Aegis of Bellevue

Facility failed to screen and document dementia screening for 6 of 7 sampled residents.

Failed to sanitize utensils and surfaces before use.

Failed to test sanitization solution to ensure correct concentration.

Failed to obtain chest X-rays for 5 staff members who tested positive for TB and failed to follow health care provider recommendations for 1 of them.

Failed to sanitize equipment and utensils correctly.

Failed to ensure staff completed required CPR/first-aid training, CE training, and specialty training for dementia/mental health as required.

Failed to properly thaw frozen beef.

Failed to secure 6 of 6 storage areas (containing hazards) and a housekeeping cart.

Facility failed to screen and document dementia screening for 1 of 1 sampled resident.

Failed to maintain on-site food service in compliance with regulations.

Failed to prevent cross-contamination in the kitchen during dishwashing processes.

Failed to ensure 5 of 5 laundry room ventilation fans were functional.

Facility failed to perform initial 3-day TB testing for 4 staff and failed to perform second-step testing within 1-3 weeks for 4 staff, placing 65 residents at risk.

Laundry room door wedged open; 4th floor laundry door needs adjustment; 2nd floor double doors will not latch.

Monthly 30-second activation testing of emergency lighting not performed and documented.

Carbon Monoxide Alarms and Detectors need to be tested, maintained, and documented on a monthly schedule.

Missing annual inspection schedule and documentation for fire-resistance-rated construction.

Facility needs to establish a schedule for annual inspection of fire doors.

Missing first semi-annual servicing, second semi-annual service, and Heat Test records.

Fire/smoke damper inspection not documented; one damper on 2nd floor not on report.

Missing 3-year dry system full flow trip test, annual forward flow test, quarterly inspections, and 3/26/2024 deficiency report follow-up.

Missing 3-Year Dry System Full flow trip test, Annual forward flow test, Quarterly inspections, and report from 3/26/2024 shows a deficiency.

Facility lacked documented annual schedule and inspection records for fire doors.

O2 tank found out of holder on the 4th floor in Health Services office.

Drills not held at unexpected times/varying conditions; records missing required components.

Missing quarterly servicing documentation for hood/grease-removal system.

Horizontal smoke wall needs to show testing.

Three extension cords in permanent use in the pizza oven area.

Damper on 2nd floor between corridor and activities office not on report; lack of inspection/maintenance documentation.

Safety cable missing between wall and kitchen appliance.

Missing monthly single and multiple station alarms test documentation.

1st floor outside above park structure entrance needs to show path of egress.

Wall penetration found in 1st floor copier room.

Missing annual service report, weekly inspection logs, monthly full load test, and diesel fuel testing for emergency power systems.

Missing semi-annual servicing records; heat test link report from 12/2023 needs update.

Annual 90 minute power test not performed and documented.

Missing receptacle covers and open junction box with exposed wires behind appliances.

2nd floor resident laundry door held open with wedge.

Facility needs to establish a schedule for annual inspection of fire doors.

O2 tank on 4th floor Health Services office was not secured in a holder.

4th floor resident laundry door needs adjustment; 2nd floor double doors by resident 213 will not latch.

Required quarterly servicing documentation not provided.

Safety cable missing between wall and kitchen appliances.

2nd floor has horizontal smoke wall that needs to be tested.

Missing inspection documentation for fire/smoke dampers; specific damper on 2nd floor not on report.

1st floor copier room has penetration found in wall.

Damper on 2nd floor between corridor and activities office not on report; inspection documentation needed.

Missing annual service report, weekly inspection logs, monthly 30-minute full load test, and diesel fuel testing records.

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

Missing documentation for monthly 30-second activation testing.

Facility lacks an established schedule and documentation for annual fire door inspections.

Missing documentation for 3-year Dry System flow test, annual forward flow test, quarterly inspections, and reports showing deficiencies.

1st floor outside above park structure entrance lacks path of egress markings.

Missing documentation for sensitivity testing and monthly single/multiple station alarm tests.

Missing documentation for annual 90-minute power test.

Pizza oven area has 3 extension cords in permanent use.

Carbon monoxide alarms and detectors need to be tested and documented on a monthly schedule.

Missing receptacle cover behind appliance under hood; open junction box with exposed wires behind appliances under hood; missing receptacle cover in director's office.

Missing documentation for first and second semi-annual servicing and heat test links.

The facility failed to ensure a staff member obtained a chest X-ray within seven days following a positive tuberculosis skin test; the X-ray was obtained 11 days after the test.

Facility failed to ensure a staff member completed a one-time TB test upon hire.

Facility failed to maintain a facility-specific emergency and disaster manual with required procedures and information.

Facility failed to implement infection control policies (Respiratory Protection Program/N95 fit testing) for staff.

Facility failed to ensure a staff member maintained a current Nursing Assistant Registered (NAR) certification.

Facility failed to ensure two staff members completed national fingerprint background checks prior to unsupervised contact with residents.

Facility failed to post the most recent full inspection report and stored sensitive information in an accessible area.

Facility failed to implement policy for 46 of 74 staff with direct resident contact and failed to ensure fit testing for required staff.

Facility failed to ensure 4 of 9 sampled residents received medications as prescribed due to availability issues and staff failure to follow up with pharmacy.

Facility failed to ensure 1 of 1 administrative staff completed the second step of the two-step TB skin test.

Laundry room and utility room air exchange vents were not functioning. Storage areas and the garage were littered with debris, construction materials, and stacked furniture, posing safety hazards.

Facility failed to ensure two staff members (General Manager and Care Manager) completed national fingerprint background checks within 120 days of hire.

Housekeeping cart (Cart 1) containing hazardous chemicals was left unlocked and unattended on the second floor while residents walked nearby.

Facility failed to maintain hot foods at or above 135 F and cold foods at or below 41 F; also 4 of 13 dietary staff lacked valid Food Worker Cards.

Facility failed to obtain required Washington state background checks for three contracted staff.

The facility failed to implement their Respiratory Protection Program (RPP) policy for 11 of 46 staff members with direct resident contact, failing to conduct required medical evaluations and respirator fit testing.

Facility failed to ensure residents in memory care had independent access to their own rooms.

Facility failed to ensure a Care Manager (Staff E) completed mandatory facility orientation training.

Facility failed to post weekly menus in advance or provide written menus in common areas for residents.

Facility failed to ensure staff with a positive TB test completed a chest X-ray within seven days and received follow-up evaluation.

The licensee failed to implement their policy for Respiratory Protection Program (RPP) for eleven staff who have direct contact with residents.

The facility failed to complete a Washington state background inquiry for 1 of 8 staff within one day of hire, allowing the staff member to work unsupervised for nine days without a completed background check.