Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at San Juan Hills Healthcare Center during CMS and state inspections, most recent first.
Failure to document a COC for IV fluids: A resident with poor oral intake had a new IV NS order entered, but the medical record did not show a COC report or 72-hour monitoring documentation. The LVN and DON both verified the missing documentation, and the DON acknowledged that the resident’s IV fluid order should have been tracked as a COC with monitoring to assess effectiveness.
A resident had multiple medications left unattended at the bedside, including unlabeled oral meds, topical gels, Trulance, and a Repatha injection case, without authorization for bedside storage. The resident said staff knew the meds were kept there and that help was needed to apply the topical meds. Record review showed no documented IDT assessment for self-administration and no physician order for Repatha, while an LVN confirmed only Trulance had supervised self-administration orders and another LVN admitted leaving Tylenol and famotidine at the bedside.
The facility failed to keep DHPPD staffing postings accurate and posted daily. Surveyors found the nurses' station posting was outdated, several forms lacked the Actual Direct Care Service Hours, required DON or designee signatures were missing, and there were no DHPPD postings for multiple days. The DSD confirmed the forms should be posted daily, including weekends.
A resident with severe cognitive impairment and no decision-making capacity was prescribed multiple psychotropic medications, including Depakote, mirtazapine, Seroquel, and PRN olanzapine. The informed consent forms signed by the resident’s responsible party were incomplete or inaccurate, with missing drug categories and durations, incorrect documentation of off-label use, and side effects listed under the wrong drug classification. Facility leadership and clinical staff acknowledged that these forms should have been fully and accurately completed so the responsible party could understand the risks, benefits, and purposes of the medications before consenting.
Kitchen Food Storage and Sanitation Deficiencies: The facility had multiple food safety and sanitation failures in the main and satellite kitchen areas. Surveyors found numerous opened food items without proper labels or use-by dates, expired food still stored, an unclean ice machine, a dry storage container not tightly sealed, damaged food prep equipment, a heavily marred cutting board, dirty utensil containers, wet equipment stored before air-drying, and debris on the walk-in refrigerator floor. The Food Services Director, Maintenance Director, Co-Food Services Manager, DON, and Regional RD Consultant were informed of the findings.
The facility failed to fully carry out its infection control surveillance program, as residents with signs and symptoms of infection were not entered for McGeer's review unless they were already prescribed antimicrobials or diagnosed with an infection. Staff also stored personal items and paperwork in clean linen areas, used a Hoyer lift for two residents without cleaning it between uses, and an LPN administered an ophthalmic medication without performing hand hygiene after handling medication cart keys.
A resident had Neosporin ointment on the bedside table and said his son brought it for him to apply to a skin tear. The resident had a BIMS score of 12, but there was no physician order, assessment, or care plan for self-administration of the medication, and the LVN and DON verified the documentation was missing.
The facility failed to develop resident-centered care plans for two residents. One resident had a right upper arm midline catheter and was receiving IV Dextrose-NaCl for poor intake, but the care plan did not address the catheter or IV fluids. Another resident used a right upper bed rail for repositioning and cleaning, but no care plan was in place for bed rail use despite the facility policy requiring it.
Care Plan Not Updated for Neck Collar Brace Use: A resident with a neck fracture was observed wearing a C collar and stated it had to stay on except when showering. The physician ordered the collar to be worn for 6 weeks and checked every shift, but the resident’s care plan only addressed pain control, gentle handling, and supporting the fracture site during care; it did not include collar use or monitoring, and the record did not show the brace was monitored as ordered.
A resident with a right upper arm midline catheter received IV fluids and antibiotics, but the IV fluid infusion was not administered at the ordered rate and the catheter dressing was overdue for change. Staff observed a dated dressing still in place, and later verified that the Dextrose-NaCl infusion had started at 0700 with less fluid infused than expected after 8 hours, with no documentation or MD order to hold the infusion.
The facility failed to provide respiratory care per policy for two residents receiving oxygen and nebulizer services. One resident with COPD had nasal cannula tubing dated and left out of a bag when not in use, and an LVN verified the tubing had not been stored as required. Another resident’s nebulizer mask and tubing were observed in a bag dated more than two weeks earlier, and the LVN confirmed the set-up had not been changed weekly as expected by the facility’s protocol.
Two residents receiving hemodialysis were not properly monitored for ordered intake/output and fluid restriction. One resident who still voided had no accurate urine output measurement documented, and staff only asked how many times he voided. Another resident with a 1500 ml/24 hr fluid restriction had nursing intake documented above the ordered amount on multiple days, with no documented dietary fluid intake, and an LVN acknowledged the resident exceeded the restriction.
A resident with moderate cognitive impairment and dependence on mobility was observed using an elevated right upper bed rail for grabbing during repositioning and cleaning. Record review showed an earlier physician order for bilateral assist handrails had been discontinued, but there was no physician order or IDT assessment documented for the continued use of the right upper bed rail. Staff, including an LVN and the DON, acknowledged the missing order and assessment.
Cold Dessert Held Above Safe Temperature: During a tray line observation, surveyors found banana pie desserts at 63 degrees Fahrenheit and 54.8 degrees Fahrenheit after they were transferred from the main kitchen to the satellite kitchen. The FSD, Regional RD consultant, and dietary aides acknowledged the desserts were not holding below 41 degrees Fahrenheit, and the facility's P&P identified 41 to 135 degrees Fahrenheit as the danger zone.
Incomplete Facility Assessment and Missing Required Input: The Facility Assessment did not include the active involvement of required individuals, including direct care staff, residents, resident representatives, and family members. The Administrator verified the assessment did not address staffing resources for weekends or emergencies and did not reflect the updated CMS guidance.
Failure to complete bed rail entrapment assessments for two residents. Two residents with cognitive impairment and mobility needs were observed using elevated bed rails for repositioning and transfers, and records showed physician orders and screening tools supporting rail use. However, the bed system measurement log did not show that the required entrapment measurements and assessment were completed before the rails were used.
A resident’s call light was observed clipped to the wall and out of reach while she was in bed and awake. A CNA verified the call light remained out of reach during a follow-up observation, and the DON stated call lights were expected to be placed near residents so they could call for help right away.
Overflowing garbage in one of four dumpsters prevented the lid from fully closing. Facility policy required refuse containers and outside dumpsters to be kept covered and closed, and the Maintenance Director acknowledged the condition during observation. The DON was later informed and acknowledged the finding.
A resident with a physician's order to hold antihypertensive medication for SBP below 110 mmHg experienced multiple low blood pressure readings, including values as low as 83/57 mmHg. Despite these findings, there was no documentation that the physician was notified of the change in condition, as required by facility policy. Staff interviews confirmed the lack of notification and awareness of the policy requirements.
A resident at risk for constipation did not receive timely as-needed bowel management interventions as ordered by the physician, despite ongoing monitoring that showed no bowel movement for several days. Nursing staff delayed administration of prescribed laxatives and other interventions, resulting in the resident developing abdominal distention, nausea, and vomiting, and ultimately requiring transfer to an acute hospital where a small bowel obstruction was diagnosed.
