Residential Care Services · 2019-06-13 · Provider/Facility: Maple Leaf Assisted Living and Memory Care (947768) Intake ID(s): 3246795 License/Cert. #: AL2364 Investigator: Vanderzee,

Residential Care Services Investigation Summary Report

Provider/Facility: Maple Leaf Assisted Living andMemory Care (947768)

Intake ID(s): 3229743

License/Cert. #: AL2364Investigator: Vanderzee, Betty Region/Unit: RCS Region 2/Unit D Investigation

Date(s):07/26/201607/26/2016

through

Complainant Contact Date(s): 07/20/2016Allegations:Bus driver verbally abusive to resident made residents get off but due to verbal altercation.

Investigation Methods:Sample: 5 residents, 6 staff Observations: Observed care, staff

interaction with residentsInterviews: Staff, residents, others

not associated with thefacilty

Record Reviews: Resident records, staffpersonnel records, facilitypolicies, investigationreports, staffing records.

Allegation Summary:The incident was unable to be verified due to conflicting statements between eye witnesses. No violation of regulation regardingabuse was identified.

Unalleged Violation(s):Violation of regulations regarding care planning and monitoring and care were identified that were unrelated to this complaint.

Yes No

Conclusion /Action:

Failed Provider Practice Identified /Citation(s) Written

Failed Provider Practice Not Identified /No Citation Written

See Statement of deficiency dated 7/26/16.

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Date(s):07/26/201607/26/2016

through

Complainant Contact Date(s): 07/20/2016Allegations:Staff to resident ratios on weekends in memory care unit are too low, which results in care issues. For instance a named residentfell and no nursing staff available, since no care staff delegated to bandage a wound.

Investigation Methods:Sample: 4 residents Observations: Care observations for

residents with skinissues, staffing in facility.

Interviews: Staff, residents, othersnot associated with thefacility.

Record Reviews: Resident records, facilitypolicies, investigationreports.

Allegation Summary:Unable to verify staffing problems. The facility had home health providing wound care for some residents, but failed to obtainwound care in timely manner for all residents sampled, and failed to identify roles of staff and home health on care plans.Violations of regulations regarding monitoring and care, and care planning were identified.

Unalleged Violation(s): Yes No

Conclusion /Action:



See Statement of Deficiency dated 7/26/16.

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Date(s):07/26/201607/26/2016

through

Complainant Contact Date(s): 07/20/2016Allegations:Named resident not allowed in dining room or other common areas with .

Investigation Methods:Sample: 4 residents Observations: Staff caring for residents,

named resident withservice dog.


Record Reviews: Resident records, facilitypolicies, residentcontracts.

Allegation Summary:The named resident's did not meet the definition of a service animal, since he had no special training to handle specificsymptoms. The facility's policy had not changed since the resident's admission to the facility, and they were enforcing theirpolicy. No violation of regulation regarding resident rights was identified.

Unalleged Violation(s):Violation of regulations regarding care planning and monitoring and care were identified for an unrelated issue.

Yes No

Conclusion /Action:




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Date(s):07/26/201607/26/2016

through

Complainant Contact Date(s): 07/20/2016Allegations:Resident has identified by the physician as a for emotional symptoms. The facility is not allowing the intothe common areas.

Investigation Methods:Sample: 4 residents Observations: Staff caring for residents,

named resident with

Interviews: Residents, staff, othersnot associated with thefacility.

Record Reviews: Resident records, facilitypolicies, residentcontracts

Allegation Summary:The named resident's did not meet the definition of a service animal, since he had no special training to handle specificsymptoms. The facility's policy had not changed since the resident's admission to the facility, and they were enforcing theirpolicy. No violation of regulation regarding resident rights was identified.

Unalleged Violation(s):Violation of regulations regarding care planning and monitoring and care were identified for an unrelated issue.

Yes No

Conclusion /Action:



see Statement of Deficiency dated 7/26/16.

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Date(s):07/26/201607/26/2016

through

Complainant Contact Date(s): 07/20/2016Allegations:The facility's elevator was out of service for almost 24 hours.

Investigation Methods:Sample: 4 residents Observations: Observations of care,

elevators functioningwell.


Record Reviews: Resident records, facilitypolicies, records forrepair.

Allegation Summary:The facility had done their best to deal with unpreventable elevator malfunction, obtaining parts and repair in timely manner. Noviolation of regulation identified.

Unalleged Violation(s):Violation of regulations regarding care planning and monitoring and care were identified for an unrelated complaint.

Yes No

Conclusion /Action:




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Completion DateLicense #: 2364

July 26, 2016

2Page 5of

Maple Leaf Assisted Living and Memory Care

Statement of Deficiencies

Plan of Correction

Licensee: CSH Maple Leaf Lessee

WAC 388-78A-2120 Monitoring residents' well-being. The assisted living facility must:

(1) Observe each resident consistent with his or her assessed needs and negotiated service

agreement;(4) Take appropriate action in response to each resident's changing needs.

Based on observation, interview, and record review the facility failed to obtain home health

services in a timely manner for one of three residents reviewed for skin (Resident #1) and failed

to have a system in place to monitor skin conditions for two of three residents reviewed for

impaired skin integrity (Residents #1-2). These failures put residents at risk for continued

impaired skin integrity. Findings include:

Observations, interviews, and record review occurred on 7/26/16 unless otherwise specified.

