investigation summary report - fortress.wa.gov · investigation summary report provider/facility:...

Residential Care Services Investigation Summary Report

Provider/Facility: THE COTTAGES AT MILL CREEK(688057)

Intake ID(s): 3242545

License/Cert. #: AL1977Investigator: Howard, Kelly Region/Unit: RCS Region 2/Unit B Investigation

Date(s):07/06/201607/21/2016

through

Complainant Contact Date(s): 07/06/2016Allegations:It was alleged the Assisted Living Facility (ALF) staff placed multiple briefs on the named resident to avoid changing her so often.

Investigation Methods:Sample: 5 residents (including the

named resident)Observations: Environment, care

provision, staff toresident interactions,resident to residentinteractions

Interviews: Residents (including thenamed resident), residentrepresentative,Administrator, Director ofOperations, Director ofNursing (DNS),caregivers, maintenancestaff

Record Reviews: Assessments, negotiatedservice agreements(NSA), progress notes,facilityinvestigations/incidentreports, medical records

Allegation Summary:Observation revealed the named resident was wearing a clean, single brief during the investigative visit. When interviewed,caregivers demonstrated following the toileting/personal care directives outlined in the named resident negotiated serviceagreement.

Unalleged Violation(s):The ALF failed to promote the safety of all residents when the ALF did not ensure all exits were adequately secured.

Yes No

of 2


Conclusion /Action:

Failed Provider Practice Identified /Citation(s) Written

Failed Provider Practice Not Identified /No Citation Written

WAC 388-78A-2700(1) Safety measures

of 2





Date(s):07/06/201607/21/2016

through

Complainant Contact Date(s): 07/13/2016Allegations:It was alleged the named resident eloped from the Assisted Living Facility (ALF).






Allegation Summary:Observation, interview and record review revealed the named resident eloped from the ALF on 6/30/16. A caregiver noticed thenamed resident was missing after doing routine checks at 7:15 PM. The caregiver had last seen the named resident at 7 PM. Thenamed resident was located on the property behind the facility. An ALF investigation revealed the named resident exitedthrough the gate from the patio behind his cottage. The gates' alarm had not alerted staff when the resident exited the property.During the investigative visit on 7/6/16, six days after the elopement, observation revealed none of the alarms on the 4 gatessurrounding the property were working. As a result, the ALF failed to promote the safety of all residents when the ALF did notensure all exits were adequately secured.

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Yes No

Conclusion /Action:




Page 2 of 2





Date(s):07/06/201607/21/2016

through

Complainant Contact Date(s):Allegations:It was alleged the named alleged victim (AV) was assaulted by another resident, the named alleged perpetrator (AP).


named residents)Observations: Environment, care


Interviews: Residents (including thenamed residents),resident representative,Administrator, Director ofOperations, Director ofNursing (DNS),caregivers, maintenancestaff


Allegation Summary:Interview and record review revealed the named residents (AV and AP) were roommates at the memory care facility. A caregiverheard a noise from the residents' room. The caregiver found the named AV on the ground with named AP grabbing her wrist. Theresidents were immediately separated and monitored for physical/psychological harm. No injuries or harm were noted. Followingthe incident, the ALF made the appropriate notifications and thoroughly investigated the incident. The named AP, who had noprevious issues with agitation/aggression, was seen by her physician and a behavioral care plan was developed after theincident.

Page 1 of 2



Yes No

Conclusion /Action:




Page 2 of 2





Date(s):07/06/201607/21/2016

through

Complainant Contact Date(s):Allegations:The named resident fell in her bedroom at the Assisted Living Facility (ALF) and sustained a injury.






Allegation Summary:The named resident was admitted to the ALF. Due to the named resident's fall risk, she was checked on hourly at night. Duringone of the checks, a caregiver found the named resident on the floor of her bedroom on. The caregiver noticed swelling aroundthe named resident's right eye and called 911. The resident was transported to the hospital and diagnosed with a injury and contusion. Following the incident, the ALF made the appropriate notifications and thoroughly investigated theincident. The named resident's NSA was updated to include additional fall prevention interventions.


Yes No

Page 1 of 2


Conclusion /Action:




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Date(s):07/06/201607/21/2016

through

Complainant Contact Date(s):Allegations:It was alleged two residents were found hitting at kicking at each other at the Assisted Living Facility (ALF).