A resident with severe cognitive impairment experienced multiple episodes of nausea, vomiting, diarrhea, and increased weakness, but the facility did not develop or update a care plan to address these changes in condition. Staff confirmed that a care plan should have been created, but none was found in the medical record.
A resident's care plan addressing constipation was not updated despite ongoing symptoms such as no bowel movement, abdominal distention, and nausea. The care plan interventions remained unchanged even after the resident's condition worsened, resulting in the need for hospital transfer. Facility staff confirmed the care plan was not revised as required by policy.
A resident with diabetes experienced a low blood sugar event, but staff failed to document a Change of Condition or notify the resident's representative as required. Additionally, vital signs were recorded as taken after the resident had already been discharged. These actions resulted in incomplete and inaccurate medical records, as confirmed by both the LVN and DON during interviews.
The facility's kitchens were found to have multiple sanitation and food safety deficiencies, including improper food storage, lack of hair restraints, and unsanitary practices. Observations included gnats, rust, and dirty equipment, as well as improper temperature control of food items. These issues indicate a failure to adhere to professional standards and food safety regulations.
The facility failed to ensure safe self-administration of medications for two residents. One resident had supplements and medications at her bedside without an assessment or physician's order, despite cognitive impairment. Another resident had eye drops at her bedside without authorization for self-administration. Staff confirmed the lack of necessary documentation and acknowledged the deficiencies.
The facility did not address concerns from resident council meetings or notify two residents about the outcomes of their grievances. Issues included staff noise, inadequate lighting, meal requests, and call button response times. Interviews confirmed the lack of follow-through and documentation, despite facility policies requiring timely investigation and resolution.
A facility failed to refer a resident with a mental disorder for a PASARR Level II evaluation, as required by their policy. The resident's PASARR Level 1 Screening Form incorrectly indicated no mental disorder, despite diagnoses of major depressive disorder, psychosis, and anxiety, and a prescription for sertraline. Interviews with the MDS Coordinator and DON confirmed the error, posing a risk for inadequate services and assessment.
The facility failed to ensure a safe environment for two residents who smoked. One resident was not assessed for smoking safety, and their smoking materials were found unsupervised. Another resident's smoking paraphernalia was left unsupervised, and they sometimes smoked without staff present. The designated smoking area lacked necessary safety measures, violating the facility's smoking policy.
The facility failed to implement bladder training for a resident and did not develop a toileting care plan for another, risking loss of bladder control. One resident, who was cognitively intact, was not provided with the ordered bladder retraining program, while another, who was continent, was placed in a diaper against her wishes and without a care plan. Staff interviews revealed a lack of awareness and documentation regarding these programs.
The facility failed to ensure clear physician's orders for oxygen administration for two residents, as the orders did not specify whether the oxygen was to be administered continuously or as needed. This lack of clarity was confirmed by the MDS Coordinator and the DON, potentially affecting the residents' respiratory health.
The facility failed to ensure proper pharmaceutical services, including inaccurate accounting of controlled medications for a resident, lack of signatures on pharmacy delivery slips, and improper documentation of medication disposal. These issues posed a risk of drug diversion and highlighted lapses in medication management processes.
A facility failed to accurately perform orthostatic blood pressure monitoring for a resident on antipsychotic medication. The physician's order required monitoring in three positions to check for orthostatic hypotension, but the MAR showed identical readings for all positions, indicating incorrect monitoring. The DON confirmed the inaccuracy, which could lead to adverse complications and incorrect data for medication adjustment.
A facility's medication error rate exceeded the acceptable threshold, with a rate of 7.14%. An LVN failed to administer medications as ordered for two residents. One resident did not receive instructions to chew a calcium carbonate tablet, and another received Effexor XR without food, contrary to physician orders. These errors were confirmed during observations and interviews.
The facility failed to ensure proper medication and supply storage, as expired medications were found in medication carts, and medications were improperly mixed in storage areas. Feeding formulas were stored without temperature monitoring, and over-the-counter medications lacked proper temperature logging. These issues were confirmed by the DON and staff, posing potential risks to residents' well-being.
The facility's dietary staff demonstrated a lack of competency, leading to potential risks in food and nutrition services. Observations revealed incorrect procedures for checking dishwasher temperatures and sanitizing solutions, unsanitary kitchen conditions, and improper handling of food temperatures. These issues highlight deficiencies in the oversight and responsibilities of the food service department.
The facility failed to follow menu and diet orders, leading to deficiencies in food service. Observations showed incorrect serving sizes, unsafe food temperatures, and inaccurate tray tickets. Specific incidents included a resident receiving an altered diet without documentation and another receiving inappropriate food items. These issues posed a risk to residents' nutritional adequacy.
The facility failed to serve prescribed therapeutic diets to two residents. An LVN did not verify meal trays against physician's orders, resulting in a resident receiving an incorrect diet. Additionally, a meal tray included a supplement not listed on the physician's order, confirmed by the Regional RD.
The facility failed to follow infection control practices, including hand hygiene during meal assistance and medication administration, proper storage in the laundry area, and implementing a water management program to prevent Legionella growth. Staff did not wash hands before and after assisting residents or administering medications, and personal clothing was stored with clean pillows. The facility lacked a comprehensive water management program, increasing the risk of pathogen spread.
The facility failed to monitor antibiotic use according to McGeer's criteria for two residents, leading to potential inappropriate antibiotic use. The Antibiotic Stewardship Program requires criteria to be met before prescribing antibiotics, but this was not confirmed for a resident with a cough prescribed azithromycin and another receiving Bactrim DS for pneumonia prophylaxis. Interviews with staff confirmed these findings.
The facility failed to monitor and record the freezer temperature in Medication Room A, leading to ice buildup in the freezer compartment. During an inspection, it was found that the freezer lacked a thermometer and the temperature log showed no documentation of monitoring. The facility's policy required twice-daily temperature checks, which were not followed, as confirmed by the DON.
A facility failed to conduct accurate and complete entrapment assessments for a resident using bed rails, potentially leading to serious injury or death. The Maintenance Director did not measure necessary entrapment zones for the resident's bed, as required by facility policy. This oversight was confirmed through observations, interviews, and document reviews, with the Director of Nursing verifying the findings.
The facility did not follow the puree recipe for seven residents on a puree diet, risking the conservation of nutritive value. Cook 1 added chicken broth instead of the cooking liquid to peas and used excessive thickener, contrary to the recipe. These actions were confirmed by the RD.
A resident with a right humerus fracture had blood pressure readings consistently taken from the affected arm, as documented in their medical records. Despite the resident's refusal and the LVN's acknowledgment that this practice was inappropriate, the facility failed to ensure accurate documentation and adherence to professional standards, potentially impacting the resident's care.
