The Arbor at Bremerton

Facility failed to provide paperwork showing fire drills are being conducted once per shift per quarter; no documentation for the last 4 quarters.

Facility failed to provide fire door annual inspection report; West IT room, penetration through electrical conduit, conduit was missing fire blocking.

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

Facility failed to provide annual backflow inspection, annual forward flow test, fire department connection hydrostatic test, and quarterly fire sprinkler inspection reports.

Kitchen suppression system needs to be inspected twice a year; documentation required.

Facility failed to maintain portable fire extinguisher, not secured to wall.

Facility failed to provide annual fire alarm report; fire alarm control panel has sticker showing deficiencies.

Facility failed to provide report showing monthly 30-second activation test of all exit signs and emergency lights.

Facility failed to provide weekly inspections report and monthly 30-minute full load test for the generator.

Fire to laundry room from clean linen room failed to latch.

A facility staff member failed to correctly re-set an exit door alarm, which allowed a resident to exit the facility without staff knowledge. The resident was returned without harm.

The facility failed to ensure that 7 of 16 staff had TB test results recorded appropriately; tests were either not read or read outside the required 48-72 hour window.

The facility failed to ensure initial admission assessments for 4 of 6 sampled residents were performed by a qualified assessor.

The facility failed to ensure staff were able to accurately document medication administration for a resident; medication was not recorded in the system in a timely manner.

Facility failed to conduct fire drills once per shift per quarter for the last 12 months.

Facility failed to provide documentation for three year dry system full flow trip test and annual forward flow test for the backflow.

Facility failed to provide documentation showing semi-annual inspection reports for the kitchen suppression system.

Fire extinguishers are due for their annual inspection.

Facility failed to provide annual report for the fire alarm system.

Facility failed to provide smoke detector sensitivity report.

Facility failed to provide documentations showing carbon monoxide testing and maintenance.

Facility failed to provide documentation showing 30 second monthly activation test of all exit signs or emergency lighting.

Facility failed to provide documentation showing 1.5 hour power test of all exit signs or emergency lighting.

Facility failed to provide annual inspection report, log of weekly inspections, and log of monthly 30 minute full load test for the generator.

Facility failed to provide annual inspection report for all fire doors.

Facility failed to ensure 1 of 3 sampled residents received the correct dietary texture (finger foods) as outlined in their negotiated service agreement.

Unable to provide after-service reports showing two semi-annual kitchen hood cleanings in the past 12 months.

Facility failed to conduct an annual inspection of all fire-resistant-rated construction assemblies and maintain records.

Unable to provide records for annual inspection/testing of fire-rated doors; door to Room 123 missing lever hardware.

Unable to provide documentation for automatic and fusible link fire/smoke damper inspection/testing in the past four years.

Unable to provide 3-year full flow trip test report; seismic clearance in concrete floor requires foam removal.

Unable to provide documentation that deficiencies noted in 9/8/23 annual servicing were corrected.

Unable to provide documentation for monthly load testing of emergency generator for August or September 2023.

Fire alarm circuit breaker missing the approved red identification lock.

Failed to conduct/document 12 planned and unannounced fire drills over the past 12 months; missing specific shift records for multiple quarters.

Facility failed to screen 4 of 4 sampled new staff members for tuberculosis within three days of employment.

Facility failed to close three large bags of flour in the dry pantry, leaving flour exposed to potential contamination.

Facility failed to maintain infection control in the laundry room; clean and soiled laundry were not separated, equipment was dirty, and soiled items were found in machines.

Facility failed to ensure medication carts were locked to secure resident medications for 1 of 2 carts reviewed.

Facility failed to implement safe medication systems. Issues included expired medications in first aid kits, medications not properly dated/labeled (insulin pens), and failure to administer medications as prescribed (R5 blood sugar readings out of parameters).

Facility failed to provide showers for hygiene care, weekly housekeeping, and resident monitoring/supervision for 7 of 10 residents as agreed in the NSA.

Facility failed to close three large bags of flour in the dry pantry, creating risk of contamination.

Failed to ensure smoking area was at least 25 feet away from building openings and failed to ensure fire extinguishers were timely checked and properly mounted.

Facility failed to provide handwashing supplies in 3 rooms, and staff were not fit-tested for N95 respirators as required.

Facility failed to ensure prescribed medications were available for Resident 5, resulting in multiple missed doses for pain and other conditions without proper notification/reordering procedures.

Facility failed to ensure 1 of 4 sampled staff had a current First Aid/CPR card on file.

Failed to secure potentially hazardous supplies (hair care chemicals, disinfectants) in the beauty salon, making them accessible to memory care residents.

Facility failed to post contact information for the state survey agency and ombudsman in required locations.

Facility failed to provide a safe, sanitary, and well-maintained environment, citing odors, unclean equipment/surfaces, and unlocked/damaged rooms.

The facility failed to ensure medication assistants had Nurse Delegated training before administering medications for 4 residents (R2, R3, R5, R7), placing them at risk for serious health consequences.

Facility failed to ensure that the negotiated service agreement (NSA) was signed annually by the resident or their representative for 5 of 7 sampled residents.

Facility failed to maintain and post the most recent survey or inspection results, leaving residents and visitors uninformed.

Facility failed to maintain records for easy access and ensure confidentiality of resident records for 2 of 2 medication carts observed.

Facility lacked adequate, safe storage space in 5 rooms (medication room, back outside resident courtyard, back dining room, maintenance office, and resident laundry room), resulting in hazards.