Deficiencies per Year
24
18
12
6
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Life Safety
Deficiencies: 24
Mar 20, 2025
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the Aegis of Bellevue residential care facility on 03/20/2025.
Findings
The inspection identified several deficiencies related to fire safety systems, including missing inspection paperwork for sprinkler systems, extinguishing system service, fire/smoke damper inspections, fire door inspections, and emergency lighting tests. Some physical deficiencies were observed such as a damper not on report, penetration in a wall, and doors needing adjustment. Most other fire safety requirements were found to be corrected.
Deficiencies (24)
| Description |
|---|
| Missing paperwork for 3-Year Dry System Full flow trip test, Annual forward flow test, Quarterly inspections, and a report showing a deficiency from 3/26/2024. |
| Missing paperwork for first and second semi-annual servicing of the extinguishing system and heat test report showing links from 12/2023. |
| Missing paperwork for fire/smoke damper inspection and documentation; damper found on 2nd floor between corridor and activities office was not on report. |
| Missing paperwork for annual inspection of fire doors and schedule establishment; physical inspection items such as labels, glazing, door operation, and self-closing device checked. |
| Missing paperwork for sprinkler system tests including 3-Year Dry System Full flow trip test, Annual forward flow test, Quarterly inspections, and a report showing deficiency from 3/26/2024. |
| Missing paperwork for quarterly servicing of grease-removal devices and cleaning. |
| Missing paperwork for annual inspection of fire-rated construction and schedule establishment. |
| Penetration found in wall of 1st floor copier room. |
| 2nd floor resident laundry door held open with wedge. |
| 4th floor resident laundry door needs adjustment; 2nd floor double doors by resident door 213 will not latch. |
| 2nd floor has a horizontal smoke wall that needs to be tested. |
| Missing paperwork for monthly 30-second activation testing of emergency lighting equipment. |
| Missing paperwork for annual 90 minute power test of battery-powered emergency lighting equipment. |
| Missing paperwork for annual service report, log of weekly inspections, monthly 30-minute full load test, and diesel fuel testing for emergency and standby power systems. |
| Missing paperwork for sensitivity testing and monthly single and multiple station alarms test. |
| Missing paperwork for carbon monoxide alarms and detectors testing and maintenance on a monthly schedule. |
| 1st floor outside above park structure entrance will need to show path of egress with exit signs. |
| O2 tank found out of holder on the 4th floor in Health Services office. |
| 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; Life's neighborhood director's office missing receptacle cover. |
| Pizza oven area has 3 extension cords in permanent use. |
| Damper found on 2nd floor between corridor and activities office was not on report. |
| Facility needs to identify and establish a schedule for inspection of fire doors; annual inspection of fire doors will need to be performed and completed. |
| Facility will need to identify and establish a schedule for inspection of fire-rated construction; annual inspection will need to be performed and completed. |
Report Facts
Next inspection scheduled on or after: Apr 21, 2025
Next inspection scheduled on or after: Mar 6, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jim Nicholson | Maintenance Director | Signed as Owner or Authorized Representative on both inspection reports |
| Jason Van Gorkum | Deputy State Fire Marshal | Signed on both inspection reports |
Inspection Report
Life Safety
Deficiencies: 18
Mar 20, 2025
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the facility on 03/20/2025.
Findings
Multiple fire safety code requirements were inspected, with several deficiencies noted primarily related to inspection documentation, fire door inspections, fire/smoke damper inspections, and maintenance/testing of fire safety systems. Most deficiencies were cited due to missing or incomplete paperwork and inspection records.
