Aegis of Issaquah

Facility failed to manage oxygen therapy for Resident 2; no documentation of actions taken or physician notification when SpO2 readings fell below 92%.

Facility failed to ensure 1 of 6 staff (Staff F) completed required 12 hours of annual continuing education.

Facility failed to complete required Washington State Name and Date of Birth background checks for 2 of 6 staff (Staff E and F) every two years.

Facility failed to ensure Resident 3 received medications with complete dosing directions; Staff applied topical gel without using a measurement device to ensure correct dosage.

Emergency exit gates in memory do not have language on how to exit within 6 feet of exit.

Escutcheon ring is missing on sprinkler head in Fur house near Life Enrichment hallway.

The IT / Electrical room had multiple items blocking electrical panels.

30 second monthly exit and emergency lighting activation test had not been performed.

Facility unable to provide documentation that 4th Quarter 2025 fire drills were performed for all buildings.

Extension cords were used for permanent wiring in the main office near the copier and in Dogwood House Room 411.

Facility states they have no fire dampers.

Monthly testing and maintenance of CO alarms/detectors had not been performed.

90 min annual exit and emergency lighting power test had not been performed.

Facility unable to provide documentation for 5-Year FDC Hydro Testing.

Alder House: Fire extinguisher near Health Director's office missing hose clamp.

Fire/smoke doors propped open with wedges; fire door near room 511 was propped open and coming apart.

Monthly 30-second activation testing not performed and documented.

Facility needs to establish a schedule for inspection of fire-rated construction.

Facility could not provide documentation for 12 planned and unannounced fire drills in the previous 12 months.

Two loose tanks found in kitchen.

Missing annual service report and diesel fuel testing records.

Missing annual fire door inspection documentation; resident doors 310 and 312 would not close and latch.

Annual 90-minute power test not performed and documented.

Missing annual forward flow test report.

Missing documentation for first and second semi-annual hood cleaning.

Missing semi-annual service records; protective covers missing from nozzles; deep fryer nozzle needs adjustment.

Vendor sticker on panel indicated Yellow status; carbon monoxide detection maintenance records not provided.

Annual forward flow test paperwork not provided.

Vendor sticker on panel indicated Yellow status.

Missing semi-annual service documentation; nozzles missing protective covers; fryer nozzle needs adjustment.

Missing documentation for first and second semi-annual hood cleaning.

Annual service report, log of weekly inspections, monthly 30-minute full load test, and diesel fuel testing documentation not provided.

Facility failed to document in 4 of 9 residents' (Resident 1, 4, 8, and 9) Negotiated Service Agreements the care needs and interventions for diagnoses and physician-ordered treatments.

Facility failed to ensure 1 of 6 staff (Staff C) completed required CPR and first aid training.

Facility failed to provide lockable drawers or cabinets in sampled unoccupied resident apartments.

Facility failed to document communication needs and behavioral interventions for a non-English speaking resident with exit-seeking behaviors.

Staff C lacked documentation for required CPR and first aid training.

Facility failed to ensure 2 of 6 staff (Staff A and Staff D) were screened for Tuberculosis as required.

Facility failed to maintain safe hot water temperatures between 105 F and 120 F in 8 of 27 tested sinks.

Facility failed to complete an investigation when a missing controlled medication (Lorazepam) was reported.

Ventilation fans in 6 of 21 laundry rooms and resident bathrooms were non-operational.

Improper working space and clearance in front of electrical service equipment.

Combustible material stored in boiler rooms, mechanical rooms, electrical equipment rooms or in fire command centers.

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

Records of required emergency evacuation drills not properly maintained.

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

Hoods, grease-removal devices, fans, ducts and other appurtenances not cleaned as required.

Improper use of extension cords as a substitute for permanent wiring.

No documentation of annual/semi-annual commercial hood servicing.

Unable to provide records of annual fire wall inspection and/or repairs.

Open junction box/missing cover plate in main building nurse's office.

Unable to provide record of annual fire alarm system inspection.

No documentation for smoke detector sensitivity test report.

Ginko building upstairs storage room smoke detector missing cover.

Large hole in ceiling in Elm building laundry room closet.

Unapproved multi plug adapter found in Birch building upstairs.

Missing annual fire sprinkler inspection documentation (pipe testing, dry system, trip test, etc.).

Heat survey required for commercial hood to determine correct fusible link rating.

Alder building dining room door did not close/latch properly.

Failed to provide automatic backup generator inspection/service report.

The licensee failed to implement their policy on required respiratory protection program for twenty-three staff in alignment with standard infection control practices.