The Arbor at Bremerton.

allegations that Hospice nurse's (not affiliated with facility) husband sexually assaulted the ED as a teenager (more than twenty years prior), and that this allegation "ruined her (hospice nurse's) life". Investigation Methods: Sample: Total residents: Resident sample size: 16 Closed records sample size: Observations: General environment Resident Condition Residents in their rooms Availability of food, supplies, utilities, etc. Food preparation and service areas Interviews: Residents Staff . Record Reviews: Staff TB test records Staff certifications/ credentials Pest control invoice Investigation Summary: 168478 1) Per record review of staff TB (Tuberculosis) skin test records, multiple (7) staff were noted to have either no record of their test results being read, or of the test results being read too soon (as per CDC- Centers for Disease Control and Prevention) protocol, TB test results are to be read between 48 and 72 hours after test administration). This issue was cited as per WAC 388- 78A-2481 (1) Testing Method Required 2) Per complainant, this allegation was related to the facility Executive Director (ED) giving the complainant a nebulizer which the complainant stated was purchased for a resident (not named) using Medicaid funds. No proof was provided to substantiate that the nebulizer had belonged to a resident, or that it had been purchased using funds (state or federal) allocated for that resident's care. Unable to substantiate this allegation. 3) Per complainant, this allegation was regarding the facility ED, who was stated as not being qualified per state regulations to hold the position of executive director at an assisted living facility. The complainant also alleged that one facility med tech (named) was not able to renew their certification due to criminal charges of abuse against a minor. Per record review of staff qualification documentation, there was no indication that the facility ED was not qualified to hold their position. Per record review of the named med tech's certification (Nursing Assistant, Registered) via the state Department of Health website, the med tech's certification was noted to be 'active', with no enforcement action against the med tech noted. 4) Per complainant interview, this allegation was related to rodents being in the facility kitchen and food service areas. Per observation of all food preparation, storage and service areas, during this investigation and during prior recent investigations, there was no indication of the presence of rodents or other pests. Per record review of routine pest control inspection invoice, there were no issues noted regarding rodents or other pests in the facility. Per interviews, staff stated there had been no rodents in the facility. No information available served to support the veracity of this allegation. 5) Per interview with complainant, this allegation was regarding facility staff allegedly sending pictures of resident's pressure ulcers to facility nursing staff for review. There is no evidence to support that this actually happened, as there have been no known reports of pressure ulcers for facility residents, but communication between facility staff for the purpose of providing appropriate care would not constitute a violation of HIPAA statutes. 6) Per observation and/or interviews with multiple residents (16), and per numerous recent visits to the facility, there have been no indications of lack of appropriate care, much less of intentional neglect. The complainant did not provide any further details supporting this allegation during several interviews. No information available served to substantiate this allegation. 7) Per complainant, this allegation stemmed from a former staff member who was terminated for "divulging (resident) information". The complainant stated this . charge was fabricated by the ED, but then stated they did not know if the charge was factual or not. No information available served to support retaliation against facility staff. 8) Per complainant, this allegation was related to the facility ED being reimbursed for purchases made to supplement resident supplies and food items purchased by the ED, and not in relation to actual theft of funds. Per observation of food storage and resident supply (briefs, wipes) storage, and per observation of food preparation, there was no indication of any lack of food or supplies for residents. The complainant stated that the facility's parent company operations manager had investigated financial fraud on the part of the ED, but as the operations manager was out on extended maternity leave, they were not able to be contacted to confirm or deny this allegation. Unable to substantiate allegation. 