Hilltop Manor Boarding Home

Failure to service automatic fire-extinguishing systems.

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

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

Improper use of extension cords.

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

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

Failure to maintain testing documentation for sprinkler systems.

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

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

3 of 6 detectors failed the last monthly inspection.

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

Facility could not produce an annual generator inspection report.

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

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

Emergency lighting equipment inspection and testing not conducted.

Improper use of extension cords.

Automatic fire-extinguishing systems not serviced.

Facility could not produce an annual generator inspection report.

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

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

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.

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

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

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

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

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.

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

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

Deficiencies previously cited have been corrected.

Deficiencies previously cited have been corrected.

Deficiencies previously cited have been corrected.

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

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

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

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

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

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

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

Extension cords prohibited as a substitute for permanent wiring.

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

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

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

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

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

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

Fire/smoke damper inspection not performed and documented.

Missing records of semi-annual servicing.

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

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

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

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

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