Aegis Living Lake Union.

This document was prepared by Residential Care Services for the Locator website. STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20425 72nd Avenue S, Suite 400, Kent, WA 98032 Statement of Deficiencies License #: 2630 Compliance Determination # 48873 Plan of Correction Aegis Living Lake Union Completion Date Page 1 of 12 Licensee: Aegis Senior Communities LLC 11/05/2024 You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for the unannounced on-site full inspection on 10/22/2024 and 10/25/2024 of: Aegis Living Lake Union 1936 Eastlake Ave E Seattle, WA 98102 The following sample was selected for review during the unannounced on-site visit: 7 of 49 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Steven Garrett, LTC Licensor Jane Hermano, NCI From: DSHS, Aging and Long-Term Support Administration Residential Care Services, Region 2 , Unit D 20425 72nd Avenue S, Suite 400 Kent, WA 98032 As a result of the on-site visit(s), the department found that you are not in compliance with the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. Residential Care Services Date I understand that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2630 Compliance Determination # 48873 Plan of Correction Aegis Living Lake Union Completion Date Page 2 of 12 Licensee: Aegis Senior Communities LLC 11/05/2024 Administrator (or Representative) Date WAC 388-78A-2610 Infection control. (1) The assisted living facility must institute appropriate infection control practices in the assisted living facility to prevent and limit the spread of infections. (2) The assisted living facility must: (d) Provide all resident care and services according to current acceptable standards for infection control; (e) Perform all housekeeping, cleaning, laundry, and management of infectious waste according to current acceptable standards for infection control; This requirement was not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure 2 of 2 (Staff G and Staff L) followed infection control practices related to proper hand hygiene procedures when providing dining services and handling dirty laundry. This failure placed all 49 residents at risk of illness or infection and decreased quality of life from possible cross-contamination. Findings included… The Centers for Disease Control and Prevention (CDC) developed guidelines for infection prevention and control practices for healthcare settings. Review of CDC’s “Health Care Providers: Hand Hygiene,” showed that hand hygiene reduced the incidents of infections. Review of the facility’s policy titled, “Hand Hygiene Protocol”, revised 06/19/2022, showed the importance of hand hygiene to prevent the transmission of infections. The policy showed staff were required to wash hands before handling clean linen and after handling dirty laundry. The policy showed staff were required to wash hands before and after using gloves. The policy showed that gloves were not used to replace the need for hand hygiene or alcohol-based hand sanitizer. The policy showed that the staff were to follow proper hand hygiene procedures. The procedures included step-by-step instructions for using paper towels to dry hands and turning off the water faucet. The hand hygiene instructions showed that spent paper towels were discarded in the designated receptacle. During the general tour on 10/22/2024 at 11:40 AM, Staff B, Care Director, stated that the memory care unit, Life’s Neighborhood, was located on the second floor. Staff B stated that all residents in the unit were diagnosed with ( This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2630 Compliance Determination # 48873 Plan of Correction Aegis Living Lake Union Completion Date Page 3 of 12 Licensee: Aegis Senior Communities LLC 11/05/2024 ), ( ) or . Observation on 10/22/2024 at 12:20 PM, showed the Life’s Neighborhood included a dining area with a dining servery (a small area with a counter where food is served). Observation showed Staff L, Care Manager 1, poured beverages into glasses that sat on top of the servery counter. After Staff L poured the beverages, they served two unidentified residents with the food that was on the counter. Observation showed that Staff L then assisted an unidentified resident in a wheelchair to move to a table. Observation showed after Staff L helped the resident to move. Staff L washed their hands in a sink located in the servery. Staff L dried their hands with a paper towel and used the paper towel to turn off the water faucet. Observation showed Staff L left the used paper towel on the servery counter. Staff L then passed out the beverages to the residents. After Staff L served the beverages, Staff L threw the dirty paper towel on the counter into the trash. Observation showed Staff L did not wash their hands after they discarded the used paper towel. During an interview on 10/22/20224 at 12:30 PM, Staff L stated that after they dried their hands, they forgot to discard the paper towel into the trash. Staff L stated that they were aware the paper towels were intended for single use only. Observation on 10/23/2024 at 9:00 AM, showed Staff G, Housekeeper, entered Apartment with gloved hands. Staff G collected worn clothes and towels from the bathroom and placed into the laundry hamper. Observation showed Staff G folded