Aegis of Bellevue

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

Safety cable missing between wall and kitchen appliance.

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

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

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

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

Wall penetration found in 1st floor copier room.

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

Horizontal smoke wall needs to show testing.

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

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

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

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

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

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

Missing monthly single and multiple station alarms test documentation.

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

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

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

Annual 90 minute power test not performed and documented.

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

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

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

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

Safety cable missing between wall and kitchen appliances.

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

Pizza oven area has 3 extension cords in permanent use.

Required quarterly servicing documentation not provided.

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

1st floor copier room has penetration found in wall.

2nd floor resident laundry door held open with wedge.

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

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

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

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

Missing documentation for monthly 30-second activation testing.

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

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

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

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

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

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

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

Missing documentation for annual 90-minute power test.

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

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

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 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 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 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.

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

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

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

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

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

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

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

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

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

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 a Care Manager (Staff E) completed mandatory facility orientation training.

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.

Unable to provide documentation for semi-annual hood cleaning.

Elevator Machine room has penetration around sprinkler head.

Unable to provide inventory record of annual inspection and/or repairs for fire-resistant-rated doors.

Unable to provide documentation for last fire/smoke damper testing.

Unable to provide annual fire sprinkler inspection documentation (backflow and quarterly).

Clean Utility room in Memory care has out of date fire extinguisher (2020).

Unable to provide documentation for testing of CO detectors in the past 12 months.

Missing fire drills for December and January.

Combustible materials stored in the PDR/Mechanical room.

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

Recruiting / Employee Appreciation room has penetration in 4th floor fire door.

Doors failing to latch/close properly: corridor by 401, exit stairwell doors, corridor by activities room, corridor by dining room.

Kitchen missing an escutcheon ring.

Unable to provide semi-annual kitchen suppression service reports; system yellow-tagged due to appliance movement.

Multiple gas fire places lack carbon monoxide detectors in the room or nearby.

Resident room 420 has an unsecured oxygen tank.