San Juan Villa.

This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website.

Statement of Deficiencies .License#: 2143 Compliance Detem1ination #53546 Plan of Correction San Juan Villa C.ompletion Date Page2 of 4 Licensee: carii1g Places Management, LLC 01/24/2025 As a result of the on-site visit(s) the department found that you are not in compliance with the licensing laws qnd regulations as stated in th~ cited deficiencies in the enclosed repqrt. Co ~4, 02/04/2025 ·································~1-:1-.................................................................... . Re~ential Care Services Date l understand that to maintain an. Assisted Living Facility license, the facility must be jn compliance with all the lic.ensing laws and regulations at all times. WAC 388-7BA-2230 Medication .refusal. (1) When a resident who is receiving medication assistance or medication administration services from the assisted living facility chooses to not take his or her medications the assisted living facility 1 must (c) Notify the physician of the refusal and follow any instructions provided, unless there. is a staff person available Who, acting within his or her scope of practice, is able to evaluate the significance of the resident not getting his or her medication, and such staff person; (ii). Takes the appropriate action, including notifying the prescriber or primary care practitioner when there is a consistent pattern of the resident choosing to not take his or her medications, This requirement was not met as evidenced by: Based on interview, and record review the facility failed to notify the physi.cian when 1 of 4 sampled residents (Resident 1 [R1]) refused their medications, This failure placed the resident atrisk for medicaf compiications due to the physician being unable to evaluate the significance of the resident not getting their medication and provide instructions. . Findings included.,, Record .review of the "Department of Social And Health Services'' document, Completion date 11/08/2024, showed "As a result-of-the on-site visit(s) the department found that you are not in compiiance with the licensing laws and regulations [including WAC 388-78A-2230) as stated in the cited deficiencies in the enclosed report. l understand that ta maintain an Assisted Living Facility license, toe facility must be in complian_ce with all the licensing laws and regulations at all times." The administrator section showed Staff . 5-Feb-2025 16:56 13607253258 WA TECH p.5 02.05.2025 08:49:53 State of Uashington 5/8 Statement of Deficiencies Li.cense #: 2143 Compliance .Determination #53546 Plan of Correction San Juan Villa Completion Date A_, Administrator, s•igned the document on 12/03/2024. Staff A signed the ''Plan/Attestation Statement'' for all citations cited that re.ad "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 facility] is or will be in compliance with this law and/or regulation on 12/22/2024." Record review of the facility's, plan of correction, undated, showed for deficiency WAC 388-78A- 2230 meqicatior:, refusals the action from the facility would be to retrai.n all medication aides to fax the resident's physician every time a medication was refused. Record review of R1's, "Med [medication] Aide Meeting Agenda", dated 11/18/2024, showed if a resident refused a medication, then the facillty staff were to ·tax the phy-sician every time the resident refused. Seven facility members signed the sign in sheet on 11/18/2024. Record review of the facility untitled and undated policy, showed when to notify the doctor and they could be faxeo 24 hours a day, The doctor should be notified when there was a refusal of medication. Record review of the facility's, "Missed/Refused Medications" document, undated, showed a prefilled fax sheet that showed a section for the date. provider name, patient name, patient date of birth, refused/mjssed medications, reason, medicat_ion a\de's name, physician reply, and physician signature. Record review of R1's, "Service Agr.eemei1t", dated 12/31/2024, showed R1 ·needed full medication administration. Th_e faGility Medication Aides were to administer R1's medication and treatment per R1's physician orders. R1 was to wear their oxygen at al_l times. R1 would take their oxygen cannula (a thin flexible tube that delivered oxygen to a resident through their nose) off or refuse to wear it, esp·ecially when R1 was