A resident with dementia and chronic kidney disease experienced a delay in receiving her lunch meal, waiting 40 minutes while other residents were served on time. The facility's PCC list of diets did not include her name, and staff, including the DON, could not explain the delay.
The facility did not ensure residents were informed of their rights and how to formally complain to the State Agency. During a resident council meeting, residents stated they were unaware of the contact information for the State Licensing and Certification Office. Interviews with the Activity Director and Admissions Director confirmed that this information was not provided in the admission packet, although it was posted on the consumer board.
A facility failed to follow a physician's order to discontinue a sling for a resident's right shoulder. The resident was seen wearing the sling despite the order, which was noted without a time or signature. Both the DON and DSD confirmed the order was not executed.
Failure to Document Change of Condition for IV Fluids
Penalty
Summary
The facility failed to complete a Change of Condition (COC) report and related documentation for one resident after a new physician order was entered for intravenous fluids due to poor oral intake. The resident had been admitted to the facility and had been documented in the H&P as having the capacity to understand and make decisions. The order summary for May 2026 showed a discontinued physician order dated 5/15/26 and an active order dated 5/22/26 for sodium chloride 0.9%, one liter at 50 ml/hr intravenously every shift for poor oral intake. Review of the medical record showed no COC report and no 72-hour documentation monitoring related to the poor oral intake and IV fluid orders. During interview and record review, an LVN verified that the new IV fluid orders would be considered a COC and stated there was no documented evidence of a COC or 72-hour monitoring. The DON also verified that the resident started IV fluids and later received a new order, and acknowledged that no COC or 72-hour documentation monitoring had been completed. The DON stated there should have been a COC to identify the reason for IV fluids and 72-hour monitoring to ensure the interventions were effective.
Unattended Medications Left at Bedside Without Authorized Self-Administration
Penalty
Summary
Medications and biologicals were left unattended at a resident’s bedside without authorization for bedside storage. During an observation and interview, multiple medications were found at the resident’s bedside table, including an unlabeled medication cup with two capsules and half of a tablet, diclofenac sodium gel 1%, an unlabeled tube of Voltaren topical gel 1%, Trulance 3 mg, and a Repatha SureClick injection case. The resident stated the licensed nurses knew the medications were kept at the bedside and said assistance was needed to apply the topical medications to the back area, which the resident could not reach independently. The resident’s record showed the resident had capacity to understand and make decisions, but there was no documented evidence of an interdisciplinary team assessment to determine the resident’s cognitive, physical, and visual ability to self-administer medications, and no evidence of a routine skilled assessment as required by facility policy. The order summary also did not show a physician’s order for the Repatha SureClick injection. Facility policy required medications to be stored securely in their original packaging and allowed bedside storage only when self-administration criteria were met and documented. During interviews, an LVN verified the bedside medications and stated the resident had an order for supervised self-administration of Trulance only, not for the other medications. The LVN also confirmed there was no physician’s order for Repatha SureClick and stated medications should be labeled and not left unattended at the bedside. Another LVN acknowledged leaving Tylenol and famotidine at the bedside after morning medication administration. The DON later confirmed medications should not be left unattended at the bedside and stated the facility did not complete the required interdisciplinary assessment for the resident’s self-administration of medications.
Incomplete and Missing DHPPD Staffing Postings
Penalty
Summary
The facility failed to ensure the DHPPD nurse staffing forms were accurate and posted daily. Surveyors reviewed the facility policy titled Posting Direct Care Daily Staffing Numbers, which required the number of licensed nurses and unlicensed nursing personnel directly responsible for resident care to be posted within two hours of the beginning of each shift, and required the shift supervisor to compute the direct care staff and complete the Nursing Staff Directly Responsible for Resident Care form. The report also cited AFL 19-16 and the CDPH 612 form requirements, including that the form be complete, true, accurate, and signed by the DON or designee. Surveyors found the DHPPD form dated 5/20/26 had no documented Actual Direct Care Service Hours and no DON or designee signature, and the DHPPD form dated 5/22/26 also lacked the Actual Direct Care Service Hours and the required signature. On 5/22/26, LVN 1 verified the posting at the nurses' station was not current and was dated 5/20/26. The DSD later verified the 5/20/26 form was incomplete and unsigned, and on 5/26/26 LVN 3 verified the posted form was dated 5/22/26, was not signed by the DON or designee, and did not include the Actual Direct Care Service Hours. The DSD confirmed there were no DHPPD postings from 5/23 through 5/26/26 and stated the form should be posted daily, including weekends.
Incomplete and Inaccurate Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure complete and accurate informed consent for multiple psychotherapeutic medications prescribed to a resident who lacked decision-making capacity. Facility policies required that psychotherapeutic drug informed consent forms include the drug category, dosage, frequency, duration of use, and possible side effects and significant risks, and that PRN psychotropic medications be limited to 14 days unless reevaluated by a practitioner. For one resident with severe cognitive impairment and no capacity to make medical decisions, several informed consent forms signed by the resident’s responsible party were found to be incomplete or inaccurate. The resident had orders for Depakote, mirtazapine, Seroquel, and PRN Zyprexa Zydis for conditions including psychosis manifested by angry outbursts and striking out, and depression manifested by poor oral intake. Review of the Depakote informed consent form showed the drug category and duration were left blank, the off-label use section incorrectly indicated the drug was not being used off-label, and the probable side effects and significant risks were documented under the antipsychotic category instead of the anticonvulsant/mood stabilizer category. Nursing and pharmacy staff confirmed that Depakote is an anticonvulsant, that it was being used as an antipsychotic (off-label), and that anticonvulsants and antipsychotics have different side effect profiles. Informed consent forms for the other psychotherapeutic medications were also incomplete. The mirtazapine consent form was missing the drug category and duration. The Seroquel consent form was missing the drug category and duration. The olanzapine (Zyprexa Zydis) PRN consent form was likewise missing the drug category and duration, despite facility policy and the DON’s acknowledgment that a PRN psychotropic medication should have a 14-day duration due to the requirement for physician reevaluation. The DON stated that the expectation was for psychotherapeutic drug informed consent forms to be fully and accurately completed before being signed so that the resident or responsible party would be aware of the risks and benefits of the medications and could make an informed decision, and that incomplete or inaccurate information meant it was not informed consent. These failures posed the risk of Resident 1's Responsible Party to not understand the risks, benefits, and purpose of the medications she was consenting for the facility to administer to Resident 1.
