Inspection Reports for
The Inn at Belle Harbour Memory Care Community

IFC 705.2 (2021) - 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 inoperable. Fusible links shall be replaced promptly. Opening protectives and smoke and draft control doors shall not be modified.

IFC 705.2.4 (2021) - Swinging fire doors shall close from the full-open position and latch automatically. The 3rd floor sky bridge south door did not latch from a fully open position but was corrected during inspection.

IFC 903.5 (2021) - Sprinkler systems shall be tested and maintained per Section 901. The facility was unable to provide documentation of required sprinkler system testing including quarterly inspections, 5-year internal pipe testing, 3-year dry system full flow trip test, annual trip test, annual fire pump, and 5-year FDC hydro testing.

IFC 904.13.5.2 (2021) - Automatic fire-extinguishing systems shall be serviced at least every six months and after activation. The facility was unable to provide documentation that annual and semi-annual kitchen suppression servicing had been performed within the last 12 months.

IFC 906.2 (2021) - Portable fire extinguishers shall be selected, installed, and maintained per NFPA 10. The facility met all requirements and was corrected.

IFC 906.6 (2021) - Portable fire extinguishers shall not be obstructed or obscured. The fire extinguisher in the main kitchen was blocked by a linen basket but was corrected during inspection.

IFC 907.4.2.6 (2021) - Manual fire alarm boxes shall be unobstructed and visible at all times. The manual fire alarm pull station near the main entrance was obstructed by carts but was corrected during inspection.

IFC 907.8 (2021) - Fire alarm testing and maintenance schedules shall be maintained. The facility was corrected.

IFC 915.6 (WAC) - Carbon monoxide alarms and detectors shall be maintained and replaced if inoperable. Monthly testing and maintenance had not been performed and remains uncorrected.

IFC 1032.1 (2018) - Means of egress shall be maintained. The facility was corrected.

IFC 5303.5.3 (2021) - Compressed gas containers, cylinders, and tanks shall be secured to prevent falling. The facility was corrected.

WAC 212-12-044 - Fire drills shall be held at least quarterly on each shift with records maintained. The facility was corrected.

IFC 1031.10.2 (2021) - Battery-powered emergency lighting equipment shall be tested annually for at least 90 minutes. The facility was corrected.

IFC 1203.4 (2021) - Emergency and standby power systems shall be maintained and tested per NFPA standards. The facility failed to perform weekly inspections and monthly 30-minute load tests and remains uncorrected.

IFC 603.4 (2021) - Working space around electrical equipment was required to meet minimum dimensions and be clear of storage. This deficiency was corrected.

IFC 603.5.2 (2021) - Relocatable power taps and current taps were required to be connected to a permanently installed receptacle. This deficiency was corrected.

IFC 606.3.3 (2021) - Hoods, grease-removal devices, fans, ducts and other appurtenances were required to be cleaned at intervals as specified. This deficiency was corrected.

IFC 703.1 (2021) - Materials and firestop systems protecting penetrations in fire-resistance-rated construction were required to be maintained and securely attached. This deficiency was corrected.

IFC 705.2 (2021) - Opening protectives in fire-resistance-rated assemblies were required to be inspected and maintained per NFPA 80 and NFPA 105. This deficiency was corrected.

IFC 705.2.4 (2021) - Swinging fire doors were required to close and latch automatically from the full-open position. The 3rd floor sky bridge south door did not latch fully but was corrected during inspection.

IFC 901.6 (2021) - Fire protection and life safety systems were required to be maintained in operative condition and tested as required. This deficiency was corrected.

IFC 903.5 (2021) - The facility was unable to provide documentation of required sprinkler system testing including quarterly inspections, 5-year internal pipe testing, 3-year dry system full flow trip test, annual trip test, annual fire pump, and 5-year FDC hydro testing.

IFC 904.13.5.2 (2021) - The facility was unable to provide documentation that annual and semi-annual kitchen suppression system servicing had been performed within the last 12 months; one servicing was performed on 06/06/2025.

IFC 906.2 (2021) - Portable fire extinguishers were required to be selected, installed, and maintained per NFPA 10. This deficiency was corrected.

IFC 906.6 (2021) - Portable fire extinguishers must not be obstructed or obscured. The fire extinguisher in the main kitchen was blocked by a linen basket but was corrected during inspection.

IFC 907.4.2.6 (2021) - Manual fire alarm boxes must be unobstructed and visible. The manual fire alarm pull station near the main entrance was obstructed by carts but was corrected during inspection.

IFC 907.8 (2021) - Fire alarm maintenance and testing schedules must be maintained. This deficiency was corrected.

IFC 915.6 (2021) WAC - Carbon monoxide alarms and detectors must be maintained and tested monthly. Monthly testing and maintenance had not been performed and the deficiency was not corrected.

IFC 1032.1 (2018) - Means of egress must be maintained. This deficiency was corrected.

IFC 1032.10.1 (2021) - Emergency lighting equipment must be tested monthly. The 30 second monthly exit and emergency lighting activation test had not been performed and was not corrected.

IFC 1203.4 (2021) - Emergency and standby power systems must be maintained and tested. Weekly inspection logs and monthly 30 minute load tests were not performed and not corrected.

IFC 5303.5.3 (2021) - Compressed gas containers, cylinders, and tanks must be secured to prevent falling. This deficiency was corrected.

WAC 212-12-044 - At least twelve planned and unannounced fire drills must be held annually with quarterly drills on each shift. This deficiency was corrected.

WAC 388-78A-2484 (1)(2) Tuberculosis – Two step skin testing. The licensee failed to complete three staff’s one-step and second-step TB skin tests as required, placing all residents at risk of tuberculosis exposure.

WAC 388-78A-2474 (2)(a)(c)(d)(3) Training and home care aide certification requirements. The licensee failed to ensure one staff completed required training, placing all residents at risk of unmet needs and decreased quality of life.