Inspection Reports for
Mountain Glen Retirement Community

IFC 603.2 (2021) - Abatement of unsafe electrical hazards is required. Conditions that constitute an electrical shock or fire hazard shall be abated.

IFC 705.2 (2021) - Fire doors and smoke and draft control doors shall not be blocked, obstructed, or otherwise made inoperable. Several resident room fire doors were blocked open preventing closure and latching.

IFC 705.2.4 (2021) - Swinging fire doors shall close from the full-open position and latch automatically.

IFC 907.8.3 (2021) - Smoke detector sensitivity shall be checked within one year after installation and every alternate year thereafter. Facility is unable to provide documentation for required smoke detector sensitivity testing.

WAC 388-78A-2305 (1) Food sanitation. The licensee failed to keep one kitchen clean, and food was not labeled and dated appropriately, creating an unsanitary environment that placed residents at risk of foodborne illness.

IFC 315.2.3 (2021) - Combustible material shall not be stored in boiler rooms, mechanical rooms, electrical equipment rooms or in fire command centers. The facility had combustible material stored in the mechanical furnace room near 423.

IFC 603.2 (2021) - Electrical panel in the electrical room near 423 has the wrong face plate installed which allows access to electrical components behind the face plate.

IFC 606.3.3 (2021) - Hoods, grease-removal devices, fans, ducts and other appurtenances shall be cleaned at intervals as required. Facility is unable to provide documentation for the 12 months of semi-annual hood cleanings.

IFC 606.4 (2021) - Gas-fired commercial cooking appliances installed on casters and appliances that are moved for cleaning shall be connected with an appliance connector and movement limited by a restraining device. The gas appliances on casters in the kitchen are not limited by a restraining device.

IFC 705.2 (2021) - Fire doors and smoke and draft control doors shall not be blocked or obstructed. Resident room fire doors 507, 543, 429, and 407 were blocked open using various items preventing closure and latching.

IFC 705.2.4 (2021) - Swinging fire doors shall close from the full-open position and latch automatically. The fire rated door from the stairwell to the corridor near 421 has a disabled door closure. The fire rated cross corridor door #22 near room 202 would not close and latch from the fully open position.

IFC 901.4.7.1 (2018) - Automatic sprinkler system risers, fire pumps and controllers shall have ready access. There were storage items in the riser room blocking access to the sprinkler system.

IFC 903.5 (2021) - Sprinkler systems shall be tested and maintained in accordance with Section 901. Facility is unable to provide documentation for the annual sprinkler system inspection, 3 year dry system full flow trip test, and annual forward flow test.

IFC 904.13.5.2 (2021) - Automatic fire-extinguishing systems shall be serviced at least every six months and after activation. Facility is unable to provide documentation for the semi-annual kitchen suppression system servicing.

IFC 906.2 (2021) - Portable fire extinguishers shall be selected, installed and maintained per NFPA 10. Facility was unable to provide required documentation for monthly fire extinguisher maintenance.

IFC 907.8 (2021) - Fire alarm and detection systems shall be maintained per NFPA 72. Facility is unable to provide documentation for the annual fire alarm system testing and semi-annual smoke detector sensitivity testing.

IFC 907.8.3 (2021) - Smoke detector sensitivity shall be checked within one year after installation and every alternate year thereafter. Facility is unable to provide documentation for required smoke detector sensitivity testing. 117 smoke detectors failed testing and replacement permits have been submitted.

IFC 915.6 (2021 WAC) - Carbon monoxide alarms and detection systems shall be maintained. Facility is unable to provide documentation for monthly carbon monoxide detector testing.

IFC 1013.5 (2021) - Electrically powered, self-luminous and photoluminescent exit signs shall be listed and labeled and illuminated at all times. The internally illuminated exit signs A19 near 423 would not illuminate when the activation test button was pushed.

IFC 1203.4 (2021) - Emergency and standby power systems shall be maintained to supply service within the required time. Facility is unable to provide documentation for weekly inspections and monthly 30 minute full load testing.

IFC 705.2 (2021) - Fire doors and smoke and draft control doors shall not be blocked or obstructed. Resident room fire doors 507, 540, 543, 429, and 407 were blocked open using various items preventing closure and latching.

IFC 705.2.4 (2021) - Swinging fire doors shall close from the full-open position and latch automatically. The fire rated door from the stairwell to the corridor near 421 has a disabled door closure.

IFC 901.4.7.1 (2018) - Automatic sprinkler system risers, fire pumps and controllers shall have ready access. There was storage blocking access to the sprinkler system in the riser room.

IFC 903.5 (2021) - Sprinkler systems shall be tested and maintained. Facility is unable to provide documentation for annual sprinkler system inspection, 3 year dry system full flow trip test, and annual forward flow test.

IFC 904.13.5.2 (2021) - Automatic fire-extinguishing systems shall be serviced at least every six months and after activation. Facility is unable to provide documentation for semi-annual kitchen suppression system servicing.

IFC 906.2 (2021) - Portable fire extinguishers shall be selected, installed and maintained per NFPA 10. Facility was unable to provide documentation for monthly fire extinguisher maintenance.

IFC 907.8 (2021) - Fire alarm and detection systems shall be maintained per NFPA 72. Facility is unable to provide documentation for annual fire alarm system testing and semi-annual smoke detector sensitivity testing.

IFC 907.8.3 (2021) - Smoke detector sensitivity shall be checked within one year after installation and every alternate year thereafter. Facility is unable to provide documentation for required smoke detector sensitivity testing.

IFC 915.6 (2021 WAC) - Carbon monoxide alarms and detection systems shall be maintained. Facility is unable to provide documentation for monthly carbon monoxide detector testing.

IFC 1013.5 (2021) - Electrically powered, self-luminous and photoluminescent exit signs shall be listed and labeled and illuminated at all times. The internally illuminated exit signs A19 near 423 would not illuminate when the activation test button was pushed.

IFC 1203.4 (2021) - Emergency and standby power systems shall be maintained to supply service within the required time. Facility is unable to provide documentation for weekly inspections and monthly 30 minute full load testing.

IFC 1604 (2021) - In all Group I, Group E, and Group R2 Occupancies licensed by the state fire marshal's office, at least twelve planned and unannounced fire drills shall be held every year. Facility cannot provide documentation for completion of twelve planned and unannounced fire drills in the previous 12 months, missing drills for 1st, 2nd, and 3rd shifts in quarters 1 and 4.

WAC 388-112A-0400 What is specialty training and who is required to take it? Specialty training classes are different for each population served and are not interchangeable. Specialty training curriculum must be DSHS developed or approved.

WAC 388-112A-0495 What are the specialty training and supervision requirements for long-term care workers in adult family homes, assisted living facilities, and enhanced services facilities? Adult family homes. The facility must ensure long-term care workers demonstrate competency in specialty training within required timeframes.

WAC 388-78A-2474 Training and home care aide certification requirements. The assisted living facility must ensure administrators and caregivers meet long-term care worker training requirements including specialty for dementia, mental illness, and developmental disabilities when serving residents with those needs.

WAC 388-112A-0600 What is continuing education and what topics may be covered in continuing education? Continuing education is annual training to promote professional development and must be DSHS approved.

WAC 388-78A-2474 Training and home care aide certification requirements. The facility must ensure administrators and caregivers hired on or after January 7, 2012 meet training requirements including continuing education.

WAC 388-78A-2160 Implementation of negotiated service agreement. The assisted living facility failed to provide showers twice per week in the spa bathroom as agreed upon in the negotiated service agreement for one resident, instead offering bed baths without proper documentation of refusal.

WAC 388-78A-2040 Other requirements. The assisted living facility failed to ensure correction of violations from multiple Fire and Life Safety annual inspections, including failure to provide required fire wall and fire door inspections, malfunctioning fire rated doors, missing documentation for fire and smoke damper inspections, sprinkler system deficiencies, and alarm system testing deficiencies.

IFC 701.6 2018 WAC 51-54A Owner's Responsibility. Facility was unable to provide the annual fire wall inspection documentation.

IFC 705.2 2018 Inspection and Maintenance. Facility was unable to provide the annual fire door inspection documentation.

IFC 705.2.4 2018 Door Operations. Multiple fire rated doors on various floors would not close and latch from a fully open position or were delaminating.

IFC 706.1 2018 Duct and Air Transfer Openings. Facility was unable to provide documentation for the four-year fire and smoke damper inspection.

IFC 903.5 2009,2012,2015,2018 Testing and Maintenance. Facility had multiple deficiencies in the latest annual sprinkler system inspection and lacked documentation for 5-year internal piping and 3-year dry system full flow trip tests.

IFC 907.8 2018 Inspection, Testing and Maintenance. Facility had multiple deficiencies in the latest annual alarm system testing and lacked documentation for required smoke detector sensitivity testing.

IFC 604.5 2018 Extension Cords. An extension cord was used as permanent wiring in the staff lounge.

IFC 607.3 2018 Cleaning. Facility was unable to provide documentation of semi-annual hood cleaning.

IFC 904.12.5.2 2018 Extinguishing System Service. Facility was unable to provide documentation for semi-annual kitchen suppression system servicing.

IFC 1003.6 2015, 2018 Means of Egress Continuity. A laundry bin was blocking the emergency exit on the first floor exit #613.

WAC 388-78A-2040 (2) Other requirements. The licensee failed to ensure the violations for four Fire and Life Safety annual inspections were corrected, placing all residents at risk of harm in the event of a fire.

IFC 701.6 2018 WAC 51-54A - The owner must maintain an inventory of all required fire-resistance-rated construction and inspect it annually. Records of inspections and repairs must be maintained. Facility was unable to provide documentation that the annual fire wall inspection has been completed.