Kitchen Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food safety and sanitation requirements were met in the kitchen areas. During observation of the main kitchen walk-in refrigerator, multiple food items were found improperly labeled or undated, including opened jars of olives, sweet and sour sauce, salsa, relish, coleslaw dressing, ketchup, mayonnaise, and other prepared foods such as peeled hard cooked eggs, sliced cauliflower, pork sausage links, and cooked turkey. The Food Services Director verified these findings and stated that opened or prepared food items should have been properly labeled with a use-by date, and that the opened package of eggs should have been kept tightly closed. The Co-Food Services Manager stated that the notation "R" meant received, and the Food Services Director stated there was no cool down process recorded for the turkey. In the satellite kitchen refrigerator, additional food items were observed without proper labeling or dating, including thickened lemon flavored water, pureed food in an unlabeled container, cut-up peaches, ketchup, caramel dessert sauce, and open chocolate ice cream labeled only with a room number rather than the resident's name and use-by date. In the main kitchen, one tray of red berries jam was found with a use-by date that had already expired, and in the satellite kitchen an open bottle of chocolate syrup was labeled with a date and use-by date that did not include the year. The Food Services Director verified these findings and stated the year should be included when labeling food items. Additional sanitation and storage concerns were observed in both kitchen areas. The interior of the satellite kitchen ice machine had slimy yellowish and brownish residue, and the Maintenance Director verified the condition. A transparent plastic container of walnut halves in dry storage was only partly covered with plastic wrap instead of being tightly sealed. Two scoops in the main kitchen were discolored with white sediment and had melted handles, and a green chopping board was heavily marred with knife marks and had black and yellowish staining. Containers holding scoops and utensils were dirty in both kitchens, one scoop in the satellite kitchen was wet, two water jars in the main kitchen were still wet, and the floor area beneath shelving in the main kitchen walk-in refrigerator was littered with vegetable and fruit debris. The facility's Diet Type Report showed 42 of 42 residents consumed food prepared in the kitchen, and the DON, Regional RD Consultant, Food Services Director, and Co-Food Services Manager were informed and acknowledged the findings.
Infection control surveillance, clean linen storage, equipment disinfection, and hand hygiene failures
Penalty
Summary
The facility failed to implement its infection prevention and control surveillance program for January 2025 through August 2025. The infection prevention and control policy stated that surveillance tools are used to recognize infections, record their number and frequency, detect outbreaks and epidemics, monitor adherence to infection prevention and control practices, and detect unusual pathogens, and that McGeer's and Loeb's criteria are used to distinguish CAIs from HAIs. During interview, the IP stated that the facility initiated McGeer's and/or Loeb's criteria only when a resident was prescribed antimicrobial medications or diagnosed with an infection. Review of the monthly Infection Prevention and Control Surveillance Logs showed only residents classified as HAI or CAI, with no residents listed as not meeting McGeer's criteria for any month reviewed. The IP verified that no residents were classified as not meeting McGeer's criteria during that period. When asked whether residents who exhibited signs and symptoms of infection but were not prescribed antimicrobial medications or not diagnosed with an infection were included in surveillance, the IP stated the facility did not initiate McGeer's criteria forms for those residents. The IP was uncertain how many residents met McGeer's criteria without being prescribed antimicrobial medications because those residents were not entered into the surveillance process. The facility also failed to keep clean laundry and clean linen areas free of contamination. In the laundry room, the clean laundry sorting counter had a facility binder and a used paper cup with a food wrapper inside it, and a clean linen cart nearby had facility paperwork stored on the top shelf with clean resident linens. Housekeeping staff verified these items should not have been stored there for infection control purposes. In addition, reusable equipment was not cleaned between residents when a Hoyer lift was used for one resident and then used for another resident without being disinfected first. The first resident had moderate cognitive impairment and was dependent with mobility, and the second resident had severe cognitive impairment and was dependent with mobility. The facility also failed to follow hand hygiene practices during medication administration. During observation, an LVN administered oral medications and then, after handling medication cart keys and placing them in his pocket, administered an ophthalmic medication to a resident without performing hand hygiene. The LVN later verified that hand hygiene was not performed before giving the eye drop after the keys were returned. The facility's hand hygiene policy stated that hands are washed before and after administration of ophthalmic medications.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that one resident was assessed, had a care plan, and had a physician's order before self-administering medication. During an initial tour, surveyors observed a tube of Neosporin ointment on the resident's bedside table, and the resident stated that his son had brought the ointment for him to apply to a skin tear. The resident's MDS admission assessment showed a BIMS score of 12, indicating cognitive impairment. Review of the resident's medical record showed no documented physician's order for Neosporin ointment, no assessment for self-administration of medications, and no care plan addressing self-administration. The facility's LVN and DON both verified that these documents were absent, and the LVN stated it was not safe for the resident to keep medications at bedside.
Failure to Develop Care Plans for IV Therapy and Bed Rail Use
Penalty
Summary
The facility failed to develop resident-centered care plans for two sampled residents. For Resident 67, who had a BIMS score of 9 and was moderately cognitively impaired, the medical record showed a right upper arm midline catheter used for antibiotics and IV fluids. Physician orders included dressing changes for the catheter site and administration of Dextrose-NaCl 5-0.45% at 100 ml/hr intravenously for poor meal intake, but the care plan did not address the midline catheter or the IV fluid administration. The DON later verified that no care plan had been developed for these needs. For Resident 72, who had moderate cognitive impairment and was dependent on mobility, staff observed the resident using the right upper bed rail while in bed and stated the resident used it to grab on during repositioning and cleaning. The facility’s bed rail policy stated bed rail use and safety provisions should be included in the care plan, but the medical record did not show any plan of care for the right upper bed rail. Staff interviews confirmed the bed rail had been in use since admission and that a care plan should have been initiated, and the DON verified that no plan of care had been formulated for the bed rail use.
Care Plan Not Revised for Neck Collar Brace Orders
Penalty
Summary
The facility failed to ensure the comprehensive plan of care was revised to reflect the current care needs and interventions for one resident with altered functional mobility and pain related to a nondisplaced type III odontoid fracture. The resident was observed in bed, alert and verbally responsive, wearing a neck collar brace. The resident stated he had fallen and broken a bone in his neck, that he needed to wear the neck collar brace at all times except when showering, and that he had neck pain that was helped by pain medication. The resident’s physician ordered the resident to wear a C collar for 6 weeks, with removal only when showering, and to monitor placement of the neck brace every shift. The resident’s care plan, which addressed altered functional mobility and pain, included interventions for pain medication, gentle handling, and support of the fractured site during turning and repositioning, but it did not include wearing or monitoring the neck collar brace. Review of the medical record also failed to show the neck collar brace was monitored per the physician’s order. An LVN confirmed the resident was admitted with a neck collar brace and stated the care plan should have been revised to reflect the resident’s most current plan of care. The DON stated the plan of care should be comprehensive based on physician orders and interdisciplinary team input.
