Woodland Village.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . . 10/4/2024 02:25 PM T0:13609927969 FROM:3607400760 Page: 6 09.30.2024 13:17:63 State of Washington 61 ~· !I i 15: ~n~~ ~~ STATE OF WASHINC::.iON DEPARTMENT OF SOCIAL AND HEALT H SERVICES AGING AND LONG-TERM SUPPm~r ADMINl6TRA1'I0N 800 NE 138th Ave Ste 1.00, Vancouver, WA 98664 sfafornent of bei'tfoieiitiias License iiC2s1 :t . c·ompliai,ce bcformlnatfori # 46629 Plan af corn:1olion Woodland Village C1>mplelion oat~ ••••• .. ••••••• .. •••••••••••••••••·• .. ,, ......... • .. •••••••••••••••••••••••••••• .... •••,••••••••••••••••••••••••••t••• .... • .. •+•"'""'•L..-••·•••z~ .. ••••••••• .. •••ll• .. ·•• .... ••••••+••u••••-... •••1. ......... ,,,.,,.,1,11 You are requirad to be In compliance at aU tlm8s with ~11 llcenslng laws and regLdations to maintain ~our Assisted Living Facility license. The department completed data collection for an unannounced onwsite complaint Investigation on 09/04/2024 and 09/04/2024 of: Woodland Village 2100 SW Woodland Circle Chehalis, WA 98532 This document references the following CQmplaint number(a): 136894 The following sample was selected for r~vlew during the unannounced on-site vie it: 3 of 45 current residents and D former residents. The department staff that investigated the Assisted Living Facmw: Pamela Horlick, NCI RN Complaint Investigator From: DSHS, Aging and Long-Term Support Administration 800 NE 136th Ave Ste 200 Vancouver, WA 98684 As a !'esult of the on-site visit(s), the department found that you are not in cornpliance with the Hcensing law$ and regulations as stated in the cited deficiencies in the enclosed report. 09/30/2024 Date I L1nderstand that to maintain Em Assisted living Facility license. the facility must be in compliance with all tha licensing laws and regulatlons at all times. . 10/4/2024 02:25 PM T0:13609927969 FROM:3607400760 Page: 7 09.30.2024 13:17:53 state or Washington 11 Staternent of Dtificlenc;las License#~2 612 Complfarme Dstermlnutlon # 46629 Plan of Con"E!ctlon Woodland VIiiage Cornpletlon Date Administrator (or Representative) Date WAC 388~78A-2600 Policies and procedures. (1) The assisted livrng facility rn1.1$t devaJop and implement policies and procedures In support of services that are provided and are necessary to: (b} Provide tha necessary care and services for residents, lncludlttg those with speclal needs; (2) The assisted living facility must develop, Implement and train staff persons on policies and procedures to address what staff parsons ml.1st do: (i) To supervise and monitor residents, including accounting for residents who leave tM premises; This requirement was not met aa evldencQd by; m Ba o s n e it d o r o a n r I e n s te id rv e i n e t w a a nd n d n r o e t c if o y r ! t ; h I e re f v a i r e n w ll , y t a h f e te f r a c a u n l t i y l' l f c a ld il a e n d t t o o c i c rn u p rr l e e d m f e o n r t 1 p o o l f ic 3 i e r s e s a id n e d n p ts ro , c ( e R d e u $ r i e d s e n to t 1 l [ ' R e 1 s J ld ). $ n T t h E is lt r r a le l k lu r fo e r p u l~ n c id e e d n R tif 1 i e '$ d f c a a m re ily n ~ e t e r d i s s . k of being unawarEI of a potential injury and placed tt,e Findings includad ... t R h e e c l o ic r e d n r s e e v d ie n w u o rs f e f a a c n il d it y t h p e o l E ic x y f , '; l t c it u l t e lv d e , D "lh ir c e i c d t e o n r t o R f a e n p o u r n t u P s o u li a c r y . o "' c u c n u d rr a e t n e c d e , s in ta v t o a l d vl , n " g P u a r r p e o s s i e d : e n T t o Inform recAivir'lg services in a Village Concepts mMaged community ... An um1sual event ia any u,~expected occurrence lnvolvli1g a r~sldent, which caused and injury or had the potential tor causing E:ln injury ... Procedure: Ttw person that witnesses or hears of an unusual event concerning a resident will complete all aspects of the Unusual Occurrence form and Resident Alert form ... Notify the appropriate people of th~ occurrence (Physician, family/guardian. ED [executive directorJ, RCD [resident care director], CasQ worker) ... Place the resident an alert and any other interventions as directed by the RCD/LN [Litensed Nurse)." Record ·revlaw of facility policy, titled, "Temporary Service Plans & Alert Charting GuideHnes." dated 08/08/2022, showed, "This prooeQL)re outlines the process to address residents addltlona! support due to a change In oortdition, hospltallz:ation, e.tc. outside the negotiations servlc~ plan. Additional $ervices may Include monitoring, AOL assistance, housekeeping, or laundry ~ervices, etc ... The care Director(s) and Executive Directors are responsible for implementing this policy ... These parues are .responsible for ensuring that all involved staff adhere to these policies." Under secti"on, "Alert Charting; General Guidelines," it showed, "Alert Charting Is appropriate under the conditions . 10/4/2024 02:25 PM T0:13609927969 FR0M:3607400760 Page: 8 09.30.2024 13:17:53 State or Washington 81 Statement of Datlciancles License #: 2512 Compliance De11mnlnation # 46629 Plan of Correction W00C!land VIilage Completion Date Page 3 of4 Uc~nsee: Woodland VIiiage Oporations LLC 09/24/2024 outlined in this operating proc:edLffa ... Alert charting is generally ueed ta address conditions that are generally expected to be resolved In 4 days or lass. If mqnftorlng exceeds 4 days, consideration of a TSP should be initiated, or a naw NSA generated accordingly." Review of R 1 's face sheet, dated 11/071.2023 1 showed that R 1 was admitted to the facility·o n /2021. Review of Department Records showed that a report was made on 07/01/2024, tnat showed ~1 had bruising on their right eye, brow, and ey&lid. Record review of facility document titled, ''Unusual Occurrence Report," showed ''Date of Discovery'' was 06/27/2024 at 7:00AM. Under ''Describe what happened" it s1ated, "black aye was noticed tha other day but looks won;;e and spread," Under notifications showed the RCD (Resident Care Director) w~e notified on 06/,29/2024, Execu~lve Dlra.ctor was notified on 06/29/2024, and R 1 's Primary Care F>hysicl~n was notified In person on 06/26/2024. Family W~$ not notified, Document w 06 a / s 3 0 c / o 2 m 02 p 4 le . ted by Staff C, Medl~ion Technician, on 06/29/.2024 1 signed by the RCO and ED on ~ecord review of R 1 's progress note, dated 06/30/2024, showed staff reported a small thin purplish bruise on R1'-S right eye lld on 06/27/2024 at 0700. R1 stated they "didn't know they had a bruise to the eyelid." Staff reported observation to ED and RCD. Staff monitored R1 ori 06/28/2024. Hospice notified and observed residents eye on 06/28/2024 per outside provider note. Family visit 011 06/29/2024 arid was conc~med about the bruising to the right eye, The bruising had Increased In size coveri1ig eyelid and outer edges of right eye. Due to family concerns anci bruise to face, the fine/Ing$ were reported to the Department. There was t'IO previous progress note entries on 06/29/20241 06/28/2024, or 06/27/2024 Indicating that a bruise to the eyelid WEIS observed. Record raview of outside provider notes, dated 06/.28/2024, showed the hospice nurse documented R1 was "noteq to have bruising to right eye and n<, one seemed to know how.11 Record review of document titled, "Temporary Service Plan,'' dated 06/30/2024, 8howed the "Reason for Temporary Service~ or Chang& to NSA." was for "Brulslng of ri·ght eyelid." Start date to monitor was 06/30/2024 through 07/07/1-02.4.

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.