a blanket and coverlet off the top of the bed and placed it on the couch. Staff G removed the bed linens. Staff G rolled up the bed linens and pillowcases and placed directly into the hamper. Observation showed Staff G, with the same gloved hands, gathered the clean bedsheets and pillowcases. Observation showed Staff G did not remove their gloves and wash their hands after they handled the dirty laundry. During an interview on 10/23/2024 at 9:30 AM, Staff G stated that they were aware of the requirements to change gloves and wash hands between dirty and clean task. Staff G stated that they forgot to take off the gloves and wash their hands before they handled the clean laundry. During an interview on 10/23/2024 at 2:43 PM, Staff B, stated that the facility provided infection control training to all staff. Staff B stated that the training included proper hand hygiene, and timing before and after changing tasks. Staff B stated that they expected the staff to follow proper hand hygiene practices, as required. Plan/Attestation Statement This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2630 Compliance Determination # 48873 Plan of Correction Aegis Living Lake Union Completion Date Page 4 of 12 Licensee: Aegis Senior Communities LLC 11/05/2024 I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Aegis Living Lake Union is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date WAC 388-112A-0060 What are the training and certification requirements for volunteers and long-term care workers in assisted living facilities and assisted living facility administrators? (1) The following chart provides a summary of the training and certification requirements for a volunteer, an administrator or designee, and a long-term care worker in an assisted living facility: Who Status Facility orientation Safety/ orientation training Seventy-hour long-term care worker basic training Specialty training Continuing education (CE) Required credential (a) Long-term care worker in assisted living facility. (iii) Employed in an assisted living facility and does not meet the criteria in subsection (1)(a) or (b) of this section. Meets the definition of long-term care worker in WAC 388-112A-0010 . Not required. Required. Five hours per WAC 388-112A-0200 (2) and 388-112A-0220 . Required. Seventy-hours per WAC 388-112A-0300 and 388-112A-0340 . Required per WAC 388-112A-0400 . Required. Twelve hours per WAC 388-112A-0611 . Home care aide certification required per WAC 388-112A- 0105 within two hundred days of the date of hire as provided in WAC 246-980-050 (unless the department of health issues a provisional certification under WAC 246-980-065 ). WAC 388-78A-2474 Training and home care aide certification requirements. (2) The assisted living facility must ensure all assisted living facility administrators, or their designees, and caregivers hired on or after January 7, 2012 meet the long-term care worker training requirements of chapter 388-112A WAC, including but not limited to: (b) Basic; (c) Specialty for dementia, mental illness and/or developmental disabilities when serving residents with any of those primary special needs; (e) Continuing education. This requirement was not met as evidenced by: Based on interview and record review the facility failed to ensure 2 of 6 staff (Staff C and Staff F) completed all required training to perform their job duties and responsibilities. This failure placed all residents at risk of unmet care needs from staff with incomplete training. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2630 Compliance Determination # 48873 Plan of Correction Aegis Living Lake Union Completion Date Page 5 of 12 Licensee: Aegis Senior Communities LLC 11/05/2024 Findings included… Review of facility’s personnel records showed the facility hired Staff C, Care Manager 1, on 06/03/2024 and Staff F, Assoc Care Director, on 08/16/2020. BASIC TRAINING/SPECIALTY TRAININGS Review of Staff C’s personnel records showed that between August 2024 and October 2024, Staff C worked providing direct care and services for residents with and diagnoses. The records showed no documentation that Staff C completed the required 70-hour Long-term care worker basic training. The records showed no documentation that Staff C completed the required specialty trainings for dementia and mental health. CONTINUING EDUCATION (CE) Review of Staff F’s personnel records showed Staff F’s date of birth as December 18. Review showed documentation that Staff F completed only eight hours of CE training between 12/18/2022 and 12/18/2023. During an interview on 10/23/2024 at 11:50 AM, Staff A, Health Services Director/Administrator, stated that they were aware of the staff basic training and CE training requirements. Staff A stated that they were unaware that Staff C and Staff F did not complete the required trainings. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Aegis Living Lake Union is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date WAC 388-78A-2480 Tuberculosis Testing Required. (1) The assisted living facility must develop and implement a system to ensure each staff person is screened for tuberculosis within three days of employment. This requirement was not met as evidenced by: This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2630 Compliance Determination # 48873 Plan of Correction Aegis Living Lake Union Completion Date Page 6 of 12 Licensee: Aegis Senior Communities LLC 11/05/2024 Based on interview and record review the facility failed to ensure 1 of 6 staff (Staff D) was screened for Tuberculosis (TB) as required. This failure placed all residents at risk of exposure to TB, an infectious disease. Findings included… Review of the facility’s personnel records showed that the facility hired Staff D, Med Care Manager, on 07/19/2024. Review showed that Staff D worked in August 2024, September 2024, and October 2024. Review of Staff D’s personnel records showed no documentation that Staff D completed any TB testing within three days of employment. During an interview on 10/23/2024 at 11:55 AM, Staff A, Health Services Director/Administrator, stated that they were aware of the TB screening requirements. Staff A stated that they were unaware Staff D was not screened for TB within three days of employment. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Aegis Living Lake Union is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date WAC 388-78A-2600 Policies and procedures. (1) The assisted living facility must develop and implement policies and procedures in support of services that are provided and are necessary to: (a) Maintain or enhance the quality of life for residents including resident decision-making rights; (b) Provide the necessary care and services for residents, including those with special needs; This requirement was not met as evidenced by: This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2630 Compliance Determination # 48873 Plan of Correction Aegis Living Lake Union Completion Date Page 7 of 12 Licensee: Aegis Senior Communities LLC 11/05/2024 Based on observation, interview, and record review the facility failed to follow their policy for 1 of 1 resident (Resident 5). This failure placed Resident 5 at risk of unmet services and decreased quality of life. Findings included… Review of the facility’s Disclosure of Services document, showed the facility permitted smoking in designated outside areas consistent with Initiative 901 as specified in the resident’s negotiated service agreement. Review of the facility’s policy titled, “Smoking Policy”, dated 06/07/2024, showed a resident assessed and able to smoke safely and independently will be expected to smoke only in the designated outdoor smoking area, using the provided appropriate ash receptacles. The policy showed the General Manager determines the location of the outside smoking area. The General Manager was responsible to provide proper signage and make sure fire-resistant receptacles were available in the designated area. The policy showed that the Maintenance Director patrolled the smoking area daily to maintain its cleanliness. The policy showed that residents who wished to smoke needed to sign the Resident Smoking Agreement as an appendix in the Resident Agreement. Review of the facility’s Resident Characteristic Roster showed that Resident 5 was identified as a . Review of Resident 5’s records showed that Resident 5 was admitted on /2024. The records showed that Resident 5 was assessed as independent and safe to outside, without staff assistance. The records showed that Resident 5’s representative signed the Policy Agreement, Appendix D, agreeing Resident 5 would in designated areas. The agreement showed Resident 5’s would be kept in the Administrative Offices and available whenever Resident 5 desired to . On 10/22/2024 at 1:25 PM, observation of the facility campus outdoor areas showed no signage that identified any designated smoking areas. Observation showed no areas that contained cigarette or cigar ash receptacles for smokers to utilize. During an interview on 10/22/2024 at 10:40 AM, Staff A (Health Services Director/Administrator), Staff B (Care Director), and Staff I (Life Enrichment Director) all stated that the designated smoking areas were the bus stops across or down the street from the facility building. Staff B stated that Resident 5 was the only . During an interview on 10/25/2024 at 9:47 AM, Staff J, Care Manager 1, stated that Resident 5 kept their and in their apartment. On 10/25/2024 at 11:30 AM, observation of Resident 5’s room showed a wooden box, on This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2630 Compliance Determination # 48873 Plan of Correction Aegis Living Lake Union Completion Date Page 8 of 12 Licensee: Aegis Senior Communities LLC 11/05/2024 top of a dresser. The box contained approximately six and a box of stick matches. During an interview on 10/24/2024 at 2:00 PM, Resident 5 stated that they have their own and in their apartment. Resident 5 stated that they have never been told where to outdoors or given an to put their into. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Aegis Living Lake Union is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date WAC 388-78A-2140 Negotiated service agreement contents. The assisted living facility must develop, and document in the resident's record, the agreed upon plan to address and support each resident's assessed capabilities, needs and preferences, including the following: (1) The care and services necessary to meet the resident's needs, including: (a) The plan to monitor the resident and address interventions for current risks to the resident's health and safety that were identified in one or more of the following: (i) The resident's preadmission assessment; (ii) The resident's full assessments; (iii) On-going assessments of the resident; This requirement was not met as evidenced by: Based on observation, interview and record review, the facility failed to document in 3 of 7 sampled residents’ (Resident 1, Resident 3, and Resident 6) Negotiated Service Agreements (NSA), the care needs and interventions for diagnoses and physician ordered medical treatments. This failure placed Resident 1, Resident 3, and Resident 6 at risk for unmet care needs and potential for worsening medical condition. Findings included… This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2630 Compliance Determination # 48873 Plan of Correction Aegis Living Lake Union Completion Date Page 9 of 12 Licensee: Aegis Senior Communities LLC 11/05/2024 RESIDENT 1 Review of Resident 1’s Face Sheet showed the facility admitted Resident 1 on /2023. Review of Resident 1’s August 2024, September 2024, and October 2024 Medication Administration Record (MAR), showed an order for wound treatment on Resident 1’s left upper chest. Review of Resident 1’s facility nursing progress notes showed Resident 1 had a skin biopsy (procedure that removed a small sample of skin to help diagnose skin conditions, including skin cancer) done at a skilled nursing facility in August 2024. The progress notes showed that the nursing staff cleaned the wound and changed the wound dressing daily. Observation on 10/23/2024 at 11:45 AM, showed Staff O, Wellness Nurse, provided wound treatment on Resident 1’s left upper chest. Observation showed Resident 1’s wound dressing was stained yellow and red caused by drainage of the wound. Staff O cleaned and covered the wound with a new wound dressing. During an interview at this time, Staff O stated that Resident 1’s wound was chronic (ongoing skin wound). Staff O stated that they monitored the wound for any sign and symptom of infection, such as redness, pain, excessive drainage and odor. Review of Resident 1’s Negotiated Service Agreement (NSA), also known as an Individualized Service Plan (ISP), dated 08/07/2024, showed no documentation Resident 1 had a wound and no information about the wound care treatment needed. There were no staff instructions about what actions to take if Resident 1’s wound showed signs and symptoms of infection. RESIDENT 3 Review of Resident 3’s Face sheet showed the facility admitted Resident 3 on /2023. Review showed Resident 3 was ambulatory and required verbal direction and cuing. Review of the facility’s Resident Characteristic Roster showed Resident 3 resided in the facility’s secured memory care unit (Life’s Neighborhood). Observation on 10/24/2024 at 10:10 AM, showed Resident 3 in the facility’s secured memory care unit. Observation showed Resident 3 sat on a couch in the common area of the memory care unit next to their wheelchair. Observation of Resident 3’s room showed a paper sign attached to the door that read “Oxygen in use Caution”. During an interview on 10/24/2024 at 10:12 AM, Staff L, Care Manager 1, stated that Resident 3 used oxygen as needed. Staff L stated that Resident 3 only used a wheelchair to get around. Staff L stated that Resident 3 required care staff assistance to This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2630 Compliance Determination # 48873 Plan of Correction Aegis Living Lake Union Completion Date Page of 12 Licensee: Aegis Senior Communities LLC 11/05/2024 transfer to the wheelchair. During an interview on 10/25/2024 at 10:07 AM, Staff M, Care Manager 2, stated that Resident 3 used oxygen as needed. Staff M stated that the Medication Technician assisted Resident 3 with the oxygen tubing when needed. During an interview on 10/25/2024 at 10:12 AM, Staff N, Med Care Manager, stated that Resident 3 received oxygen when needed. Staff N stated that Resident 3 was on hospice services. Review of Resident 3’s current ISP, dated 09/09/2024, showed that Resident 3 was in the Assisted Living unit, effective 06/02/2024. The ISP showed Resident 3 independently wandered throughout the common areas of the facility and was unaware they lived in an assisted living apartment on the fourth floor. The ISP showed that Resident 3 used a four-wheeled walker for stability while ambulating. There was no documentation that showed Resident 3 used supplemental oxygen therapy. RESIDENT 6 Review of Resident 6’s Face Sheet showed the facility admitted Resident 6 on /2022. During an interview on 10/24/2024 at 10:00 AM, Resident 6 stated that they were independent with their basic care tasks, such as bathing and toileting. Resident 6 stated that they managed their own medications and urostomy care (a surgical procedure that creates an opening in the stomach to allow urine to drain from the kidneys and collect in a bag). Resident 6 stated that they notified the nurse for signs of infection, such as low back pain. Resident 6 stated that they monitored the stoma for redness, pus, or odor. Review of Resident 6’s ISP, dated 09/30/2024, showed documentation Resident 6 had a urostomy and ordered their own supplies. The ISP showed that Resident 6 managed their urostomy care and changed their urine pouch (a sterile container that collects urine). Review of the ISP showed no documentation of an alternative plan in the event Resident 6 was unable to monitor and managed their urostomy care. Review of the ISP showed no documentation that provided the staff with guidance about the possible complications of a urostomy, such as urinary tract infections, blood in urine, or skin irritation around the stoma. During an interview on 10/24/2024 at 3:18 PM, Staff A, Health Services Director, stated that Resident 6 reported any change of their health condition to the staff. Staff A stated that Resident 6’s ISP did not document any safety plan related to possible complications of a urostomy. Plan/Attestation Statement This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2630 Compliance Determination # 48873 Plan of Correction Aegis Living Lake Union Completion Date Page of 12 Licensee: Aegis Senior Communities LLC 11/05/2024 I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Aegis Living Lake Union is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date WAC 388-78A-2305 Food sanitation. The assisted living facility must: (1) Manage food, and maintain any on-site food service facilities in compliance with chapter 246-215 WAC, Food service; This requirement was not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure 1 of 1 kitchen (first floor kitchen) provided staff with proper waste receptacles with covers. The facility failed to ensure 1 of 1 observed kitchen staff practiced proper food handling guidelines when preparing foods. These failures placed all 49 residents at risk of contracting food-borne illnesses. Findings included… Note: Per WAC 246-215-05565, facilities on the premises, operation and maintenance—Covering receptacles (FDA Food Code 5-501.113). Receptacles and waste handling units for refuse, recyclables, and returnables must be kept covered: (1) Inside the food establishment if the receptacles and units: (a) Contain food residue and are not in continuous use; or (b) After they are filled. Note: Per WAC 246-215-02410 Hair restraints—Effectiveness (FDA Food Code 2-402.11). (1) Except as provided in subsection (2) of this section, food employees shall wear short hair or use hair restraints such as hats, hair coverings or nets, rubber bands, or hair clips to keep their hair off the face and behind their shoulders, and clothing that covers body hair to protect exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Review of the facility’s policy titled, “Culinary Staff Hygiene and Illness Policy,” revised 05/06/2024, showed that staff were expected to always maintain proper hygiene. During the general tour on 10/22/2024 at 11:46 AM, observation showed the main kitchen used six uncovered garbage receptacles for waste collection. Observation This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2630 Compliance Determination # 48873 Plan of Correction Aegis Living Lake Union Completion Date Page of 12 Licensee: Aegis Senior Communities LLC 11/05/2024 showed two receptacles contained food waste and four receptacles contained other kitchen waste. During an interview on 10/22/2024 at 1:36 PM, Staff P, Regional Culinary Director, stated that they were called in from another building to assist the culinary department in this facility, as the facility was hiring for the position. Staff P stated that the culinary staff were responsible to empty the kitchen’s garbage regularly throughout the day. Staff P stated that the garbage containers were left open due to constant use. Observation on 10/23/2024 at 2:45 PM, showed an uncovered garbage container was placed close to the dishwashing station. The garbage container was half filled with uneaten food. Observation showed that inside another garbage container, there was food scraps from earlier food preparations. Observation showed four uncovered garbage containers were filled with food cans, paper towels, used gloves, food packaging boxes, and plastics. Observation showed there were no food prep staff in the kitchen. During an interview at this time, an unidentified dishwasher stated that the food in the garbage container was scraped from the resident’s plates. Observation on 10/24/2024 at 3:00 PM, showed six uncovered garbage containers were filled with food scraps and kitchen waste. Observation showed Staff Q, Cook, was in the office corner of the kitchen area. Observation showed an unidentified staff in the food preparation section, sliced brown bread into a baking pan. Observation showed the unidentified staff wore some of their hair pulled back, off their shoulders. Observation showed the unidentified staff had long, loose hair that hung down over their face. During an interview on 10/24/2024 at 3:10 PM, Staff Q stated that there were no lids for the garbage container. Staff Q stated that the brown bread sliced by the unidentified staff was to be served after dinner. Staff Q stated that all the kitchen staff were aware of the requirement to keep all hair tied back and away from their face and foods to prevent possible contamination of foods. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Aegis Living Lake Union is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20425 72nd Avenue S, Suite 400, Kent, WA 98032 11/07/2024 Aegis Senior Communities LLC Aegis Living Lake Union 1936 Eastlake Ave E Seattle, WA 98102 RE: Aegis Living Lake Union # 2630 Dear Administrator: The Department completed a full inspection of your Assisted Living Facility on 11/05/2024 and found that your facility does not meet the Assisted Living Facility requirements. The Department: • Wrote the enclosed report; and • May take licensing enforcement action based on many deficiency listed on the enclosed report; and • May inspect your program to determine if you have corrected all deficiencies; and • Expects all deficiencies to be corrected within the timeframe accepted by the department. You Must: • Begin the process of correcting the deficiency or deficiencies immediately; • Contact the Field Manager for clarifications related to the Statement of Deficiencies (SOD); • Within 10 calendar days after you receive this letter, complete and return the enclosed 'Plan/Attestation Statement'; o Sign and date the enclosed report; o For each deficiency, indicate the date you have or will correct each deficiency; o Mail the Plan/Attestation Statement and report with original signatures to: Laurie Anderson, Field Manager Residential Care Services Region 2, Unit D 20425 72nd Avenue S, Suite 400 This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. Aegis Living Lake Union # 2630 11/05/2024 Page 2 of 4 Kent, WA 98032 • Complete correction(s) within 45 days, or sooner if directed by the Department, after review of your proposed correction dates. • Have your plan approved by the Department. Consultation(s): In addition, the Department provided consultation on the following deficiency or deficiencies not listed on the enclosed report. WAC 388-78A-2730 Licensee's responsibilities. (2) The licensee must: (b) Maintain and post in a size and format that is easily read, in a conspicuous place on the assisted living facility premises: (i) A current assisted living facility license, including any related conditions on the license; The assisted living facility license was not located in a clearly visible area of the facility. During the inspection, facility staff located and posted the current assisted living facility license on the wall, next to the front lobby desk. WAC 388-78A-3030 Toilet rooms and bathrooms. (2) The assisted living facility must provide each toilet room and bathroom with: (e) Provide mechanical ventilation to the outside; and The first-floor community bathroom’s, across from the massage room, fan did not operate to ventilate to the outside. During the inspection, the facility staff repaired the fan to make it operational and ventilate to the outside. WAC 388-78A-3100 Safe storage of supplies and equipment. The assisted living facility must secure potentially hazardous supplies and equipment commensurate with the assessed needs of residents and their functional and cognitive abilities. In determining what supplies and equipment may be accessible to residents, the assisted living facility must consider at a minimum: (2) The degree of hazardousness or toxicity posed by the supplies or equipment; An oxygen container was stored in the third-floor community storage room, next to Apartment 302. There was no signage on the outside of the door that indicated the presence of oxygen in the storage room. During the inspection, facility staff placed a cautionary warning sign indicating the presence of oxygen within the storage room to meet the regulatory requirement. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. Aegis Living Lake Union # 2630 11/05/2024 Page 3 of 4 WAC 388-78A-2150 Signing negotiated service agreement. The assisted living facility must ensure that the negotiated service agreement is agreed to and signed at least annually by: (1) The resident, or the resident's representative if the resident has one and is unable to sign or chooses not to sign; The facility failed to obtain acknowledgment signatures for several resident’s latest and updated Individualized Service Plan (ISP), equivalent to the Negotiated Service Agreement. During the inspection, facility staff obtained signatures acknowledging the current ISP from residents or their representatives, to meet regulatory requirements. You Are Not: • Required to submit a plan of correction for the consultation deficiency or deficiencies stated in this letter and not listed on the enclosed report. You May: • Contact me for clarification of the deficiency or deficiencies found. In Addition, You May: • Request an Informal Dispute Resolution (IDR) review within 10 working days after you receive this letter. Your IDR request must include: o What specific deficiency or deficiencies you disagree with; o Why you disagree with each deficiency; and o Whether you want an IDR to occur in-person, by telephone or as a paper review. o Send your request to: IDR Program Manager Department of Social and Health Services Aging and Long-Term Support Administration Residential Care Services PO Box 45600 Olympia, WA 98504-5600 If You Have Any Questions: • Please contact me at (253)234-6020. Sincerely, Laurie Anderson, Field Manager Region 2, Unit D Residential Care Services This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. Aegis Living Lake Union # 2630 11/05/2024 Page 4 of 4 Enclosure This document was prepared by Residential Care Services for the Locator website.