9) Per interview and observation of the named resident, and per prior interactions with this resident, there was no indication of any drastic weight loss. The resident was observed to be at normal weight, and per interview stated they have had no issues with food or care provided at the facility. 10) Per staff interview, and per record review of the named resident's progress notes, there was no indication of any unattended abdominal or gastrointestinal issues. The resident was noted to have experienced a fall leading to femur fracture, and after hospitalization the resident's family decided to decline surgical repair of the resident's femur and elected to have the resident placed on comfort measures/ hospice care only. No information available served to support the veracity of this allegation. 11) Per record review of all resident medication administration records (72) for two months (January/ February 2025), there was no instance noted of the facility ED administering medications. No other information served to support this allegation. 12) Per observation, no expired medications found in facility medication cart. Record review of Medication Destruction Forms supported that licensed nursing staff do oversee appropriate disposal of expired or unneeded (discharged or deceased residents) medications. 13) Per record review of the named resident's medication administration record, the resident is receiving ordered breathing treatments administered by staff twice daily. No information available served to support the veracity of this allegation. 14) It is unclear why this allegation was made, as it has nothing to do with the facility, involves people (hospice nurse and their spouse) who have no association with the facility, and regards an allegation outside the purview of the department and which allegedly occurred approximately twenty (or more) years ago. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Statement of Deficiencies License #: 2619 Compliance Determination # 55949 Plan of Correction The Arbor at Bremerton Completion Date As a result of the on-site visit(s), the department found that you are not in compliance with the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. I understand that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. Administrator (or Representative) Date WAC 388-78A-2481 Tuberculosis Testing method Required. The assisted living facility must ensure that all tuberculosis testing is done through either: (1) Intradermal (Mantoux) administration with test results read: This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure that 7 of 16 Staff (Staff B, C, F, J, K, O and P) had the results of their TB (tuberculosis, a communicable disease) tests recorded appropriately to ensure compliance with testing requirements. This failure placed 36 of 36 facility residents at risk of harm related to potential transmission of disease (TB). During record review on 03/07/2025 at 3:05pm of Staff B’s TB testing records, it was noted that there was no indication of the results of the TB test for Staff B, Caregiver, being read/observed as required. During record review on 03/07/2025 at 3:05pm of Staff C’s TB testing records, it was noted that there was no indication of the results of the TB test for Staff C, Caregiver, being read/observed as required. During record review on 03/07/2025 at 3:05pm of Staff F’s TB testing records, it was noted that there was no indication of the results of the TB test for Staff F, Caregiver, being read/observed as required. During record review on 03/07/2025 at 3:05pm of Staff J’s TB testing records, it was noted that there was no indication of the results of the TB test for Staff J, Caregiver, being read/observed as required. .

Conclusion/ Action: ~ Failed Provider Practice Identified/ Citation(s) Written D Failed Provider Practice Not Identified / No Citation Written □ N/A . Investigation Summary Report Provider/Facility: The Arbor at Bremerton Provider Type: Assisted Living Facility License/Cert.#: 2619 Intake ID: 167053 Compliance Determination #: 54035 Region/Unit#: RCS Region 3 J Unit o Investigator: Michael Goulet Investigation Date(s): 01/30/2025 through 03/13/2025 Complainant Contact Date(s): 02/19/2025, 03/13/2025 Allegation(s): 1) Facility med tech stated to complainant that there had been no med tech on duty on the night/ morning that the named resident passed away (2/10/25), leading to the resident not being administered medication during this time. Investigation Methods: Sample: Total residents: 37 Resident sample size: 37 Closed records sample size: 1 Observations: General environment Interviews: Staff Record Reviews: Medication Administration Record Narcotics Log Staff Time Card records Facility Staffing Schedule Investigation Summary: 1) Per interview, the facility med tech who was stated by the complainant as admitting to there not being a med tech on duty the night the named resident