Deficiencies (18)
| Description |
|---|
| Missing paperwork for 3-Year Dry System Full flow trip test, Annual forward flow test, Quarterly inspections, and a report from 3/26/2024 showing a deficiency. |
| Missing paperwork for first semi-annual servicing, second semi-annual service, and heat test showing links from 12/2023. |
| Damper found on 2nd floor between corridor and activities office was not on report. |
| Facility needs to identify and establish a schedule for inspection of Fire Doors; annual inspection required. |
| Missing paperwork for fire/smoke damper inspection and documentation. |
| Missing paperwork for first and second quarterly servicing, third and fourth quarterly servicing of cleaning systems. |
| Missing paperwork for inspection of fire-rated construction; annual inspection required. |
| Penetration found in 1st floor copier room wall. |
| 2nd floor resident laundry door held open with wedge; 4th floor resident laundry door needs adjustment; 2nd floor double doors by resident door 213 will not latch. |
| 2nd floor has a horizontal smoke wall that needs to show tested documentation. |
| Missing paperwork for 3-Year Dry System Full flow trip test, Annual forward flow test, Quarterly inspections, and a report from 3/26/2024 showing a deficiency. |
| Missing paperwork for first and second semi-annual servicing and heat test showing links from 12/2023. |
| Missing paperwork for sensitivity testing and monthly single and multiple station alarms test. |
| Missing paperwork for Carbon Monoxide Alarms and Detectors testing and maintenance on a monthly schedule. |
| Missing paperwork for monthly 30-second activation testing of emergency lighting equipment. |
| Missing paperwork for annual 90 minute power test of battery-powered emergency lighting equipment. |
| Missing paperwork for annual service report, log of weekly inspections, monthly 30-minute full load test, and diesel fuel testing for emergency and standby power systems. |
| O2 tank found out of holder on the 4th floor in Health Services office. |
Report Facts
Deficiencies cited: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Van Gorkum | Deputy State Fire Marshal | Conducted the inspection and signed the report. |
| Jim Nicholson | Maintenance Director | Named as Owner or Authorized Representative signing the report. |
Inspection Report
Follow-Up
Census: 77
Deficiencies: 1
Jan 16, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to tuberculosis testing compliance.
Findings
The follow-up inspection found no deficiencies, confirming that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiency involved failure to ensure a staff member obtained a chest x-ray within seven days following a positive tuberculosis skin test.
Complaint Details
Complaint investigation regarding staff tuberculosis testing not meeting regulatory requirements. The investigation found a failed provider practice and citation was issued.
Deficiencies (1)
| Description |
|---|
| Failure to ensure a staff person obtained a chest x-ray within seven days following a positive tuberculosis skin test. |
Report Facts
Total residents: 77
Resident sample size: 0
Closed records sample size: 0
Days late for chest x-ray: 11
Staff hired date: Jul 11, 2024
Positive TB test date: Nov 8, 2024
Chest x-ray date: Nov 19, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Yip | ALF Licensor | Investigator and on-site verification staff |
| Laurie Anderson | Field Manager | Signed report and correspondence |
| Staff B Cook | Staff member with positive TB test and late chest x-ray | |
| Staff A | Health Services Director | Interviewed regarding Staff B's late chest x-ray |
Inspection Report
Follow-Up
Census: 79
Deficiencies: 6
Nov 21, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies, indicating the facility meets Assisted Living Facility licensing requirements. The prior deficiencies related to infection control, emergency preparedness, staff qualifications, background checks, tuberculosis testing, and posting of inspection reports were corrected.
Deficiencies (6)
| Description |
|---|
| Failure to implement infection control policies to protect 79 residents from infectious illnesses. |
| Failure to maintain an emergency and disaster manual with required procedures for staff. |
| Failure to ensure 1 of 6 staff maintained current certification prior to providing care. |
| Failure to ensure 2 of 6 staff completed national fingerprint background checks prior to unsupervised contact with residents. |
| Failure to ensure 1 of 6 staff completed tuberculosis testing as required. |
| Failure to post the last Department of Social and Health Services full inspection report in a visible location. |
Report Facts
Residents at risk: 79
Staff with incomplete qualifications: 1
Staff without fingerprint background checks: 2
Staff without tuberculosis testing: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Claudia Allis | ALF Licensor | Department staff who did on-site verification and inspection |
| Michelle Yip | ALF Licensor | Department staff who did on-site verification and inspection |
| Staff A | General Manager | Interviewed regarding facility policies and staff compliance |
| Staff B | Care Manager | Facility staff with incomplete fingerprint background check and tuberculosis testing |
| Staff C | Facility staff with incomplete fingerprint background check | |
| Staff D | Care Manager | Facility staff with expired nursing assistant certification |
Inspection Report
Follow-Up
Census: 78
Deficiencies: 1
Aug 11, 2023
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to licensing laws and regulations.