IV Fluid Infusion and Midline Dressing Not Managed as Ordered
Penalty
Summary
The facility failed to provide the necessary care and services for Resident 67 related to IV fluids and midline catheter care. Resident 67 had a right upper arm midline catheter used for antibiotics and IV fluids. During an initial observation, the resident was lying in bed with a midline catheter dressing dated 1/7/26, and a one-liter bag of Dextrose-NaCl 5-0.45% was hanging and connected to the catheter at 100 ml/hr. The facility's policy stated that transparent dressing changes are to be performed at least weekly by RNs and IV certified LVNs according to state law and facility policy. Medical record review showed a physician's order dated 1/7/26 to change the catheter site dressing every Wednesday and an order dated 1/19/26 to administer Dextrose-NaCl 5-0.45% at 100 ml/hr intravenously for poor meal intake for 5 liters. Later review confirmed the IV infusion had been started at 0700 hours and that only 600 ml had infused after 8 hours, although 800 ml should have infused at the ordered rate. RN 1 verified there was no documentation or physician's order to hold the infusion and acknowledged the dressing was overdue for change. The resident's MDS showed a BIMS score of 9, indicating moderately impaired cognition.
Respiratory tubing and nebulizer equipment not changed or stored per policy
Penalty
Summary
The facility failed to provide respiratory services for two residents who were receiving oxygen and nebulizer treatments. For one resident with COPD and an order for continuous oxygen at 4-6 LPM via nasal cannula, surveyors observed the resident in bed with oxygen in place while the portable oxygen tubing at the bedside was dated 12/13/25 and was not stored inside a bag. The DON verified the tubing date and stated the nasal cannula tubing needed to be inside a bag to prevent dirt and dust contaminating the tubing. The facility's respiratory infection prevention policy required oxygen cannula and tubing to be changed every seven days or as needed and kept in a bag when not in use. For a second resident with an order for albuterol sulfate nebulizer treatments as needed for shortness of breath or wheezing, surveyors observed the nebulizer machine on the bedside drawer with the mask and tubing placed in a clear plastic bag dated 1/3/26. The facility's policy required the nebulizer administration set-up to be stored in a plastic bag marked with the date and resident's name and changed every seven days. An LVN verified the bag had not been changed every week and stated it was last changed more than two weeks earlier. The DON stated she expected the oxygen tubing, including the nebulizer mask and tubing, to be changed every week or as needed per facility protocol.
Dialysis Residents Not Properly Monitored for Output and Fluid Restriction
Penalty
Summary
The facility failed to ensure dialysis-related monitoring was carried out for two residents. One resident was cognitively intact, receiving hemodialysis on Tuesdays, Thursdays, and Saturdays, and stated he was still producing urine and using the restroom to void. He also stated he did not think his urine was being measured and that no one had informed him that his urine output needed to be measured. His care plan included monitoring intake and output, but the record showed only a continent check mark on the bladder elimination task and did not show that urine output was properly monitored. During interview, an LVN verified the resident was on dialysis and still voided independently. The LVN stated that when intake and output monitoring was ordered, staff would provide a graduated cup for intake, but for output they would only ask the resident how many times he voided during the shift. The LVN acknowledged that for residents with renal failure or on dialysis, intake and output should be measured more accurately by exact amounts to determine whether the resident was retaining fluid, and verified the output for this resident was not being measured properly. A second resident had moderate cognitive impairment and was on hemodialysis three times per week with a physician order for a 1500 ml/24 hour fluid restriction. The order specified 540 ml to be provided by nursing and 960 ml by dietary. The MAR showed nursing fluid intake entries that exceeded the nursing allotment on multiple days, and the record did not show documented evidence of the dietary fluid intake portion. Interviews with a CNA and an LVN confirmed how fluids were being measured and documented, and the LVN acknowledged that the dietary fluid intake was not documented and that the resident received more than the ordered fluid restriction on several days. The DON was informed and acknowledged the findings.
Failure to Obtain Order and IDT Assessment for Bed Rail Use
Penalty
Summary
The facility failed to ensure Resident 72 remained free from accident hazards associated with the use of an elevated right upper bed rail. During the initial tour, Resident 72 was observed awake and lying in bed with the right upper bed rail elevated, and the resident stated he used the bed rail to grab when he was being turned or cleaned. A CNA stated the resident was dependent on mobility and had been using the right upper bed rail since admission to assist with repositioning and cleaning. Record review showed Resident 72 was readmitted to the facility and had moderate cognitive impairment and dependence on mobility. The Side Rails Screening Tool documented an IDT recommendation for a bilateral assist rail to support ADLs, repositioning, transfers, and bed mobility, and the order summary showed a physician's order for bilateral assist handrails that was later discontinued. The medical record did not show a physician's order for the right upper bed rail or that an IDT assessment was completed before its use. An LVN stated the resident used the right upper bed rail for grabbing during repositioning and verified there was no physician's order and no IDT assessment for that rail. The DON acknowledged the findings.
Cold Dessert Held Above Safe Temperature
Penalty
Summary
The facility failed to ensure food items were served at an appetizing and safe temperature. During review of the facility's Diet Type Report dated 1/20/26, surveyors found that 42 of 42 residents consumed food prepared in the kitchen. The facility's P&P titled Food Preparation and Service, revised 10/2017, stated that the danger zone for food temperatures is between 41 degrees Fahrenheit and 135 degrees Fahrenheit. On 1/21/26 at 1220 hours, a tray line observation and concurrent interview were conducted with the Food Service Director, the Regional RD Consultant, and Dietary Aides 1 and 2. Dietary Aide 1 checked the temperatures of banana pie desserts and found the first plate was 63 degrees Fahrenheit and the second plate was 54.8 degrees Fahrenheit. Dietary Aides 1 and 2 stated the banana pie desserts had been transferred to the satellite kitchen from the main kitchen around 1200 hours. The Food Service Director and the Regional RD Consultant stated the banana pie dessert was not holding the cold temperature of below 41 degrees Fahrenheit and acknowledged the dessert temperatures were above the recommended temperature for cold food.
Incomplete Facility Assessment and Missing Required Input
Penalty
Summary
The facility failed to ensure the Facility Assessment was complete and did not include the active involvement of required individuals in developing the assessment. The report states that the Facility Assessment was required to address staffing resources necessary to care for residents, including weekends, as well as a plan to maximize recruitment and retention of direct care staff and a contingency plan for staffing needs for events not requiring activation of the emergency plan. Review of the Facility Assessment dated [DATE] showed that direct care staff members, direct care representatives, residents, residents' representatives, and residents' family members were not actively involved in developing the assessment. During an interview and concurrent document review on 1/22/26 at 1003 hours, the Administrator verified the Facility Assessment was dated 9/25/25, acknowledged being unaware of the updated CMS guidance, and confirmed there were no direct care representatives, residents, resident representatives, or family members involved. The Administrator also verified there were no resources necessary to care for residents including weekends and emergencies, and acknowledged the Facility Assessment was not updated based on the latest CMS guidance.