passed denied having made any such statement. Per facility director interview, the med tech on duty that morning (2/10/25) at the facility's sister facility next door (Arbor Assisted Living) did cover the named resident's medication pass at 2:00am. This was recorded in the narcotics logbook, but was not recorded in the medication administration record as the med tech administering the medications did not have access to this facility's computer system. Per record review of the medication administration record (MAR), it was noted that the medications administered (Lorazepam, Oxycodone) to the named resident at 2:00am were signed off as 'out of parameters' (which would mean they were not administered) by the oncoming day shift med tech (the same med tech referred to by the complainant). Record review of the facility staff timecard records showed that this med tech was not on duty until approximately 6:00am on 2/10/25. The facility failed to ensure that the med tech covering for the named resident's medications was able to notate the . administration of these medications in the facility MAR, leading to the notation of the medication administration as being 'out of parameters' by a med tech who was not in the facility at the time of the actual administration. While no missed administration of medication or harm was substantiated, this failure to note the actuality of the resident's medication administration had the potential to lead to significant harm for the resident. Cited as per WAC 388-78A-2210 (1 b) Medication Services Conclusion/ Action: ~ Failed Provider Practice Identified/ Citation(s) Written D Failed Provider Practice Not Identified / No Citation Written □ N/A . 03/20/2025 THU 13,20 FAX The Arbor ~t Bremerton (i]J004/006 03, 18,2025 15:41 d6 State or IJashlngton 6/1 ::lletcment of Deflclc:ncle3 Lice1ue #: 201 ll Compliance Determinl'lllan # 540:JG Pl·Eln of Correction The Arbor at ~remerlon camplelia,1 Datw As a result of tl11, 011•site visit(s), tile dapartrm,mt found that you ara not in t:0rnpliam;1,1 with tt11,1 licensing laws and regulations as stated in the cited deficiencies in the enclosed report. y,t,.:-_·;.i,)"-A,.~::~), Resid-:-e-n"'"tia...,.l""C,-are Services Date I understand that to maintain an Assisted Living Facility license, the facility mw;t be in compliance with all the licensing laws and regulations at all times, WAC 388-78A-2080 Qualified assessor. The assisted living facility must ensure the person respon!fibl111 for completing a preadmlsslon assessment of a prospective resident: (1) Has a master's degree in social services, human services, behavioral sciences or an allied field and two years social service experience working with ad1.1lts who have functional or cognitive disabilities; or (2) Has a bachelor's degree in social services, h1.1man services, behavioral sciences, or an allied field and three years social service experience working with adults who have functional or cognitive dlsabllltles: or (~) Ha~ tt valid Wa::;hinglun ::;lal1:1 lic;i:,n~c lv pn~-;lh;;,:i nur~ing, in <1c;c;vrciarn:;e vvill1 c;l·,aple,r,; 16.79 RCW and 246-840 WAC; or (4) Is a physician with a valid state license to practice medicine; or (5) Has three years of successful experience acquired prior to September 1, 2004, assessing prospeotive and ourrent assl!lted living faclllty residents In a setting lloensed by a state agency for the care of vulnerable adults, such as a nursing home, assisted living facility, or adult family home, or a setting having a contract with a recognized social service agency for the provision of care to vulnerable adults, such as supported living. This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure that resident assessments were performed by a qualified assessor for 4 of 6 sampled residents (Residents 3, 4, 5, & 6 [R3, 4, 5, & 6]). This failure placed these residents at rlsK of not having their needs adequately met and addressed by the facility staff. Findings ir1cluded .. , . 03/20/2025 THU 13,20 FAX The Arbor ~t Bremerton (i]J005/006 03,18,2025 15,41 ,16 state of I.Jashlngton 7/1 Statement of DeflaienciC'it' ... , Licenae #: 2019 Compliance Determination'# :l4030 Pl.an of Correction The Arbor at Bremerton Completion Dale Record review on 03/07/2025 at 3:05pm of the An1:11>sment History Records for all facility residents showed that four facility residents (R3 ,4, 5, & 6) had their initial admission assessments provided by Staff A, Executive Director. During an interview on 03/12/2025 at 1 :20pm, Staff A stated that they had initially been directed by senior management staff to provide assessments for residents on admission to the facility, but that later they (Staff A) were informed by Staff D, the facility's parent company's regional licensed nurse, that they were not qualified to perform resident assessments, and to discontinue assessments for residents. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, The f' 0bor at Bremerton Is or WIii be in compliance with thi11 law and/ or regulatio!'1 on (Datei) /1 , ,.. . 'IL? In addlUon, I will implement a system to monitor and ensure continued compliance with this requirement. )YV\1\/\V \/\ ;vvJ _illo 12.5 Administrator (or Repreientitive) Date WAC 388-78A-2210 Medication services. (1) An assisted living faclllty providing medication service, either directly or indirectly, must: (b) Develop and implement systems that support and promote s,1fa medication service for each resident. This requirement w.11s not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure facility medication technician (med tech) staff were able to accurately document medication administration e for 1 of facility residents (Resident1 [R 1) ) . This failure placed Resident 1 at risk of not receiving adequate or safe administration of medications as the resident's administration of narcotic medications was not able to be accurately noted in the facility medication administration system. Findings included ... Record review on 02/19/2025 at 2:00pm of the February 2025 Medication Administration .Record (MAR) for Resident 1 showed that Staff B, facility Mad Tech, had noted the administration of narcotic medications (Oxycodone, pain medication, and . 03/20/2025 THU 13,21 FAX The Arbor at Bremerton (i]JOOS/006 03, 18,2025 15:41 :16 state of Washington 8/l Statement of Deflcle:ncles LlceMe #: 201 8 Compliance Determi11atlo11 # 54O3G Pl.an of Correction The Arbor at Bremerton Completion Date Lorazepam, anti-anxiety medication) scheduled to be given at 2:00am on 02/10/2025 as 'out of parameters.,' meaning the medications were not administered. Record review on 03/12/2025 at 2:30pm of facility tlmecard logs for February 2025 showed that Staff B was not at the facility until 6:07am on 02/10/2025. During an I ntervlew on 03/06/2025 at 11 :20am, Staff A, facility Executive Direc.1:or, stated that Staff C; Med Tech, from the facility's sister facility next door (Arbor Assis.led Living) had actually administered the scheduled medications to R1 at 2:00am on 02/10/2025, but Staff C was not able to entGr the documentation of this administration into the facility Medication Administration Record (MAR) due to not having access to the facilitll's computer system. Staff A stated that because of Staff C's lack of access to the computer-based MAR, that Staff B had entered the Information Into the system when they arrived at the facility later that morning (appraximately6:00am on 02/10/2025) but that this administration was entered as 'out of parameters' due to the time lapse between the times of administration and data entry, making it appear that the medication was not actually administered.

findings. Based on interview and record review there was insufficient evidence to support failed practice. No failed practice identified. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION Statement of Deficiencies License #: 2619 Compliance Determination # 50019 Plan of Correction The Arbor at Bremerton Completion Date You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for an unannounced on-site complaint investigation on 11/08/2024 and 11/08/2024 of: The Arbor at Bremerton 3510 9th Street Bremerton, WA 98312 This document references the following complaint number(s): 154180, 155015 The following sample was selected for review during the unannounced on-site visit: 3 of 42 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Nikolas Jennings, Community Nurse Complaint Investigator From: DSHS, Aging and Long-Term Support Administration Lakewood, WA 98496 As a result of the on-site visit(s), the department found that you are not in compliance with the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. I understand that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. . Statement of Deficiencies License #: 2619 Compliance Determination # 50019 Plan of Correction The Arbor at Bremerton Completion Date Administrator (or Representative) Date WAC 388-78A-2160 Implementation of negotiated service agreement. The assisted living facility must provide the care and services as agreed upon in the negotiated service agreement to each resident unless a deviation from the negotiated service agreement is mutually agreed upon between the assisted living facility and the resident or the resident's representative at the time the care or services are scheduled. This requirement was not met as evidenced by: Based on interviews, observation and records review the facility failed to ensure 1 of 3 sampled residents (Resident 1 [R1]) was provided the correct dietary texture. This failure resulted in the risk of dietary complications including weight loss and potential aspiration. Findings