IFC 705.2 2018 - Opening protectives in fire-resistance-rated assemblies must be inspected and maintained per NFPA 80 and NFPA 105. Facility was unable to provide documentation that the annual fire door inspection has been completed, including verification of labels, glazing, hardware, door operation, and signage.

IFC 705.2.4 2018 - Swinging fire doors must close from the full-open position and latch automatically. Multiple fire rated doors including rooms #513, #412, #435, #525, #433, #545, and lobby elevator door were delaminating or would not close and latch properly.

IFC 706.1 2018 - Dampers protecting ducts and air transfer openings must be inspected and maintained per NFPA 80 and NFPA 105. Facility was unable to provide documentation for the 4-year fire and smoke damper inspection. Two dampers have failed and need replacement.

IFC 903.5 2009, 2012, 2015, 2018 - Sprinkler systems must be tested and maintained per Section 901. Facility's latest annual sprinkler system inspection had multiple deficiencies not corrected and lacked documentation for 3-year dry system full flow trip test and 5-year internal piping inspection.

IFC 907.8 2018 - Fire alarm and detection systems must be maintained and tested per Sections 907.8.1 through 907.8.5 and NFPA 72. Facility's latest annual alarm system testing had multiple deficiencies not corrected.

IFC 907.8.3 2012, 2015, 2018 - Smoke detector sensitivity must be checked annually or biennially with calibration tests. Facility was unable to provide documentation for required smoke detector sensitivity testing. Testing completed on 12/19/22 showed 167 detectors failed and must be replaced.

IFC 604.5 2018 - Extension cords shall not be a substitute for permanent wiring and must be listed and labeled. Multiple extension cords were used as permanent wiring in staff lounge, Dining Services Director's office, and other areas.

IFC 607.3.3 2018 - Hoods, grease-removal devices, fans, ducts and other appurtenances must be cleaned at required intervals. Facility was unable to provide documentation for semi-annual hood cleaning and kitchen suppression system servicing.

IFC 904.12.5.2 2018 - Automatic fire-extinguishing systems must be serviced at least every six months. Facility lacked documentation for semi-annual kitchen suppression system servicing.

IFC 906.2 2015, 2018 - Portable fire extinguishers must be selected, installed, and maintained per NFPA 10. Facility lacked required maintenance documentation for kitchen fire extinguisher.

IFC 1003.6 2015, 2018 - Means of egress travel must not be obstructed or diminished. A laundry bin was blocking the emergency exit on the 1st floor near exit #613.

IFC 1013.5 2018 - Internally illuminated exit signs must be listed, labeled, and illuminated at all times. Exit signs near stairwell exits #612 and #432 did not illuminate in normal operation.

IFC 5303.5.3 2018 - Compressed gas containers must be secured to prevent falling. Oxygen cylinders in room #414 were not secured to prevent falling.

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 outdoors.

IFC 607.3.3 2018 Hoods, grease-removal devices, fans, ducts and other appurtenances shall be cleaned at required intervals.

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

IFC 705.2 2018 Opening protectives in fire-resistance-rated assemblies shall be inspected and maintained in accordance with NFPA 80 and NFPA 105. 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. Multiple fire rated doors would not close and latch from a fully open position or are delaminating.

IFC 706.1 2018 Dampers protecting ducts and air transfer openings shall be inspected and maintained. Facility is unable to provide documentation for the 4 year fire and smoke damper inspection.

IFC 903.5 2009, 2012, 2015, 2018 Sprinkler systems shall be tested and maintained in accordance with Section 901. Facility's latest annual sprinkler system inspection had multiple deficiencies not corrected and documentation missing for 5 year internal piping and 3 year dry system full flow trip test.

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

IFC 906.2 2015, 2018 Portable fire extinguishers shall be selected, installed and maintained per NFPA 10. The required maintenance for the fire extinguisher in the kitchen has not been completed.

IFC 907.8 2018 Fire alarm and detection systems shall be maintained and tested per NFPA 72. Latest annual alarm system testing had multiple deficiencies not corrected.

IFC 907.8.3 2012, 2015, 2018 Smoke detector sensitivity shall be checked within one year after installation and every alternate year thereafter. Facility unable to provide documentation for required smoke detector sensitivity testing.

IFC 1003.6 2015, 2018 The path of egress travel shall not be interrupted or diminished. A laundry bin was blocking the emergency exit on the 1st floor exit #613.

IFC 1013.5 2018 Electrically powered, self-luminous and photoluminescent exit signs shall be listed and labeled and illuminated at all times. Two internally illuminated exit signs did not illuminate in normal operation.

IFC 5303.5.3 2018 Compressed gas containers, cylinders and tanks shall be secured to prevent falling. Oxygen cylinders in room #414 are not secured to prevent falling.