilized as permanent wiring in room 212.

IFC 705.2 (2021) - Resident room 306 fire door would not close and latch from the fully open position.

IFC 903.3.3 (2021) - The sprinkler head in the walk-in refrigerator and freezer had boxes and food obstructing the flow pattern of the sprinkler.

IFC 903.5 (2021) - Facility is unable to provide documentation for the annual forward flow test in accordance with NFPA 25.

IFC 904.13.5.2 (2021) - Facility is unable to provide documentation for the semi-annual kitchen suppression system servicing.

IFC 906.2 (2021) - Facility was unable to provide required documentation for monthly fire extinguisher maintenance and the portable fire extinguisher in the kitchen was missing the tamper seal.

IFC 906.7 (2021) - Fire extinguisher in the parking garage was not mounted in accordance with the manufacturer's installation instructions.

IFC 1008.3.1 (2021) - Emergency egress lights near 220 and in the north stairwell would not illuminate when the test button was pressed.

IFC 1013.6 (2021) - Internally illuminated exit sign near 316 and exit signs near elevator 2 would not illuminate when the activation test button was pushed.

IFC 5303.5.3 (2021) - Oxygen cylinders in room 305 are not secured to prevent the cylinders from falling.

IFC 705.2 (2021) - Fire rated doors to 3rd floor elevator, resident rooms 216 and 208 were blocked open or missing strike plates, preventing proper closing and latching.

IFC 705.2 (2021) - Fire rated door to a storage room converted to a vending area was removed without approval.

IFC 705.2.4 (2021) - Resident room 305 fire door would not close and latch from the fully open position.

WAC 388-78A-2462 Background checks Who is required to have. The facility failed to ensure 1 of 6 staff did not complete a national fingerprint background check, placing residents at risk.

IFC 315.3.3 2018 - 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 604.5 2018 - Extension cords and flexible cords shall not be a substitute for permanent wiring and shall be listed and labeled in accordance with UL 817. Extension cords marked for indoor use shall not be used outdoors.

IFC 604.6, 2018 - Open junction boxes and open-wiring splices shall be prohibited. Approved covers shall be provided for all switch and electrical outlet boxes.

IFC 607.1 2018 - Commercial kitchen exhaust hoods shall comply with the requirements of the International Mechanical Code.

IFC 607.3.3 2018 - Hoods, grease-removal devices, fans, ducts and other appurtenances shall be cleaned at intervals as required by Sections 607.3.3.1 through 607.3.3.3.

IFC 703.1 2018 - Materials and firestop systems used to protect membrane and through penetrations in fire-resistance-rated construction shall be maintained and securely attached or bonded to the construction being penetrated with no openings visible through or into the cavity of the construction.

IFC 705.2 2018 - Opening protectives in fire-resistance-rated assemblies and smoke barriers shall be inspected and maintained in accordance with NFPA 80 and NFPA 105. Fire doors and smoke and draft control doors shall not be blocked, obstructed, or otherwise made inoperable.

IFC 705.2.4 2018 - Swinging fire doors shall close from the full-open position and latch automatically.

IFC 903.5 2009, 2012, 2015, 2018 - Sprinkler systems shall be tested and maintained in accordance with Section 901. The facility is unable to provide documentation for the annual backflow forward flow test, quarterly sprinkler system inspections, and the sprinkler system is missing the hydraulic calculation data plate. Both sprinkler heads in the walk-ins were blocked by food storage and a missing escutcheon plate was noted.

IFC 904.12.5.2 2018 - Automatic fire-extinguishing systems shall be serviced not less frequently than every six months and after activation of the system. Documentation for the kitchen suppression system deficiencies has not been corrected.

IFC 906.2 2015, 2018 - Portable fire extinguishers shall be selected, installed and maintained in accordance with NFPA 10. Required annual maintenance for fire extinguishers in specified locations has not been completed.

IFC 907.8 2018 - The maintenance and testing schedules and procedures for fire alarm and fire detection systems shall be maintained. Documentation for monthly single station smoke alarm testing is not provided.

IFC 915.6 2018 - Carbon monoxide alarms and detectors shall be maintained and replaced if inoperable or end-of-life signals occur. Documentation for monthly carbon monoxide detector testing is not provided.

IFC 1003.6 2015, 2018 - The path of egress travel shall not be interrupted or obstructed. The emergency exit doors in the activity room had anti-draft devices creating a tripping hazard.

IFC 1008.3.1 2015, 2018 - Emergency egress lighting shall automatically illuminate aisles, corridors, and exit access stairways and ramps upon power failure. Several emergency egress lights near elevator #2, main entry, and test button locations would not illuminate when tested.

IFC 1013.5 2018 - Electrically powered exit signs shall be illuminated at all times. Internally illuminated exit signs near rooms 316 and 56 would not illuminate when activation test buttons were pushed.

IFC 1008.3.1 2015, 2018 - Emergency egress light near elevator #2 would not illuminate when the test button was pressed.

IFC 1003.6 2015, 2018 - Resident room #211 fire door that opens to the corridor was blocked open by a wedge, preventing it from closing and latching.

IFC 705.2.4 2018 - Resident room #306 fire door would not close and latch from the fully open position.

IFC 315.3.3 2018 - There was combustible storage within the elevator equipment room #1.

IFC 604.6 2018 - There was an electrical outlet without a faceplate in the kitchen exposing the inner electrical fixture and a breaker missing in electrical panel A1 in the boiler room without protective coverings installed.

IFC 607.1 2018 - The explosion proof light in the kitchen hood is missing the glass globe.

WAC 246-215-06505(1) Methods—Cleaning, frequency, and restrictions (FDA Food Code 6-501.12). The licensee failed to maintain a clean kitchen, resulting in an unsanitary environment placing residents at risk of food borne illness.

WAC 388-78A-2305(1) Food sanitation. The licensee failed to maintain a clean kitchen, resulting in an unsanitary environment placing residents at risk of food borne illness.

WAC 246-215-06505 Methods Cleaning, frequency and restrictions (FDA Food Code 6-501.12). The facility failed to maintain a clean kitchen, with food debris, dirty shelves, sticky surfaces, and dead flies observed, placing residents at risk of food borne illness.

WAC 388-78A-2600 Policies and procedures. The facility failed to implement policies regarding daily food and equipment temperature monitoring, with incomplete temperature logs, risking food borne illness.

WAC 246-215-03351 Preventing contamination from the premises Food storage (FDA Food Code 3-305.11). The facility failed to ensure two open bags of dried food products were covered, risking contamination.

WAC 388-78A-2450 Staff. The facility failed to train three of four kitchen staff adequately, resulting in an unclean and unsanitary kitchen and placing residents at risk for food borne illnesses.

WAC 388-78A-2600-2-n - The facility failed to implement policies and procedures regarding daily food temperatures and equipment temperatures in the main kitchen, placing residents at risk of food borne illness. Temperature logs were not maintained and no entries were documented since 05/31/2023.

IFC 604.5 2018 Extension cords and flexible cords shall not be a substitute for permanent wiring and shall be listed and labeled in accordance with UL 817. Extension cords shall be used only with portable appliances and not affixed to structures or extended through walls, ceilings, or floors.

IFC 607.3.3 2018 Hoods, grease-removal devices, fans, ducts and other appurtenances shall be cleaned at required intervals. Facility is unable to provide documentation for the semi-annual hood cleaning.

IFC 701.6 2018 WAC 51-54A The owner shall maintain an inventory of all required fire-resistance-rated construction and visually inspect it annually. Facility is unable to provide documentation that the annual fire resistance rated construction material inspection has been completed.

IFC 703.1 2018 Materials and firestop systems used to protect membrane and through penetrations in fire-resistance-rated construction shall be maintained and inspected. Facility had a hole in the ceiling of the linen room where a leak was repaired but the ceiling fire barrier was not repaired.

IFC 705.2 2018 Opening protectives in fire-resistance-rated assemblies shall be inspected and maintained. Several fire doors were blocked open by objects preventing closure and latching. Facility is unable to provide documentation that the annual fire door inspection has been completed.

IFC 705.2.4 2018 Swinging fire doors shall close from the full-open position and latch automatically. The fire rated door from the 3rd floor library to the corridor would not close and latch from a fully open position.

IFC 903.3 2015, 2018 Automatic sprinkler systems shall be designed and installed in accordance with applicable sections. There were both standard response and quick response sprinkler heads within the same compartment in the kitchen.

IFC 903.3.3 2018 Automatic sprinklers shall be installed with regard to obstructions that delay activation or obstruct water distribution. The sprinkler head in the walk-in refrigerator and freezer had boxes and food obstructing the flow pattern.

IFC 903.5 2009, 2012, 2015, 2018 Sprinkler systems shall be tested and maintained in accordance with Section 901. Facility is unable to provide documentation for the quarterly sprinkler system inspections.

IFC 904.12 2015, 2018 The automatic fire-extinguishing system for commercial cooking systems shall be tested and installed per standards. Facility is unable to provide documentation for the required monthly inspection for the kitchen suppression system.

IFC 904.12.5.2 2018 Automatic fire-extinguishing systems shall be serviced at least every six months. Facility is unable to provide documentation for the semi-annual kitchen suppression system servicing.

OFC 906.2 2015, 2018 Portable fire extinguishers shall be selected, installed and maintained per NFPA 10. Facility was unable to provide documentation for monthly fire extinguisher maintenance and required annual maintenance for extinguishers near rooms 202 and 105.

IFC 907.8 2018 Fire alarm and detection systems shall be maintained and tested per NFPA 72. Facility is unable to provide documentation for single station smoke alarm testing.