Note: WAC 388-78A-2410 states, "...Active records must include the following...(9)

Documentation consistent with WAC 388-78A-2120 Monitroing residents' well-being..."

RESIDENT #1:

Resident #1 moved into the facility in of 2011 for care due to multiple disabling

conditions including advanced dementia. Resident #1's most recent service plan, dated 4/13/16,

noted she was nonverbal, and was completely dependent on staff for all mobility and for her

activities of daily living.

Resident #1 was observed lying on her right side in bed, propped with pillows, with her arms

crossed over her chest. Her husband was sitting in a wheelchair at her bedside. When greeted

Resident #1 made no response, and made no voluntary movement while the Investigator was in

the room.

FAILURE TO OBTAIN HOME HEALTH SERVICES TIMELY:

Review of Resident #1's progress notes revealed a note dated 5/24/16 documented, "Resident

identified to have open areas on buttocks...PCP faxed for orders for Home Health to eval for

wound care." Nothing was documented regarding home health services until 6/1/16, (eight days

later) when a progress note documented, "Referral for wound care sent to (named agency)". On

6/6/16, (13 days after the open areas were documented), a progress note stated, "Referral re-sent

to (named agency)." Two days after this, a note documented "Called (named agency) to check

status of referral. Informed they do not accept (Resident #1's) insurance...referral sent to

(another named agency)..." On 6/13/16 a note documented the home health nurse came to see

Resident #1, over three weeks after the open areas were identified by facility staff.

FAILURE TO MONITOR: A facility progress note dated 5/24/16 documented "Resident

identified to have open areas on buttocks." No measurements or descriptions of the open areas

were documented. The next progress note, dated 5/30/16, documented "Staff applying barrier

cream to red area on buttock..." No descriptions of the wound or reddened areas were found in

the facility's documentation. A progress note dated 6/14/16 noted "drg C/D/I (dressing clean,

dry, and intact)." A note 6/22/16 stated "(name of home health agency) completing wound

care."

A temporary service plan dated 5/24/16 for "Redness on bottom" instructed staff to change

This requirement was not met as evidenced by:

Completion DateLicense #: 2364

July 26, 2016

4Page 5of

Maple Leaf Assisted Living and Memory Care

Statement of Deficiencies

Plan of Correction

Licensee: CSH Maple Leaf Lessee

other than a caregiver is to be responsible for providing care or services to the resident in the

assisted living facility, the assisted living facility must specify in the negotiated service

agreement an alternate plan for providing care or service to the resident in the event the

necessary services are not provided. The assisted living facility may develop an alternate plan:(a) Exclusively for the individual resident; or

(b) Based on standard policies and procedures in the assisted living facility provided that they

are consistent with the reasonable accommodation requirements of state and federal law.

Based on observation, interview, and record review the facility failed to identify home health

responsibilities and which facility staff was responsible for skin care for two of three residents

reviewed for impaired skin integrity (Residents #1 and #2). This failure put residents at risk for

lack of care coordination and potential lack of care. Findings include:

Observations, interview, and record review occurred on 7/26/16 unless otherwise specified.

RESIDENT #1:

Resident #1 moved into the facility in of 2011 for care due to multiple disabling

conditions including advanced dementia. Resident #1's most recent service plan, dated 4/13/16,

noted she was nonverbal, and was completely dependent on staff for all mobility and for her

activities of daily living.

Resident #1 was observed lying on her right side in bed, propped with pillows, with her arms

crossed over her chest. Her husband was sitting in a wheelchair at her bedside. When greeted

Resident #1 made no response, and made no voluntary movement while the Investigator was in

the room.

Review of Resident #1's progress notes revealed a note dated 5/24/16 documented, "Resident

identified to have open areas on buttocks...PCP faxed for orders for Home Health to eval for

wound care." On 6/13/16 a note documented the home health nurse came to see Resident #1. A

progress note dated 6/22/16 stated, "(named) home health care agency) completing wound care".

A note dated the next day, 6/23/16, stated the wound care ws being completed twice weekly by

the home health agency. the note stated, "service plan updated."

Review of home health agency nurse's notes in Resident #1's record revealed that Resident #1

was seen by the home health nurse inconsistently. The notes documented she was seen twice the

week of June 12, 2016, three times the week of June 19, once during the week of June 26, twice

during the week of July 3, once during the week of July 10, zero times during the week of July

17, and once during the week of July 24, 2016. There was no documentation of facility staff

providing care when home health agency staff did not come.

When asked for the resident's service plan, facility staff provided two documents: a temporary

service plan (TSP), and a "Resident Service plan." The TSP's start date was 5/24/16 for

"Redness on bottom". The TSP instructed staff to change Resident #1's position every two

hours, and to use barrier cream as needed. The TSP's discontinuation date was documented as

6/23/16. The TSP did not mention dressings for the open areas, monitoring, or include the

home health agency.

This requirement was not met as evidenced by:

Documents

Residential Care Services · 2019-06-13 · Provider/Facility: Maple Leaf Assisted Living and Memory Care (947768) Intake ID(s): 3246795 License/Cert. #: AL2364 Investigator: Vanderzee,