Ashley Gardens of Bremerton

Sprinkler head loaded with debris in D-side kitchen. Fire alarm does not communicate with monitoring company and facility is on fire watch until fire alarm panel is fixed.

Facility failed to provide documentation showing annual fire door inspection.

Facility failed to provide active food handler’s cards for 4 of 6 sampled staff members.

Facility failed to ensure 2 of 6 staff had TB skin tests completed within three days of employment.

Water temperatures in Cottage D bathroom were measured at 97 degrees, 101.9 degrees, and 93 degrees, failing to meet the required 105-120 degree range. The issue was corrected on-site by maintenance.

Facility failed to investigate or report a resident-to-resident incident where a resident threatened and entered another resident's room.

Facility failed to report an incident of resident-to-resident abuse to the Complaint Resolution Unit.

Facility failed to ensure 2 of 6 staff completed required specialty training and 3 of 6 staff had active CPR/First Aid cards.

Facility failed to ensure the Executive Director (Staff A) completed the required seventy-hour long-term care worker basic training.

Facility failed to maintain exit signs in Building C-D (light #6) and Building A-B (light #5).

Facility failed to provide documentation for annual report, three-year dry system full flow trip test, annual trip test, annual forward flow test, and 20-year sprinkler head sample test.

Facility failed to provide documentation showing monthly, single or multiple station smoke alarm tests.

Storage maintained too high in building A maintenance closet.

Vent fan in building A housekeeping closet had exposed wires; electrical outlet missing plate in building C nurse's office.

Failed to provide documentation of 4-year fire/smoke damper inspection.

Failed to provide documentation for 90-minute power test of exits and emergency lighting.

Facility failed to provide documentation for the automatic sprinkler system including annual inspection, full flow test, annual trip test, five-year backflow testing, five-year fire department connection test, and 2022 quarterly reports.

Facility failed to provide documentation showing annual replacement of fusible links.

Facility failed to provide documentation showing annual inspection report of the fire alarm system.

Facility failed to provide documentation showing 90-minute power test for exits and emergency lighting.

Facility failed to provide documentation showing annual inspection of fire doors.

Facility failed to provide emergency plan binder.

Failed to provide documentation for first and second semi-annual kitchen hood cleaning for 2022.

Failed to provide documentation for annual trip test of automatic sprinkler system.

Failed to provide documentation for annual inspection of fire doors.

Facility failed to provide documentation showing service technician for the kitchen suppression system holds ICC/NAFED certification.

Facility failed to provide documentation showing annual servicing and monthly inspections of portable fire extinguishers.

Facility failed to provide sensitivity testing documentation and nuisance logs for smoke alarms.

Facility failed to provide generator documentation including annual inspection report, weekly inspection log, and monthly full load test log.

Failed to provide documentation showing fire drills were conducted once per shift per quarter for 2022.

Failed to provide documentation showing annual fire wall inspection.

Failed to provide documentation for sensitivity testing for the smoke alarms.

Facility failed to provide documentation of 4 year fire/smoke damper inspection.

Facility failed to provide documentation showing first and second semi-annual servicing of kitchen suppression system for 2022.

Facility failed to provide documentation showing fire alarm technician holds NICET II or ESA/NTS certification.

Facility failed to provide documentation that carbon monoxide alarms are being tested and maintained.

Facility failed to properly secure oxygen tanks in building C; tanks were stacked on boxes and on top of each other.