Legacy House

The facility failed three consecutive fire and life safety inspections (February, May, and September 2025) for missing fire/smoke damper inspections and documentation, affecting all 74 residents. The facility acknowledged the deficiency, scheduled installation of two fire/smoke dampers, and committed to corrective action by October 15, 2025. A follow-up inspection on December 9, 2025 confirmed all deficiencies were corrected and the facility met licensing requirements, demonstrating effective remediation of the fire safety violations.

Legacy House had recurring documentation violations for required fire safety inspections including fire/smoke dampers, fire drills, fire door testing, emergency lighting, fire alarm maintenance, and emergency power system logs. The facility also had minor physical deficiencies including a non-latching 4th floor chute door and an improper door gap in room 223. The facility responded appropriately by correcting all deficiencies between the February and October 2025 inspections, demonstrating good follow-through on fire safety compliance requirements with no immediate resident safety threats identified.

The facility failed to provide documentation of fire/smoke damper inspections as required by NFPA 80, which mandates testing 1 year after installation and every 4 years thereafter. This is a procedural compliance violation related to life-safety system documentation rather than an actual fire safety hazard, though proper damper function is critical for smoke compartmentalization. No evidence of facility response is documented in this initial inspection report, and the facility status shows 'Disapproved' pending corrective action. A follow-up inspection is scheduled for October 2025 to verify compliance.

Legacy House failed multiple fire safety documentation and maintenance requirements across two inspections (February and May 2025), including missing fire/smoke damper inspections, incomplete fire drill records, annual testing documentation for sprinkler systems and fire doors, and emergency power system logs. The facility also had physical deficiencies including a non-latching 4th floor chute door and a door with excessive gap. The facility's response was inadequate, failing to correct violations between inspections and unable to provide required documentation at re-inspection, demonstrating systemic compliance failures in fire safety record-keeping and maintenance programs.

This is an IDR results letter confirming that disputed deficiencies from a 12/10/2024 inspection were upheld after the facility's appeal, but the actual Statement of Deficiencies document is not included. Without the underlying inspection report detailing what violations were found, it is impossible to assess event severity or the facility's response quality. No violations or corrective actions can be evaluated from this administrative cover letter alone.

The facility received citations for violations of WAC 388-78A-2140 and WAC 388-78A-2483 during an inspection completed December 10, 2024. The facility responded by formally requesting an Informal Dispute Resolution (IDR) to contest the cited deficiencies, demonstrating engagement with the regulatory process. The specific nature of the violations is not detailed in this scheduling letter, but the facility's proactive dispute and preparation of additional documentation indicates a reasonably responsible response to the findings. An IDR hearing is scheduled for January 9, 2025, to review the contested citations and supporting evidence from both parties.

The facility had a violation of infection control requirements related to aerosol-generating procedures (AGP) and COVID-19 protocols, failing to fully implement CDC guidance for protecting residents and staff from respiratory illness transmission. The facility demonstrated adequate response by issuing an Administrator letter addressing the deficiency and implementing CDC-recommended procedures. While the infection control gap presented moderate risk given COVID-19 concerns, no actual resident harm was documented and the facility took corrective action to align with CDC guidelines.