Findings
The follow-up inspection found no deficiencies, confirming that the facility meets the Assisted Living Facility licensing requirements. Previously cited deficiencies related to background checks were corrected.
Complaint Details
The complaint investigation found that the facility failed to complete a background inquiry for one new employee within one day of hire. This was substantiated with a failed provider practice identified and citation written.
Deficiencies (1)
| Description |
|---|
| Facility failed to conduct a DSHS Washington state name and date of birth background inquiry (BGI) within one day of hire for one staff. |
Report Facts
Total residents: 78
Personnel charts reviewed: 8
Days late for background check submission: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Forkgen | ALF Licensor | Department staff who conducted on-site verification and complaint investigation |
| Steven Garrett | LTC Licensor | Department staff who conducted on-site verification |
Inspection Report
Follow-Up
Census: 78
Deficiencies: 1
Jun 29, 2023
Visit Reason
The Department of Social and Health Services completed a follow-up visit to the assisted living facility to verify correction of previously cited deficiencies.
Findings
The licensee failed to implement their Respiratory Protection Program policy for eleven staff members who have direct contact with residents, placing 78 residents at risk of contracting and spreading a potentially life-threatening disease. This deficiency was previously cited and remains uncorrected.
Deficiencies (1)
| Description |
|---|
| Failure to implement Respiratory Protection Program (RPP) policy for eleven staff with direct resident contact. |
Report Facts
Civil fine amount: 300
Number of staff involved: 11
Resident census at risk: 78
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter regarding the civil fine. |
| Laurie Anderson | Field Manager | Contact person for plan of correction and appeals. |
Inspection Report
Life Safety
Deficiencies: 16
Feb 7, 2023
Visit Reason
An unannounced Fire and Life Safety Code inspection was conducted at Aegis of Bellevue by the Office of the State Fire Marshal to determine compliance with applicable codes.
Findings
The facility was found to have multiple violations including combustible materials stored improperly, missing documentation for cleaning and inspections, malfunctioning doors, missing fire drills, and unsecured oxygen tanks among others. The facility was disapproved due to these deficiencies.
Deficiencies (16)
| Description |
|---|
| PDR/Mechanical room has combustible materials stored in it. |
| Facility unable to provide documentation for semi-annual hood cleaning. |
| Facility unable to provide record of annual fire wall inspection and repairs for fire-resistant-rated construction. |
| Elevator Machine room outside has a penetration around the sprinkler head needing an escutcheon ring or fire rated material. |
| Recruiting / Employee Appreciation room has penetration in its fire door on 4th floor. |
| Facility unable to provide inventory record of annual inspection and/or repairs for all fire-resistant-rated doors. |
| Several doors do not close/latch properly including cross corridor by 401 and exit stairwell doors. |
| Facility unable to provide documentation for last fire/smoke damper testing. |
| Kitchen is missing an escutcheon ring. |
| Facility unable to provide annual fire sprinkler inspection documentation including annual backflow and quarterly inspections. |
| Facility unable to provide service reports showing kitchen suppression system serviced semi-annually in past 12 months; system currently yellow tagged and needs re-piped. |
| Clean Utility room in Memory care has an out of date fire extinguisher (tag shows 2020). |
| Facility has multiple gas fireplaces and no carbon monoxide detectors in rooms or near fireplaces. |
| Facility unable to provide documentation showing testing of CO detectors performed in past 12 months. |
| Resident room 420 has an unsecured oxygen tank. |
| Facility is missing fire drills for December and January. |
Report Facts
Provider Number: 2491
Fire extinguisher tag year: 2020
Resident room number: 420
Missing fire drills: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Stewart | Maintenance Director | Named in signatures and inspection context |
| Cozetta Christian | Deputy State Fire Marshal | Conducted inspection and signed report |
Report
File
R_Aegis_of_Bellevue_Inspection_03-08-2023_-EW.pdf
Loading inspection reports...