Failure to Complete Bed Rail Entrapment Assessments
Penalty
Summary
The facility failed to ensure entrapment assessments were completed and the measurements were recorded during bed inspections for two residents who used bed rails. The deficiency involved Resident 72 and Resident 75, both of whom had bed rail use documented in their records and were observed in bed with the upper rail(s) elevated during the survey. Resident 72 was observed awake in bed with the right upper bed rail elevated and stated he used the rail to grab when being turned or cleaned. CNA 3 confirmed the resident was dependent on mobility and had used the right upper bed rail since admission. The medical record showed a physician order for bilateral assist handrails for bed mobility, repositioning, and transfers, along with a Side Rails Screening Tool that recommended bilateral assist handles. The MDS showed moderate cognitive impairment and dependence on mobility. The facility's Bed System Measurement Device Test Results Worksheet Log for January 2026 did not show evidence that the entrapment assessment was completed before the bed rail was used. Resident 75 was observed awake in bed with bilateral upper bed rails elevated and stated he could help with turning in bed and used the bed rails to hold on to. CNA 5 stated the resident used the bilateral upper bed rails during repositioning and transferring. The medical record showed a physician order for bilateral assist handrails, a Side Rails Screening Tool recommending bilateral assist handles, and an MDS showing moderate cognitive impairment and need for partial or moderate assistance with mobility. The Maintenance Director stated he would complete the entrapment assessment by measuring bed zones and checking fitment and locking, but the worksheet log did not show evidence that the assessment was completed for Residents 72 and 75 prior to bed rail use.
Call Light Out of Resident’s Reach
Penalty
Summary
The facility failed to provide reasonable accommodations for Resident 62 by not keeping the call light within reach. During the initial tour, Resident 62 was observed in bed, awake, and covered with a blanket. When asked if she knew how to call the nurse, she did not answer. The call light button was observed clipped, with the cable hanging on the wall, and it was out of the resident’s reach. On follow-up observation with a CNA at the resident’s bedside, the call light button was again verified to be clipped and the cable hanging on the wall, still out of Resident 62’s reach. The resident’s face sheet identified her as self-responsible for her care. The DON stated that call lights were expected to be placed near residents so they could call for help right away if needed, and the DON was informed and verified the findings.
Overflowing Dumpster Prevented Proper Closure
Penalty
Summary
The facility failed to dispose and store trash in a sanitary manner. During observation and concurrent interview, one of four dumpsters was found overflowing with garbage, which prevented the lid from being fully closed. The facility’s policy stated that garbage and refuse containers must be kept covered when stored or not in continuous use, and outside dumpsters must be kept closed and free of surrounding litter. The Maintenance Director observed the overfilled dumpster and acknowledged that the lid could not be completely closed, and the DON was later informed and acknowledged the findings.
Failure to Notify Physician of Resident's Low Blood Pressure Readings
Penalty
Summary
The facility failed to notify a resident's physician when the resident experienced multiple episodes of low blood pressure, as required by facility policy. The resident had a physician's order for Benazepril HCL to be held if systolic blood pressure (SBP) was less than 110 mmHg. Medical records showed several instances where the resident's SBP was below this threshold, including readings as low as 100/60 mmHg and, during a physical therapy session, as low as 83/57 mmHg while sitting. Despite these low readings, there was no documentation indicating that the physician was notified of the change in the resident's condition. Interviews with facility staff, including the physical therapist and the Director of Nursing (DON), confirmed awareness of the low blood pressure readings and acknowledged that the physician should have been informed. The DON also verified that facility policy required physician notification when blood pressure medication was held for three consecutive days, but there was no evidence this occurred. The deficiency was identified through interviews, medical record review, and review of facility policies and procedures.
Failure to Provide Timely Bowel Management Interventions
Penalty
Summary
The facility failed to provide necessary care and services for a resident at risk for constipation, as required by their own policies and physician orders. The resident, who had decreased mobility and was at risk for constipation due to possible medication side effects, was to have their bowel movements monitored every shift, with interventions such as prune juice, medications, and physician notification if no bowel movement occurred for more than three days. Despite these orders, the resident did not have a bowel movement from 5/30 to 6/6, and as-needed bowel management medications were not administered as ordered until six days after the last recorded bowel movement. During this period, the resident experienced abdominal distention, nausea, and vomiting. Medical record review showed that the resident was administered some scheduled bowel management medications, but the escalation to as-needed interventions, including Milk of Magnesia, Dulcolax suppository, and Fleet Enema, was delayed. Nursing staff and the DON confirmed that the as-needed medications were not provided in a timely manner according to the physician's orders. The resident's condition worsened, leading to transfer to an acute hospital, where a small bowel obstruction was diagnosed.
Failure to Update Care Plan for Change in Condition
Penalty
Summary
The facility failed to develop and implement a care plan that addressed a resident's change in condition, specifically episodes of nausea, vomiting, diarrhea, and increased generalized weakness. Despite documentation in the medical record of multiple episodes of these symptoms and the administration of non-pharmacological interventions and medication as ordered by the physician, there was no evidence that a care plan was created or updated to reflect these changes. The facility's policy requires that a comprehensive, person-centered care plan with measurable objectives and timetables be developed and revised as residents' conditions change, but this was not followed in this case. Interviews with facility staff, including an LVN and the DON, confirmed that a care plan should have been developed in response to the resident's change in condition, and both verified that no such care plan was present in the medical record. The resident involved had severe cognitive impairment and experienced multiple documented episodes of gastrointestinal symptoms and increased weakness, yet the care plan was not updated to address these needs.
Failure to Revise Care Plan for Constipation Management
Penalty
Summary
The facility failed to revise and update the care plan for a resident who was at risk for constipation, despite ongoing changes in the resident's condition. The care plan initially addressed the risk for constipation related to decreased mobility and possible medication side effects, with interventions such as monitoring and recording bowel movements every shift, reporting abnormal stool, and notifying the physician if there was no bowel movement for more than three days. However, when the resident experienced no bowel movement for more than three days, along with symptoms of abdominal distention, nausea, and vomiting, the care plan was not updated to include additional or different interventions. Medical record review showed that the resident continued to have no bowel movement and worsening symptoms, leading to the administration of a fleet enema and eventual transfer to an acute care hospital due to persistent constipation and related symptoms. Interviews with facility staff, including an LVN and the DON, confirmed that the care plan was not revised in response to the resident's ongoing issues. The facility's policy required care plans to be updated when a resident's condition changed or when desired outcomes were not met, but this was not followed in this case.
Incomplete and Inaccurate Medical Record Documentation for Diabetic Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with diabetes, as required by their own policies and professional standards. Specifically, when the resident experienced a low blood sugar level of 58 mg/dL, there was no documentation that a Change of Condition (COC) was initiated, nor was there evidence that the resident's representative was notified of the hypoglycemic event. The facility's policies require that such events be documented, including notification of the physician and the resident's representative, but these steps were not recorded in the medical record. Both the LVN and the DON confirmed during interviews that a COC should have been initiated for blood sugar levels below 70 mg/dL, and acknowledged that the required documentation was missing. Additionally, the resident's medical record contained inaccuracies regarding the timing of vital sign documentation. Vital signs were recorded as being taken after the resident had already been discharged and transferred to an acute care hospital. The DON verified that these entries were made post-discharge, which is inconsistent with accurate and timely recordkeeping practices. The facility's policy mandates that all documentation be objective, complete, and accurate, including the date and time care was provided and the name and title of the individual documenting. These documentation failures were identified through interviews, medical record reviews, and policy reviews. The lack of proper documentation for a significant change in condition and the inaccurate recording of vital signs after discharge had the potential to impact the provision of necessary care and services due to incomplete medical record information.
