Hilltop Manor Boarding Home

Combustible materials stored in exits or enclosures for stairways and ramps.

Failure to clean hoods, grease-removal devices, fans, and ducts at required intervals.

Failure to maintain records of emergency evacuation drills and conduct drills as required.

Lack of documentation/maps for fire-rated construction locations and maintenance/inspection reports.

3 of 6 detectors failed the last monthly inspection.

Lack of required periodic inspection and testing for fire/smoke dampers and fire door assemblies.

Facility could not produce an annual generator inspection report.

Improper use of extension cords.

Failure to service automatic fire-extinguishing systems.

Stand alone smoke alarms in resident rooms do not have monthly testing documentation.

Failure to perform and document required inspections and tests of emergency lighting equipment.

Failure to maintain testing documentation for sprinkler systems.

Stand alone smoke alarms in resident rooms lack monthly testing documentation.

Drills not held at unexpected times/varying conditions; missing required drill records; fire alarm system not used for drills.

Hoods, grease-removal devices, fans, and ducts not cleaned at required intervals.

Facility could not produce an annual generator inspection report.

3 of 6 carbon monoxide detectors failed the last monthly inspection.

Automatic fire-extinguishing systems not serviced.

Fire/smoke dampers and fire doors not inspected and tested per code requirements.

Combustible materials stored in exits or enclosures for stairways and ramps.

Facility failed to provide detailed documentation and maps of fire-rated construction locations and annual inspection reports.

Sprinkler system not tested and maintained in accordance with Section 901.

Improper use of extension cords.

Emergency lighting equipment inspection and testing not conducted.

The licensee failed to ensure hot water temperatures were between 105 and 120 degrees Fahrenheit, placing 26 residents at risk of burn injuries. This is a recurring and uncorrected deficiency.

Failed to support safe medication services for 1 resident (Resident 3); staff did not assist with prescribed clobetasol cream as directed by physician.

Facility failed to ensure 4 of 4 sampled staff received orientation and 2 of 2 sampled staff completed required home care aide certification.

Facility failed to ensure 1 of 4 staff members completed the required two-step tuberculin skin test.

Failed to obtain prescribed nasal spray in a timely manner for 1 resident (Resident 3), leaving the resident without medication for 32 days.

Failed to provide specialty diet options (e.g., sugar-free, vegetarian) and alternate choices to residents with diabetes.

Facility failed to provide sugar-free desserts and alternatives for residents with diabetes, and failed to maintain food temperatures and sanitizing systems.

Facility failed to maintain hot water temperatures in resident sinks between 105 F and 120 F; measured temperatures reached 140 F.

Deficiencies previously cited have been corrected.

Deficiencies previously cited have been corrected.

Deficiencies previously cited have been corrected.

Missing annual report, sensitivity testing, and monthly single/multiple station alarms test reports.

Missing annual service report and monthly 30-minute full load test documentation.

Relocatable power taps and current taps must be directly connected to a permanently installed receptacle.

Missing annual servicing documentation, missing monthly maintenance logs, and a missing fire extinguisher in the lobby.

Missing required service reports and logs for emergency and standby power systems.

Missing required maintenance, service, and inspection records; missing portable fire extinguisher in lobby.

Fire/smoke damper inspection needs to be performed and documented.

Extension cords prohibited as a substitute for permanent wiring.

Failure to maintain inventory and annual inspection records of fire-resistance-rated construction.

Annual 90-minute battery-powered emergency lighting power test not performed or documented.

Missing required sprinkler system inspection/test records (e.g., annual reports, pipe testing, flow tests).

Missing required semi-annual service records for fire-extinguishing systems.

Loose tanks found in the basement boiler room and outside by the generator.

The facility failed to ensure compliance with the Washington State Patrol Office of State Fire Marshal (OSFM) follow-up Fire and Life Safety Inspection (LSI), posing a risk of harm to 26 residents, staff, and visitors. This is an uncorrected citation previously cited on October 24, 2024.

Missing annual service report, log of weekly inspections, and monthly 30-minute full load test.

Missing annual service report, log of weekly inspections, and monthly 30-minute full load test for emergency/standby power systems.

Annual 90-minute battery-powered emergency lighting test not performed and documented.

Missing records of semi-annual servicing.

Fire/smoke damper inspection not performed and documented.

Loose/unsecured compressed gas tanks found in basement boiler room and outside by generator.

Missing annual report, sensitivity testing records, and monthly single/multiple station alarm test records.

Missing annual report, 5-year internal pipe testing, 3-year dry system full flow trip test, annual trip test, annual forward flow test, 5-year FDC hydro testing, and quarterly inspections.

Missing annual service records, monthly inspection logs, and a missing fire extinguisher in the lobby area.