Aegis Lodge of Kirkland

This assisted living facility exhibited severe and systemic fire safety violations across three inspections (March, June, September 2025), including multiple fire doors failing to self-close, missing fire-rated doors, unsealed fire barrier penetrations, loaded sprinkler heads in the kitchen, missing carbon monoxide alarms in boiler room, and comprehensive failures to maintain required documentation for fire systems, alarms, sprinklers, emergency generators, and mandatory fire drills. The facility's response was inadequate, as identical violations persisted across all three inspections with no evidence of corrective action—the facility was repeatedly 'Disapproved' and required multiple re-inspections, demonstrating systemic neglect of life-safety systems in a vulnerable population setting. The pattern of non-compliance with critical fire protection measures, combined with failure to conduct required emergency drills, creates substantial risk to resident safety during fire emergencies.

The facility had multiple violations across several regulatory areas including unauthorized apartment conversions without construction review approval (18 apartments affected), incomplete tuberculosis testing protocols for staff (4 staff members), maintenance and safety issues (non-functioning ventilation, unsecured oxygen storage, trip hazards, unlocked hazardous areas), outdated service plans for residents with complex medical needs, expired background checks for 6 staff members, and missing weekly menu postings in memory care. The facility acknowledged the violations and provided correction plans with target dates, but demonstrated a pattern of repeat non-compliance as several deficiencies (room conversions and TB testing) remained uncorrected from a prior April 2025 citation through the June 2025 follow-up, indicating inadequate initial corrective action and monitoring systems. A subsequent August 2025 follow-up confirmed all deficiencies were ultimately corrected.

This document is an Informal Dispute Resolution (IDR) decision letter regarding a Statement of Deficiencies from June 12, 2025, but does not contain the actual inspection findings or violations. The facility disputed citations and participated in the IDR process, demonstrating engagement with the regulatory process. The state upheld the original deficiencies and civil fines after review, and the facility is required to submit correction plans within 10 days and complete corrections within 45 days. Without access to the underlying violations, no event severity can be assessed, but the facility's use of the formal dispute process indicates a procedurally appropriate response to regulatory concerns.

This is an administrative correspondence scheduling an Informal Dispute Resolution (IDR) meeting, not an inspection report detailing violations. The facility is formally disputing a citation under WAC 388-78A-2485 from a June 12, 2025 Statement of Deficiencies that resulted in a civil fine. The facility's response demonstrates appropriate engagement with the regulatory process by requesting an IDR and assembling a management team to address the disputed finding. Without access to the underlying violation details, severity cannot be fully assessed, but the administrative nature of this document suggests routine regulatory dispute procedures rather than immediate safety concerns requiring corrective action beyond the formal appeal process already initiated by the facility's leadership team including General Manager, VP of Regulatory Affairs, VP of Operations, and VP of Clinical Services on July 9, 2025 for a scheduled July 29, 2025 conference call review with state regulators to resolve the disputed citation through established administrative channels per Washington state assisted living facility oversight protocols and dispute resolution procedures managed by the Department of Social and Health Services Residential Care Services IDR Program which provides facilities an opportunity to present additional documentation and argument regarding contested regulatory findings before final enforcement action determinations are made by the licensing authority following full consideration of facility submissions and explanations during the scheduled telephonic dispute resolution conference with appropriate senior facility leadership participation to address the specific regulatory compliance matter at issue under the applicable Washington Administrative Code provision cited in the original deficiency statement that triggered this administrative review process. No specific violation details are provided in this scheduling letter to evaluate event severity or facility corrective response adequacy beyond procedural dispute filing compliance demonstrated by timely IDR request submission within appeal deadlines and coordination of appropriate management personnel for the regulatory conference.

The facility failed to obtain required state approval before altering 18 assisted living apartments, placing 8 current residents at risk, and failed to ensure two staff completed required tuberculosis follow-up testing within mandated timeframes, exposing all 61 residents to potential TB infection. Both violations were repeat offenses previously cited on April 30, 2025, demonstrating a pattern of non-compliance with life-safety and infectious disease protocols. The facility's inadequate response to prior citations resulted in civil fines totaling $800, indicating failure to implement timely corrective actions despite previous regulatory intervention.

This residential care facility has multiple severe life-safety violations including seven malfunctioning fire doors that failed to self-close/latch, missing fire alarm and sprinkler system documentation, non-compliant emergency generator maintenance, inadequate fire drill documentation, missing carbon monoxide alarm in boiler room, unsealed fire-rated wall penetrations, and non-fire-rated door in health services office. The facility's response has been inadequate, as evidenced by identical violations cited in both March and June 2025 inspections with no corrective action taken, resulting in continued 'Disapproved' status. The facility failed to address critical fire protection system deficiencies over a three-month period, demonstrating systemic failure in compliance and resident safety management. The pattern of repeated violations across multiple life-safety systems creates substantial risk of resident harm in fire emergency situations.

A resident was admitted from the hospital without all prescribed medications available from the pharmacy, and was subsequently re-admitted to the hospital three days later with a diagnosis (details redacted). This represents a serious medication management failure with direct resident harm - hospitalization. The facility's response was documented through staff interviews and record reviews, resulting in a citation, but the report does not indicate comprehensive corrective actions beyond the investigation, suggesting an adequate but incomplete response to a severe care failure.

This residential care facility had severe life-safety violations including blocked egress paths, combustible materials in stairwells and electrical rooms, deficient fire protection systems, and extensive missing required inspections and maintenance documentation across 21 code violations. Critical issues included a non-functional CO detector, fire alarm system in trouble status, improperly installed cooking equipment without required hood, loaded sprinkler heads in kitchen, and systematic failure to maintain required records for fire drills, emergency systems testing, and fire-rated construction inspections. The facility's response was minimal, showing no evidence of corrective actions, investigation, or remediation plans at time of inspection, resulting in disapproval status.

The facility had three serious violations: failure to implement proper COVID-19 respiratory protection program (5 staff not fit-tested for N95 respirators during active COVID outbreak), failure to conduct required tuberculosis screening for 4 staff members, and unsafe bed rail creating entrapment risk for a high-risk resident with dementia. The facility responded appropriately by acknowledging all deficiencies, implementing immediate corrections, and achieving full compliance within 60 days as verified by follow-up inspection on 01/31/2024. The systemic nature of infection control failures and safety equipment violations during an active COVID case warranted serious concern, but the facility's comprehensive corrective actions demonstrated good response quality.

The February 2023 inspection identified 16 fire and life safety code violations at this residential care facility, including improper storage clearances near sprinklers, electrical safety issues (blocked panel access, daisy-chained power strips, open junction boxes), compromised fire-rated construction (missing fire doors, unsealed wall penetrations), deficient fire suppression systems (yellow-tagged kitchen suppression system, missing CO alarms), and inadequate maintenance documentation. The facility responded appropriately by correcting all violations within three months, as confirmed by the May 2023 follow-up inspection showing full compliance. While the violations represented systemic maintenance and documentation deficiencies affecting multiple fire safety systems, none posed immediate life-threatening danger, and the facility's timely comprehensive remediation demonstrates a good faith commitment to regulatory compliance.