Aegis of Bellevue.

Residential Care Services Investigation Summary Report Provider/Facility: Aegis of Bellevue Provider Type: Assisted Living Facility License/Cert.#: 2491 Compliance Determination #: 50730 Intake ID: 156489 Investigator: Michelle Yip Region/Unit #: RCS Region 2 / Unit D Investigation Date(s): 11/21/2024 through 11/21/2024 Complainant Contact Date(s): Allegation(s): Staff tuberculosis testing did not meet regulatory requirements Investigation Methods: Sample: Total residents: 77 Resident sample size: 0 Closed records sample size: 0 Observations: Activities Staff to resident interactions Resident to resident interactions Interviews: Business office manager Nursing staff Record Reviews: Personnel files Investigation Summary: During the follow-up inspection, review of the facility's personnel records showed that one staff completed a one-step Tuberculosis test with a positive result. The records showed that the alleged staff completed a chest x-ray with a negative results, 11 days after the positive TB test results. The facility failed to ensure the staff person obtained a chest x-ray within seven days following a positive result to the TB skin test, as required. Failed practice identified. Citation issued. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website.

This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website.

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 July 6, 2023 ELECTRONIC-FACSIMILE Administrator Aegis of Bellevue 148 102nd Ave SE Bellevue, WA 98004 Assisted Living Facility License #2491 Licensee: 102 Ave Bellevue LLC IMPOSITION OF A CIVIL FINE Dear Administrator: On June 29, 2023, the Department of Social and Health Services (DSHS), Residential Care Services completed a follow-up visit at your facility. This letter constitutes formal notice of a civil fine on the license for your assisted living facility, also known as Aegis of Bellevue, located at 148 102nd Ave SE, Bellevue, by the State of Washington, Department of Social and Health Services. These actions are taken under the authority granted pursuant to Laws of 1998, Chapter 272 and RCW 18.20.190. The civil fine on the license is based on the following violation of the RCW and/or WAC as described in the attached Statement of Deficiencies (SOD) report dated June 29, 2023. Civil Fine WAC 388-78A-2730 (1)(a)(b) Licensee's responsibilities. $300.00 The licensee failed to implement their policy for Respiratory Protection Program (RPP) for eleven staff who have direct contact with residents. This failure placed 78 residents at risk of contracting and spreading a potentially life-threatening disease. This is an uncorrected deficiency previously cited on March 08, 2023. NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Administrator Aegis of Bellevue License #2491 July 6, 2023 Page 2 Attestation (Plan of Correction): Return the enclosed SOD within 10 calendar days with the following: • The date you have or will have each deficiency corrected; • A signature and date attesting that you are taking actions to correct and maintain correction for each cited deficiency. Return the signed and dated SOD to: Laurie Anderson, Field Manager Region 2, Unit D 20425 72nd Ave S suite 400 Kent, WA 98032-2388 Phone: (253)234-6020 / Fax: (253) 395-5071 rcsregion2email@dshs.wa.gov Appeal Rights: You have two appeal rights: Informal Dispute Resolution (IDR) and an Administrative Hearing. Each has a different request timeline. Informal Dispute Resolution [RCW 18.20.195] You have an opportunity to challenge the deficiencies and/or enforcement actions through the state's IDR process. All IDR requests must be in writing and include: • The deficiencies you are disputing; and • The method of review you prefer (face-to-face, telephone conference or documentation review). The written request must be received by the 10th working day from receipt of this letter. During the IDR process, you will have the opportunity to present written and/or oral evidence to dispute the deficiencies. Send your written request to: Informal Dispute Resolution Program Manager Residential Care Services PO Box 45600 Olympia, Washington 98504-5600 Administrator Aegis of Bellevue License #2491 July 6, 2023 Page 3 Formal Administrative Hearing You may contest the civil fine by requesting a formal administrative hearing to challenge the deficiency, which resulted in the civil fine. All hearing requests must be in writing and include: • A copy of this letter; and • A copy of the Statement of Deficiencies. The written request must be received within twenty-eight (28) calendar days of receipt of this letter. Send your written request to: Office of Administrative Hearings PO Box 42489 Olympia, Washington 98504-2489 Payment: If you do not request a formal administrative hearing, the civil fine is due to the Office of Financial Recovery twenty-eight (28) calendar days after receipt of this letter. Mail a check for $300.00 payable to the ‘Department of Social and Health Services’, and if you have or have had a Medicaid resident(s), please include your ProviderOne ID Number # on the check, to: DSHS Office of Financial Recovery PO Box 9501 Olympia, Washington 98507-9501 1-800-562-6114 (extension 45919) OFRMMISVendor@dshs.wa.gov If the Office of Financial Recovery has not received your payment within twenty-eight (28) days after receipt of this letter, interest will begin to accrue immediately on the balance, at the rate of one percent per month. If you do not submit a hearing request or make payment within twenty-eight (28) days, the balance due will be recovered. Administrator Aegis of Bellevue License #2491 July 6, 2023 Page 4 If you have any questions, please contact Laurie Anderson, Field Manager, at (253) 234-6020. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 2, Unit D RCS Regional Administrator, Region 2 HCS Regional Administrator, Region 2 DDA Regional Administrator, Region 2 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW JB