agitated. Record review of R1's, "Medication Administration Record", dated 01/01/2025 - 01/23/2025, showed R1 had an order to wear their oxygen at two liters. R 1 used their concentrator (a medical device that separated nitrogen from the a.ir to produce oxygeri) when in their .room and a portable (lightweight device that provided oxygen) when they were out of their roorn. The medication pass notes section showed on 01/11/2025 R1 refused to wear their oxygen and got aggressive during their care at night. On 01/18/2025 R1 refused to wear their oxygen. In an interview on 01/23/2025 at 12:58 PM, Staff A, Executive Director, said if a resident refused their medication their physician should be notified after every occurrence .. In an interview and· observation on 01/23i2025 at2:36 PM, Staff 8, Medication Aide, said if a resident refused their medication, t_hen the facility staff were to notlfy the residents physician every time. Staff B said 1he facility staff notified resident physicians by fax . 5-Feb-2025 16:56 13607253258 WA TECH p.6 02.05.2025 08:49:53 State of Washington 6/8 Statement of Deficiencies .License·#: 2143 Compliance Determination #53546 Plan of Correction San Juan Villa Completion Date Page4 of 4 Uc.ensee: Caring Places Management, LLC 01/24/2025 and provided the Department a copy of the prefilled out sheet to review .. Record review of an. email sent to the Department on 01/23/2025 at2:17 PM, showed Staff A said the f~cility could not provicte documentation to show R.1'!i physieian had been notified when R1 refused their medication on 01/11/2025 and 01/18/2025. This is an uncorrected deficiency previously cited on 11/08/2024. Plan/Attestation Statement I hereby certify that I have reviewed this report ano have taken~ o::r'. 1w i)I take active meas~ires to ~orre:t this deficiency. By t~king. this actiomn, Soa i: ( - W Villa ;7199r~be in comphance With this law and/ or regulation on (Date) \(')I . LV J_C.) In addition, I will implement a system to monitor and ·ensure continued compliance with this requirement. ..................... \ls~ ...........................· ..... .................... .. ............ '1-.. \.\... -1015 ... . Administrator (or Representative) Date . STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 100 NE. 136th Ave Ste 200, Vallcower, WA g16U Statement of Def1c1enc1es Deen se #. 2143 Comphance Determmatlon #496o6 Plan of Correction San Juan Villa Completion Date You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for the unannounced on-site full inspection on 10/29/2024 and 10/30/2024 ot San Juan vma 112 Castellano Way Port Townsend, WA 98368 The following sample was selected for review during the unannounced on-site visit 7 of 32 current residents and O former residents. The department staff that inspected the Assisted Living Facility· Anissa Bearden, Licensor Emily Boniface, Comm.mity Program Nurse Licensor Celeste Vashey, ALF LT C Ucensor From: DSHS, Aging and Long-Term Support Administration 800 NE 136th Ave Ste 200 Vancouver, WA 98684 As a result of the on-site visit(s), the department found that you are not in compliance with the licensing laws and regulations as stated in the cited deficiencies ln the enclosed report. 0 ~4, 12/02/2024 ReZntial Care Services Date I understand that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. . Statement of Deficiencies License# 2143 Compliance De1ermination # 49506 Plan of Correction San Juan Villa Completion Date WAC 388-78A-2950 Water supply. The assisted living facility must: (6) Provide all sinks in resident rooms, toilet rooms and bathrooms, and bathing fixtures used by residents with hot water between 105 F and 120 F at all times; and This requirement was not met as evidenced by: Based on observation, interview, and record review the facility failed to ensure water temperature was maintained between 105 degrees and 120 degrees Fahrenheit (F) in 6 of 6 resident accessible sinks and 4 of 4 sampled sinks inside resident rooms (Resident 4 [R4], Resident 9 [R9], Resident 7 [R7], and Resident 1 [R1]). This failure placed 32 of 32 residents and 30 staff at risk for potential skin burns. Findings included ... Record review of the facility provided document titled, "water temperature log for San Juan Villas", undated, showed "'hot water in all sinks and fixtures used must be between 105-120 Fat all times.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . . .