Woodland West Homes III

Type of visit: Required - 1 Year

At approximately 8:50 a.m. on 10/09/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and disclosed the reason for the visit. The facility was last visited on 08/23/24 for an annual inspection. It is a single story building with seven (07) bedrooms, three (03) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents. The facility serves residents with dementia. Approved hospice waivers for six (06). Surveillance cameras are located in common and exterior areas. The front driveway was gated and unlocked. Shaded seating was available at the front along with gardened areas. A ramp which led up to the front entrance was in good condition. Inside the main entrance, LPA observed postings for facility sketch, administrator certificate, a blank copy of the admission agreement, emergency disaster plan, rights of resident councils, personal rights, COVID precautions, confidential complaint contacts, and ombudsman contacts. A screening station contained a visitor log and hand sanitizer. Walls, floors, windows, screens, and blinds were clean and in good repair. At 9:00 a.m. LPA measured the room temperature to be 72 degrees Fahrenheit. A resident was observed in the living room watching television. The living room also contained furniture in good condition, board games, reading materials, and exercise equipment. Night lights were present in hallways. Two (02) hallway closets contained adequate supplies of fresh linens and hygiene supplies. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen and the garage. The stove and the hood were clean. Appliances were in good condition. Sharps were locked below the counter top. Cleaning solutions were locked in the laundry area and in a locked chest outside. Medications and confidential files were locked in the office area. At approximately 9:20 a.m., LPA and staff conducted a medication review. All medications were maintained in the proper quantities. A washing machine and dryer were located near the kitchen. Both were in working order. At 9:35 a.m. LPA observed three (03) fully charged fire extinguishers throughout the home. All were last inspected on 06/04/25 with tags attached. The facility has seven (07) bedrooms. One (01) bedroom is designated as a staff room. The staff room was free of hazards. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. All beds with wheels were in the locked position. The facility has three (03) bathrooms. One (01) bathroom is private and two (02) are shared. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, commodes, and a non-skid mat in the shower. At approximately 9:45 a.m. LPA measured the water temperature in the front, shared bathroom to be 118.8 degrees Fahrenheit. LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition. The back yard was maintained and contained gardened areas and a locked storage shed. Two (02) out of two (02) emergency exit paths were free from obstructions. Exit gates were unlocked with self-closing latches. At approximately 9:50 a.m., smoke and carbon monoxide detectors were tested and operational. At 9:55 a.m. the house telephone was called and deemed functional. The garage was accessible and contained extra supplies and perishable food. At 10:15 a.m. LPA conducted a records review of resident and personnel files. All files were complete and available for audit. No immediate health and safety risks were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Oct 9, 2025

Type of visit: Required - 1 Year

At approximately 9:05 a.m. on 08/23/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and disclosed the reason for the visit. The facility was last visited on 03/22/23 for a complaint visit. It is a single story building with seven (07) bedrooms, three (03) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents. The facility serves residents with dementia. Approved hospice waivers for six (06). Surveillance cameras are located in common and exterior areas. The front driveway was gated and unlocked. Shaded seating was available at the front. A ramp in good condition led up to the front entrance. Inside main entrance, LPA observed postings for facility sketch, administrator certificate, emergency disaster plan, rights of resident councils, COVID precautions, confidential complaint contacts, ombudsman contacts, and signs stating “No Smoking – Oxygen in use”. A screening station contained a visitor log and sanitizer. Walls, floors, windows, screens, and blinds were clean and in good repair. At 9:15 a.m. LPA measured the room temperature to be 76 degrees Fahrenheit. Two (02) residents were observed in the living room watching television. The living room also contained furniture in good condition. Night lights were present in hallways. Two (02) hallway closets contained adequate supplies of fresh linens and extra hygiene supplies. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen and the garage. The stove and the hood were clean. Appliances were in good condition. Sharps were locked below the counter top. Cleaning solutions were locked in the laundry area. Medications and confidential files were locked in the office area. A washing machine and dryer were located near the kitchen. Both were in working order. At 9:35 a.m. LPA observed three (03) fully charged fire extinguishers throughout the home. All were last inspected on 06/04/24. The facility has seven (07) bedrooms. One (01) bedroom is designated as a staff room. The staff room was occupied and free of hazards. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. The facility has three (03) bathrooms. One (01) bathroom is private and two (02) are shared. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, commodes, and a non-skid mat in the shower. At approximately 9:50 a.m. LPA measured the water temperature in the front, shared bathroom to be 107.2 degrees Fahrenheit. LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition. The back yard was maintained and contained gardened areas and a locked storage shed. Two (02) out of two (02) emergency exit paths were free from obstructions. Exit gates were unlocked with self-closing latches. Auditory alarms were functioning. At approximately 10:10 a.m., smoke and carbon monoxide detectors were tested and operational. At 10:20 a.m. the house telephone was called and deemed functional. The garage was accessible and contained extra supplies and perishable food. At 10:30 a.m. LPA conducted a records review of resident and personnel files. All files were complete and available for audit. During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Aug 23, 2024

Allegation investigated: Resident sustained an unexplained bruise while in care Staff are pinching residents Staff did not notify residents authorized representatives of residents new medical concerns Staff yells at residents Staff sleep during their shift in the day

At 8:45 a.m. on 01/03/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with Administrator and disclosed the reason for the visit. To investigate the allegations above, LPA Martinez conducted an initial visit at 10:45 a.m. on 12/01/22 and interviewed five (05) out of five (05) residents and two (02) staff members between 10:45 a.m. and 1:00 p.m. Today, LPA Reed interviewed six (06) out of six (06) residents and four (04) staff members between 9:00 a.m. and 11:00 a.m., toured the facility at 09:15 a.m., and conducted a record review at 11:15 a.m. Regarding the allegation “Resident sustained an unexplained bruise while in care“ it was alleged staff had different explanations of a bruise on the index finger of Resident #1 (R1). It was also suspected that R1’s bruising resulted from having their finger slammed in a door. Unsubstantiated From LPA Martinez’ interview with the administrator, the facility was aware of R1’s bruising but not aware of the cause. R1 sustained bruises frequently due to bumping into furniture. LPA Reed’s interviews with Staff #1 (S1) at 10:10 a.m. and Staff #2 (S2) at 10:45 a.m. revealed no information about R1’s bruising but did confirm that R1 was aggressive with staff and bumped into objects in the house. Neither staff recalled R1 having their fingers slammed in a door. S1, S2, and Staff #3 (S3) who was interviewed at 9:15 a.m. today revealed that residents are observed for any physical changes or bruising every morning when dressing and showering. No residents interviewed reported any bruises or seeing bruises on other residents. Based on interviews, no staff or residents knew of causes for R1’s bruising, and nobody recalled R1 slamming their finger in a door. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff are pinching residents“ it was alleged that residents reported a staff member pinching them. LPA Martinez’ interview with the administrator revealed staff had not pinched residents and no residents reported being pinched by staff. Four (04) out of four (04) staff and all residents interviewed today revealed staff did not pinch residents. LPA did not observe any pinching during today’s visit. Based on interviews and observations, staff are not pinching residents. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff did not notify residents authorized representatives of residents new medical concerns“ it was alleged R1 had redness on their chest and face that were not reported to R1’s representatives. Record review revealed R1’s emergency information form showed Visitor #1 (V1) as their person responsible for financial affairs and Visitor #2 (V2) and Visitor #3 (V3) to be notified in an emergency. R1 had a history of breast cancer noted on their preplacement appraisal. LPA Martinez’ interview with the administrator revealed R1 had redness on their face prior to their admission. Therefore, the administrator assumed R1’s representatives already knew about the facial redness and history of breast cancer. The administrator reported R1’s facial redness to V2. S1 reported R1’s redness on their face and chest directly to V3. The facility treated R1’s face with Neosporin and V3 took R1 to urgent care. The administrator called 9-1-1 for R1’s chest redness and assisted R1 and V2 in getting to the hospital. Based on interviews and record review, the facility properly reported R1’s medical concerns to their representatives. Therefore the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff yells at residents“ it was alleged that staff told residents to shut up when they talked to themselves. Interview with Resident #3 (R3) at 9:30 a.m. today revealed that staff have to increase their speaking volume when talking to residents who are hard of hearing, but staff do not yell at or tell residents to shut up maliciously. Four (04) out of four (04) staff interviewed confirmed staff only yell when a resident is hard of hearing and never tell a resident to shut up. Based on interviews, staff do not tell residents to shut up when talking to themselves. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff sleep during their shift in the day“ it was alleged that a visitor found multiple staff members asleep. It was alleged that Staff #5 (S5) and Staff #6 (S6) were sleeping during a day shift. S1 recalled the incident and stated staff do sleep on their breaks in the back room, however one staff is always awake and observing residents. S1 further stated that S5 was awake while S6 was resting on their break. The administrator also confirmed that S6 was awake while S5 was sleeping on break. The Administrator allows for staff to rest on their breaks in the afternoon. Four (04) out of four (04) staff and all residents interviewed today confirmed they have not witnessed staff sleeping while on shift. Based on interviews, staff do not sleep during the day shift. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety risks were observed. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 3, 2024 · control 31-AS-20221123081117