Inspection Reports for Aegis Living Ravenna

The inspection was conducted as an unannounced on-site complaint investigation following the facility's failure of their 4th fire and life safety re-inspection on 2025-04-23.

The facility failed to ensure compliance with the Washington State Patrol Office of State Fire Marshal (OSFM) regulations due to failure of initial and follow-up fire and life safety inspections, placing 65 residents, staff, and visitors at risk. Deficiencies were cited related to lack of documentation for annual fire wall inspection and annual backflow forward flow test.

The complaint investigation was triggered by the facility's failure of their 4th fire and life safety re-inspection on 2025-04-23. The investigation included interviews, observations, and record reviews. The complaint was substantiated with citations issued.

The Office of the State Fire Marshal conducted a fire safety inspection at the facility to assess compliance with fire-resistance construction, sprinkler system maintenance, carbon monoxide detection, power testing, and other fire protection requirements.

The facility was found to be unable to provide documentation for multiple required fire safety inspections and tests, including annual fire wall inspection, annual backflow forward flow test, monthly carbon monoxide detector testing, and annual power tests for emergency lighting. Additional deficiencies include missing documentation for fire drills, sprinkler system inspections, fire extinguisher inspections, smoke alarm testing, and maintenance of emergency power systems.

The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.

The follow-up inspection found no deficiencies and confirmed that the facility meets the Assisted Living Facility licensing requirements. The prior deficiencies related to signing negotiated service agreements and food sanitation were corrected.

The Department completed a follow-up inspection of the Assisted Living Facility on 10/20/2023 to verify correction of previously cited deficiencies.

The follow-up inspection found no deficiencies and confirmed that the facility meets the Assisted Living Facility licensing requirements. The prior deficiencies related to background checks, tuberculosis testing, posting of inspection reports, protection of resident records, and maintenance/housekeeping were corrected.

The Office of the State Fire Marshal conducted an inspection at the facility to assess compliance with fire protection and safety regulations.

The facility was found to have multiple deficiencies related to fire safety, including lack of documentation for fire drills, hood cleaning, fire wall inspections, damper inspections, fire extinguisher accessibility, and emergency system testing. Several fire doors were found propped open, and compressed gas containers were not properly secured.

The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to compliance determinations 22118 and 19223.

The follow-up inspection found no deficiencies, confirming that the facility meets Assisted Living Facility licensing requirements. The prior complaint investigation found a caregiver working with an expired license, resulting in a failed provider practice citation.

The complaint investigation was triggered by allegations that a named resident had multiple bruises of unknown origin. The investigation did not substantiate abuse or neglect but found a caregiver with an expired license, resulting in a failed provider practice citation.

The investigation was conducted due to allegations that a resident was fearful of another resident who exhibited harassment behaviors, including entering the resident's apartment and removing oxygen tubing, and that the facility was not addressing the problem.

The facility provided care according to the assessment and negotiated service agreement but failed to have detailed instructions on the private caregiver for safety after the perpetrator touched the named residents. The investigation substantiated the alleged resident incidents and identified a failed provider practice with citations written.

The complaint investigation substantiated that Resident 1 was fearful of another resident who exhibited harassment behaviors, including removing oxygen tubing and touching other residents. The facility failed to ensure proper safety measures and monitoring of Resident 1's behaviors by private caregivers as required.