Aegis of Queen Anne on Galer

One of 5 culinary staff did not have a valid food worker card on file; staff had worked 16 shifts with an expired card.

Facility failed to ensure 1 staff received facility orientation and 1 staff completed required annual 12 hours of continuing education.

Facility failed to ensure 3 of 6 sampled staff completed the required two-step tuberculin skin test after their date of hire.

Combustible materials being stored in main electrical room located in the garage.

Extension cord being used for decoration lighting in room 213 in memory care.

Gas appliances in kitchen need tetherin in accordance with appliance manufacturer's instructions.

Fire/smoke damper report from 10/2/23 by Brimstone shows deficiencies that shall be corrected or proof that deficiencies have been corrected.

Facility failed to provide documentation showing annual 1.5 hour power test for all exit signs and emergency lights.

Double doors by room 406 (right side) and by room 207 in memory care (right side) failed to open when push bar was pressed.

Staff failed to document medication administration on the eMAR, leading to a second staff member administering a double dose of medication to a resident, which required emergency room cardiac monitoring.

Water temperatures in common areas (2nd, 3rd, and 4th floors) were observed between 122.7 F and 127.0 F, exceeding the regulatory limit of 120 F.

Open junction found in room 214 next to bed.

Blocked electrical panels found in kitchen.

Multi plug found on 2nd floor kitchen nook TV.

Missing schedule/paperwork for inspection of fire-rated construction.

Multiple doors failing to latch: room 305, double doors by room 207, double doors entering dining, and back door in kitchen.

Missing records for 3-Year Dry System Full flow trip test and Annual forward flow test.

Blocked fire extinguisher found in parking garage with boxes.

Missing records for Fuel Testing and 4 hour load test of emergency/standby power systems.

Combustible material stored in the electrical room in the parking garage.

Lack of annual inspection documentation for fire-rated construction; no established schedule for inspection.

Issues with firestop systems/penetrations in the electrical room in memory care and the ground floor A/V room.

Quarterly inspection paperwork missing; bent sprinkler head observed between 1st and 2nd floor west stairwell.

Missing documentation for carbon monoxide alarm testing and maintenance.

Fire alarm breaker needs a lock.

Fire/smoke damper 4-year inspection needs to be performed and documented.

Facility failed to ensure NSAs were signed at least annually for 6 of 8 sampled residents.

Facility failed to identify catheter care interventions in the Negotiated Service Agreement (NSA) for one resident, placing them at risk for harm.

Facility failed to ensure 1 of 8 kitchen staff had a valid food handler's permit, placing residents at risk for foodborne illness.

Facility failed to ensure 4 of 4 pets had up-to-date immunizations and were certified free of disease by a veterinarian.

The facility failed to ensure the results of the previous full inspection were accessible and available for residents and visitors to review.

Facility failed to ensure 3 of 6 staff members completed the required two-step tuberculin skin test (TST).

The facility failed to ensure a resident who had a camera in their apartment had an initial evaluation and signed consent as required by regulation.