IFC 915.6 2018 Carbon monoxide alarms and detectors shall be maintained and tested per NFPA 720. Facility is unable to provide documentation for carbon monoxide detector testing.

IFC 1011.2 2018 Stairways shall have minimum widths as specified. There was a chair in the stairway restricting the size of the exit access.

IFC 1031.10.1 2018 Emergency lighting equipment shall be tested monthly for at least 30 seconds. Facility is unable to provide documentation for the second activation test for emergency lights.

Facility is required to conduct at least twelve planned and unannounced fire drills annually. Facility cannot provide documentation for completion of twelve planned and unannounced fire drills in the previous 12 months.

WAC 388-78A-2610 Infection control. The facility failed to ensure staff wore required Personal Protective Equipment (PPE) and had been fit tested for respirator masks, placing residents, staff, and visitors at risk of contracting communicable disease.

WAC 246-215-06505 Methods -- Cleaning, frequency and restrictions (2009 FDA Food Code 6-501.12). The facility failed to ensure systems were in place for overall cleaning of the main kitchen, placing residents at risk of food borne illness.

WAC 388-78A-2305 Food sanitation. The assisted living facility failed to manage food and maintain on-site food service facilities in compliance with chapter 246-215 WAC, Food service.

WAC 388-78A-2650 Reporting fires and incidents. The facility failed to report a COVID-19 outbreak when residents tested positive, resulting in inability to ensure infection prevention practices during the outbreak.

WAC 388-78A-2850 Required reviews of building plans. The facility failed to request project review with the Department of Health Construction Review Services prior to repair work, resulting in lack of approval for the repair.

WAC 388-78A-2570 Notification of change in administrator. The facility failed to notify the department in writing of the change in administrator within ten calendar days, preventing review of the administrator's qualifications.

IFC 604.5 (2018) - Extension cords and flexible cords shall not be a substitute for permanent wiring and must be listed and labeled. Extension cords marked for indoor use shall not be used outdoors.

IFC 607.3.3 (2018) - Facility is unable to provide documentation for the semi-annual hood cleaning.

IFC 701.6 (2018) WAC 51-54A - Facility is unable to provide documentation that the annual fire resistance rated construction material inspection has been completed.

IFC 703.1 (2018) - Materials and firestop systems used to protect membrane and through penetrations in fire-resistance-rated construction shall be maintained and inspected per manufacturer's instructions.

IFC 705.2 (2018) - Resident room #208 and #105 fire doors to the corridor were blocked open by objects preventing closing and latching.

IFC 705.2.4 (2018) - The fire rated door from the 3rd floor library to the corridor would not close and latch from a fully open position.

IFC 903.3 (2015, 2018) - Both standard response and quick response sprinkler heads were found within the same compartment in the kitchen.

IFC 903.3.3 (2018) - Sprinkler head in the walk-in refrigerator and freezer had boxes and food obstructing the flow pattern of the sprinkler.

IFC 903.5 (2009, 2012, 2015, 2018) - Facility is unable to provide documentation for the quarterly sprinkler system inspections.

IFC 904.12 (2015, 2018) - Automatic fire-extinguishing system for commercial cooking systems shall be tested and labeled for the intended application.

IFC 904.12.5.2 (2018) - Facility is unable to provide documentation for the semi-annual kitchen suppression system servicing.

IFC 906.2 (2015, 2018) - Portable fire extinguishers shall be selected, installed, and maintained per NFPA 10.

IFC 907.8 (2018) - Maintenance and testing schedules for fire alarm and detection systems shall be maintained with records of inspection and testing.

IFC 915.6 (2018) - Carbon monoxide alarms and detectors shall be maintained and replaced if inoperable or end-of-life signals are produced.

IFC 1011.2 (2018) - Stairways shall have minimum widths and clearances; a chair was found restricting the size of the exit access.

IFC 1031.10.1 (2018) - Emergency lighting equipment shall be tested monthly for at least 30 seconds; documentation for the monthly 30 second activation test was not provided.

IFC 1031.10.1 (2018) - Facility cannot provide documentation for completion of twelve planned and unannounced fire drills in the previous 12 months.

WAC 388-78A-2040-2 The assisted living facility must have its building approved by the Washington state fire marshal in order to be licensed. The facility failed to meet this requirement during prior inspections but has since corrected the deficiencies.

WAC 388-78A-2610 (1)(2)(a)(b)(c)(d)(f) Infection control. The licensee failed to ensure staff wore required Personal Protective Equipment and had been fit tested for respirator masks. This failure placed 38 residents, staff, and visitors at risk of contracting communicable disease.

WAC 388-78A-2305 (1) Food sanitation. The licensee failed to ensure systems were in place for overall cleaning of one kitchen. This failure placed all the residents at risk for a food borne illness.