included… Record review of the Negotiated Service Agreement (NSA), undated, for R1 showed that R1 required the dietary texture of finger foods with an intervention revision date of 08/07/2024. On 11/08/2024 at 12:34PM R1 observed eating corn and a ground beef on their plate with a spoon by themselves while staff members were in the area and not assisting them. On 11/08/2024 at 1:16PM observation of the serving area noted a paper on the wall labeled “Diet type report” with R1’s name highlighted along with the diet texture of “finger foods.” On 11/08/2024 at 12:55PM in an interview with Staff A, Medication Technician, Staff A stated, “It’s harder if the kitchen isn’t meeting our dietary needs which happens frequently. R1 is on finger foods and often finger foods is not an option that are provided from the kitchen.” On 11/08/2024 at 2:17PM in an interview with Staff B, Executive Director, stated that the kitchen, care staff, and server should all check to ensure that the resident is getting the correct foods. . Statement of Deficiencies License #: 2619 Compliance Determination # 50019 Plan of Correction The Arbor at Bremerton Completion Date Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, The Arbor at Bremerton is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date . STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 12/05/2024 Bremerton SCC LLC The Arbor at Bremerton 3510 9th Street Bremerton, WA 98312 RE: The Arbor at Bremerton # 2619 Dear Administrator: The Department completed a complaint investigation of your Assisted Living Facility on 12/04/2024 and found that your facility does not meet the Assisted Living Facility requirements. The Department: • Wrote the enclosed report; and • May take licensing enforcement action based on any deficiency listed on the enclosed report; and • May inspect the facility to determine if you have corrected all deficiencies; and • Expects all deficiencies to be corrected within the timeframe accepted by the department. You Must: • Begin the process of correcting the deficiency or deficiencies immediately; • Contact the Field Manager for clarifications related to the Statement of Deficiencies (SOD); • Within 10 calendar days after you receive this letter, complete and return the enclosed 'Plan/Attestation Statement'; o Sign and date the enclosed report; o For each deficiency, indicate the date you have or will correct each deficiency; o Next to each deficiency, sign and date certifying that you have or will correct each cited deficiency; and o Mail the Plan/Attestation Statement and report with original signatures to: Manfay Chan, Field Manager . The Arbor at Bremerton # 2619 12/04/2024 Region 3, Unit D Lakewood, WA 98496 • Complete correction(s) within 45 days, or sooner if directed by the Department, after review of your proposed correction dates. • Have your plan approved by the Department. Consultation(s): In addition, the Department provided consultation on the following deficiency or deficiencies not listed on the enclosed report. WAC 388-78A-2930 Communication system. (1) The assisted living facility must: (a) Provide residents and staff persons with the means to summon on-duty staff assistance from all resident-accessible areas including: (i) Bathrooms and toilet rooms; (ii) Resident living rooms and resident sleeping rooms; and (iii) Corridors, as well as common and outdoor areas accessible to residents. Facility call bell system was not adequately notifying on duty staff of when a call light was being used. Facility management was already aware of the issue and had already purchased additional pagers from their vendor to ensure that staff had pagers available along with the management staff. Receipt was provided for pagers purchased. This deficiency was corrected on-site at the time of visit. Consultation provided. You Are Not: • Required to submit a plan of correction for the consultation deficiency or deficiencies stated in this letter and not listed on the enclosed report. You May: • Contact me for clarification of the deficiency or deficiencies found. In Addition, You May: • Request an Informal Dispute Resolution (IDR) review within 10 working days after you receive this letter. Your IDR request must include: o What specific deficiency or deficiencies you disagree with; o Why you disagree with each deficiency; and o Whether you want an IDR to occur in-person, by telephone or as a paper review. o Send your request to: IDR Program Manager Department of Social and Health Services . The Arbor at Bremerton # 2619 12/04/2024 Olympia, WA 98504-5600 If You Have Any Questions: • Please contact me at (253)442-3013. Sincerely, Manfay Chan, Field Manager Region 3, Unit D Enclosure .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A .

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . . . .