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Page 1: dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · qualifications. Allegation Summary: 1) Prior to fall, Named Resident recognized need to toilet and walked with and without assistive

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Page 2: dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · qualifications. Allegation Summary: 1) Prior to fall, Named Resident recognized need to toilet and walked with and without assistive

Residential Care Services Investigation Summary Report

Provider/Facility: AVALON ADULT FAMILY HOMES LLC(688676)

Intake ID(s): 3630333

License/Cert. #: AF751473Investigator: Whitney, Jo Region/Unit: RCS Region 1/Unit C Investigation

Date(s):04/04/201904/22/2019

through

Complainant Contact Date(s): 04/04/2019Allegations:1) Named Resident was up at night to the bathroom; they lost balance and fell resulting in a fractured pelvis.

Investigation Methods:Sample: six residents in home,

three in investigationsample including NamedResident.

Observations: Home for safety andquality of life, staffresponse to residentneeds, residentindependent and assistedmobility with medicaldevices, incident area.

Interviews: Resident Manager, staff,Collateral contact

Record Reviews: Resident record includingassessment, negotiatedcare plan, medication log,physician notes, hospitalrecords, incident log,employee files forqualifications.

Allegation Summary:1) Prior to fall, Named Resident recognized need to toilet and walked with and without assistive device to bathroom next to theirbedroom per the assessment/negotiated care plan and verified by interview with staff and collateral contact. Named Residentwho preferred privacy, had closed and locked the door, then lost balance and sat on floor. On duty staff responded, made timelyand appropriate notifications for emergency medication evaluation. Accident/incident reporting and documentationrequirements met for incidents reviewed. Staff responsive to resident mobility needs.

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Page 3: dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · qualifications. Allegation Summary: 1) Prior to fall, Named Resident recognized need to toilet and walked with and without assistive

Residential Care Services Investigation Summary Report

Unalleged Violation(s):Investigation in conjunction with reinspection. Staff qualifications did not meet requirements.

Yes No

Conclusion /Action:

Failed Provider Practice Identified /Citation(s) Written

Failed Provider Practice Not Identified /No Citation Written

Statement of deficiencies dated 04/22/19: WAC 388-76-10285 TB testing, WAC 388-76-10176 fingerprint background results.

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Page 4: dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · qualifications. Allegation Summary: 1) Prior to fall, Named Resident recognized need to toilet and walked with and without assistive

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Page 5: dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · qualifications. Allegation Summary: 1) Prior to fall, Named Resident recognized need to toilet and walked with and without assistive

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Page 6: dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · qualifications. Allegation Summary: 1) Prior to fall, Named Resident recognized need to toilet and walked with and without assistive

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Page 7: dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · qualifications. Allegation Summary: 1) Prior to fall, Named Resident recognized need to toilet and walked with and without assistive

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