Interviews: Residents (including thenamed residents),resident representative,Administrator, Director ofOperations, Director ofNursing (DNS),caregivers, maintenancestaff


Allegation Summary:Interview and record review revealed the named residents were observed hitting and kicking each other. Both residents hadhistories of impulsivity and aggressive behaviors. There behavioral care plans were followed at the time of the incident. Thenamed residents were immediately separated and monitored for physical/psychological harm. No injuries or harm were noted.Following the incident, the ALF made the appropriate notifications and thoroughly investigated the incident.

Unalleged Violation(s):Based on observation, interview, and record review, the facility followed it's policy. No failed practice.

Yes No

Page 1 of 2


Conclusion /Action:




Page 2 of 2





Date(s):07/06/201607/21/2016

through

Complainant Contact Date(s):Allegations:It was alleged the named alleged victim (AV) was assaulted by another resident, the named alleged perpetrator (AP).


named resident)Environment, careprovision, staff toresident interactions,resident to residentinteractions

Observations: Residents (including thenamed resident), residentrepresentative,Administrator, Director ofOperations, Director ofNursing (DNS),caregivers, maintenancestaff



Allegation Summary:Interview and record review revealed the named residents (AV and AP) were roommates at the memory care facility. On12/24/16 at 12 AM, a caregiver heard a noise from the residents' room. The caregiver found the named AV on the ground withnamed AP grabbing her wrist. The residents were immediately separated and monitored for physical/psychological harm. Noinjuries or harm were noted. Following the incident, the ALF made the appropriate notifications and thoroughly investigated theincident. The named AP, who had no previous issues with agitation/aggression, was seen by her physician and a behavioral careplan was developed after the incident.

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Yes No

Conclusion /Action:




Page 2 of 2

Completion DateLicense #: 1977

July 21, 2016

1Page 3of

THE COTTAGES AT MILL CREEK

Statement of Deficiencies

Plan of Correction

STATE OF WASHINGTONDEPARTMENT OF SOCIAL AND HEALTH SERVICES

AGING AND LONG-TERM SUPPORT ADMINISTRATION3906-172nd St NE, Suite #100, Arlington, WA 98223

Licensee: MILL CREEK SPECIAL

From:

DSHS, Aging and Long-Term Support Administration

Residential Care Services, Region 2, Unit A

3906-172nd St NE, Suite #100

Arlington, WA 98223

(360)651-6863

As a result of the on-site complaint investigation 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.

You are required to be in compliance at all times with all licensing laws and regulations to

maintain your assisted living facility license.

Kelly Howard, RN, MSN, Complaint Investigator

I understand that to maintain an assisted living facility license I must be in compliance with all

the licensing laws and regulations at all times.

This document references the following complaint numbers: 3233561 , 3239555 ,

3239515 , 3239623 , 3242545 , 3242890

The department staff that inspected and investigated the assisted living facility:

The department has completed data collection for the unannounced on-site complaint

investigation on 7/6/2016 and 7/7/2016 of:


13200 10TH DRIVE SE

MILL CREEK, WA 98012

The following sample was selected for review during the unannounced on-site complaint

investigation : 6 of 37 current residents and 0 former residents.

Residential Care Services Date

DateAdministrator (or Representative)

Completion DateLicense #: 1977

July 21, 2016

3Page 3of


Statement of Deficiencies

Plan of Correction

Licensee: MILL CREEK SPECIAL

When interviewed, the Maintenance Director stated he was aware that all outdoor gates were

malfunctioning since 6/30/16. He said he contacted two vendors to "get quotes" on costs

associated with fixing the alarms. The Maintenance Director had no documentation of the

communication with the alarm companies and had no time line as to when the alarms would be

repaired.

During the investigation, the ALF's Director of Operations directed the Maintenance Director to

immediately purchase and install alarms for all gates at the facility. A visit to the ALF on

7/7/16 revealed the facility had working alarms on all outdoor gates to immediately alert staff

when the gates were opened.

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 COTTAGES AT

MILL CREEK 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.

I understand that to maintain an assisted living facility license, the facility must be in

compliance with the licensing laws and regulations at all times.

Administrator (or Representative) Date

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