Sanitation and Food Safety Deficiencies in Facility Kitchens
Penalty
Summary
The facility failed to maintain sanitary conditions in both the satellite and main kitchens, posing a risk to food service standards. Observations included improper defrosting of juice in a hand wash sink, presence of gnats, rust on equipment, and dirty drains. Staff were observed without proper hair and beard restraints, and cutting boards were found marred and improperly stored. Food storage practices were inadequate, with items stored too close to the sprinkler system and unlabeled food in the residents' refrigerator. Further inspections revealed ongoing issues, such as staff using inappropriate methods to open equipment, improper storage of personal items near food, and continued presence of gnats. The facility also failed to maintain proper temperature control for food items, as evidenced by the cottage cheese being left unrefrigerated and served at an unsafe temperature. The Cool Down Log was incomplete, missing entries for chicken salad, and there was no documentation for the use of precooked chicken. Additionally, staff were observed engaging in unsanitary practices, such as touching masks and meal carts without hand hygiene, and placing personal items in the ice machine. These deficiencies indicate a lack of adherence to professional standards and food safety regulations, as outlined by the USDA Food Code 2022, potentially compromising resident safety.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the safe self-administration of medications for two residents. Resident 132 was observed with several bottles of supplements and medications at her bedside, including Biotin, coconut oil, and a hair growth medication. Despite the resident's fluctuating capacity to understand and make decisions, as indicated by a BIMS score of 9, there was no documented assessment for her ability to self-administer these medications. Additionally, there were no physician's orders authorizing self-administration, and the MDS Coordinator confirmed the absence of such orders in the resident's medical records. Similarly, Resident 14 was found with eye drops at her bedside, which she had been using for six weeks. Although there was a physician's order for the administration of artificial tears, there was no documented evidence of an assessment or physician's order permitting self-administration. LVN 3 verified the lack of documentation and confirmed that the medication should not have been kept at the bedside. The DON was informed of these findings and acknowledged the deficiencies.
Failure to Address Resident Council Concerns and Notify Residents of Outcomes
Penalty
Summary
The facility failed to address concerns raised during resident council meetings and did not notify two residents about the outcomes of their grievances. The facility's policy and procedure (P&P) required the use of a Resident Council Response Form to track issues and their resolution, with the relevant department responsible for addressing the concerns. However, documentation from the Resident Council Meeting Agenda & Notes showed unresolved issues, such as staff being loud in hallways, a resident needing more light in their room, and another resident having issues with meal requests and call button response times. There was no documentation on how these concerns were resolved or if the residents were informed of the outcomes. Interviews with the Activity Director and the Director of Nursing (DON) confirmed the lack of follow-through on the concerns raised. The Activity Director stated that the Administrator was notified of the concerns, and they were discussed in meetings with department heads, but admitted there was no follow-up. The DON verified the absence of documentation on the investigation and resolution of the concerns, as well as the lack of communication with the residents about the outcomes. The facility's P&P required concerns to be investigated within 72 hours, but this was not adhered to.
Failure to Refer Resident for PASARR Level II Evaluation
Penalty
Summary
The facility failed to ensure that a resident with a mental disorder was referred to the state PASARR representative for a Level II evaluation and determination screening process. This deficiency was identified during a review of the facility's Preadmission Screening & Resident Review (PASRR) policy and procedure, which mandates that the facility confirm the PASARR process was completed by the hospital before accepting a resident. In the case of Resident 16, the PASARR Level 1 Screening Form incorrectly indicated that the resident did not have a mental disorder or intellectual disability, despite the resident's admission record showing diagnoses of major depressive disorder, psychosis, and anxiety. Additionally, the resident was prescribed sertraline, an antidepressant medication, which further indicated the presence of a mental disorder. Interviews with the MDS Coordinator and the Director of Nursing (DON) confirmed the error in the PASARR assessment for Resident 16. The MDS Coordinator acknowledged that the PASARR Level 1 was not accurately completed and that the resident had been receiving antidepressant medication for depression. The DON was informed of these findings and verified the deficiency. This oversight posed a risk for the resident not receiving the appropriate level of services, comprehensive assessment, intervention, and evaluation for their mental disorder.
Failure to Ensure Safe Smoking Practices for Residents
Penalty
Summary
The facility failed to provide a safe environment free from accident hazards for two residents who smoked. Resident 383 was not accurately assessed to determine if supervision or adaptive equipment was needed while smoking, nor was there a determination if they could safely store their own cigarettes or lighters. The resident's smoking materials were found unsupervised on their bedside drawer, and the facility staff were unaware of the resident's smoking habits. The medical records did not show evidence of a smoking assessment, physician's order, or a developed care plan for smoking. Resident 432's smoking paraphernalia was left unsupervised on their overbed table while they were not in the room. The resident, who was assessed as requiring supervision, sometimes smoked without staff present. The facility's care plan for Resident 432 included interventions for observing unsafe smoking practices, but these were not adequately followed. Additionally, the designated smoking area lacked readily available and accessible safety measures such as fire-retardant smoking aprons and portable fire extinguishers, as verified by the Activity Director. The facility's policy and procedure for safe smoking required that residents be evaluated for their ability to smoke safely and that safety measures be in place in designated smoking areas. However, these protocols were not followed, leading to potential fire hazards and risks of serious injuries to residents who smoked and others in the facility. The Director of Nursing verified the findings, confirming the facility's failure to adhere to its smoking policy and procedures.
Failure to Implement Bladder Training and Toileting Programs
Penalty
Summary
The facility failed to provide necessary care and services to maintain or restore bladder functions for two residents. Resident 285, who was cognitively intact, expressed a preference to use the bathroom rather than a disposable brief at night. Despite a physician's order for a bladder retraining program and a care plan intervention to follow a toileting schedule every two hours, there was no documented evidence that this program was implemented. Interviews with facility staff, including a CNA and LVN, revealed a lack of awareness and documentation regarding the bladder training program for Resident 285. Resident 436, who was continent for bladder needs, was placed in a diaper against her wishes and without a care plan addressing her specific toileting needs. Despite being able to verbalize her need to use the toilet, she was wearing a diaper, which she was allergic to. The DON confirmed that a care plan for Resident 436's toileting needs was not developed, and acknowledged that even residents in diapers could be taken to the toilet. These failures posed a risk for the residents to lose their bladder control.
Oxygen Administration Orders Lacked Clarity
Penalty
Summary
The facility failed to ensure that the physician's orders for oxygen administration for two residents were clear regarding whether the oxygen was to be administered continuously or as needed. Resident 132 was observed receiving oxygen at 2 liters per minute via nasal cannula, but the physician's order did not specify if this was to be continuous or PRN. The MDS Coordinator confirmed the lack of clarity in the physician's order during a review of the medical records. Similarly, Resident 282 was observed receiving oxygen at 3 liters per minute via nasal cannula, with the physician's order also lacking specification on whether the administration was continuous. The MDS Coordinator verified the ambiguity in the physician's order, and the DON confirmed these findings. This lack of clarity in the physician's orders had the potential to affect the respiratory health and well-being of the residents.
Deficiencies in Pharmaceutical Services and Medication Management
Penalty
Summary
The facility failed to ensure proper pharmaceutical services, resulting in several deficiencies. One significant issue was the inaccurate accounting and documentation of controlled medications for a resident. During an inspection, a discrepancy was found in the count of buprenorphine-naloxone tablets for a resident, with the physical count not matching the controlled medication accountability record. The Director of Nursing (DON), who was involved in the count, confirmed the discrepancy but did not initiate an investigation or provide a response when questioned about the facility's protocol for such discrepancies. Additionally, the facility did not follow proper procedures for receiving medications from the pharmacy. Several pharmacy delivery slips for controlled medications lacked signatures from the receiving nurse, indicating a failure to verify and document the receipt of medications. Furthermore, the facility did not properly document the disposal of medications, as observed in the drug disposition records, which lacked dates for when the medications were disposed of. These failures posed a risk of drug diversion and highlighted lapses in the facility's medication management processes.
Inaccurate Orthostatic Blood Pressure Monitoring for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to accurately perform orthostatic blood pressure monitoring as ordered by the physician for a resident receiving antipsychotic medication. The physician had ordered the monitoring of blood pressure in three positions (lying, sitting, and standing) once a week to check for orthostatic hypotension, which is defined as a significant decline in blood pressure upon standing. However, the medical administration record (MAR) for November showed identical blood pressure readings for all three positions on two separate occasions, indicating that the monitoring was not conducted correctly. During an interview and concurrent medical record review, the Director of Nursing (DON) confirmed that the licensed nurses did not accurately monitor the orthostatic hypotension, as evidenced by the same blood pressure readings for all positions. This inaccuracy in monitoring had the potential to result in adverse complications for the resident due to the use of antipsychotic medication and could lead to incorrect data being provided to the prescriber, affecting the adjustment of the medication dose.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 7.14%. This deficiency was identified during a survey where a licensed nurse, LVN 4, did not administer medications as per physician orders for two residents. Resident 134, who had a physician's order for Calcium Carbonate Tablet Chewable 500 mg to be chewed and swallowed for indigestion, was not instructed to chew the tablet before swallowing. This oversight occurred during a medication administration observation, where LVN 4 prepared and administered multiple medications to Resident 134 without providing the necessary instructions for the calcium carbonate tablet. Additionally, Resident 4, who had a physician's order for Effexor XR to be administered with food for depression, received the medication without food. During the medication administration observation, LVN 4 administered several medications to Resident 4, including Effexor XR, before the resident had eaten breakfast. This failure to follow the physician's order for administering the medication with food was confirmed during an interview and record review with LVN 4, who verified the findings.
Medication and Supply Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage, which was identified through observations and interviews. During an inspection of Medication Cart A, expired povidone-iodine prep pads were found, and the Director of Nursing (DON) confirmed these findings. Additionally, Medication Cart B contained a mix of Zofran, acetaminophen suppositories, and bisacodyl suppositories, which was verified by an LVN. Furthermore, in Medication Room B, eye drop medications were stored alongside oral medications, and nasal sprays were stored with oral medications, which was acknowledged by an LVN. The facility also failed to properly store feeding formulas and monitor temperatures. The Central Supply Designee confirmed that enteral feeding formulas and oral supplements were stored in a room with a temperature of 75 degrees Fahrenheit, but the temperature log had not been maintained. Additionally, over-the-counter medications were stored in the Health Equipment room without a thermometer or temperature log. These deficiencies in medication and supply storage practices had the potential to negatively impact residents' well-being and lead to medication errors.
Deficiencies in Dietary Staff Competency and Kitchen Sanitation
Penalty
Summary
The facility failed to ensure that dietary staff were competent in performing their duties, which posed a risk to residents receiving appropriate food and nutrition services. During a kitchen inspection, it was observed that the Certified Dietary Manager (CDM) 1 incorrectly checked the dishwasher's temperature during the prewash cycle instead of the wash cycle, as required for proper operation. Additionally, CDM 1 was unable to demonstrate the correct procedure for checking the sanitizing solution's range, using soap and water instead of the appropriate sanitizing solution. The posted instructions indicated that the sanitizer solutions should be maintained at a range of 150-250 ppm, but the logs showed inconsistencies in the recorded ppm levels. Further observations revealed unsanitary conditions in the main kitchen, which had been previously discussed with CDM 2. During a lunch trayline observation, a container of cottage cheese was left unrefrigerated, and its temperature was not checked until prompted, revealing it was at 53 degrees, outside the acceptable range. Despite this, CDM 1 continued to serve the cottage cheese until the Registered Dietitian (RD) confirmed the temperature issue, at which point it was disposed of. These findings indicate a lack of competency and oversight in the food service department, as outlined in the duties and responsibilities of the RD and CDMs.
Deficiencies in Dietary Management and Food Service
Penalty
Summary
The facility failed to ensure that the menu and diet orders were followed, leading to several deficiencies in food service and dietary management. Observations revealed that chicken salad was not documented on the cool down log, and the kitchen staff used incorrect serving sizes, such as using a 3 oz slotted spoon instead of the required #8 scoop for noodles. Additionally, temperatures for milk and cottage cheese were not taken at the tray line, with cottage cheese being stored at an unsafe temperature of 53 degrees Fahrenheit. Plates of dessert were placed near a dirty sink, and tray tickets were inaccurate for some residents, leading to inappropriate food items being served. Specific incidents included a meal tray for a resident on a Consistent Carbohydrate Diet No Added Salt (CCHO NAS) being altered to a regular diet without proper documentation, and another resident on a liberal renal diet receiving inappropriate food items such as gravy and yogurt, which were not listed on their meal ticket. Furthermore, a resident's food tray did not include a bread roll as requested, despite the presence of butter on the tray. These findings indicate a risk of residents not receiving nutritional adequacy due to the facility's failure to adhere to prescribed diet orders and menu plans.
Failure to Serve Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to ensure that therapeutic diets were served as prescribed by the residents' physicians for two residents. During a dining room observation, an LVN was seen checking meal trays against meal tickets but not against the physician's orders. This resulted in a resident being served a no added salt, regular diet instead of the prescribed no added salt, mechanical soft diet. The LVN admitted to having memorized most of the residents' diets and acknowledged the oversight in not verifying the meal served against the physician's orders. In another instance, during a lunch trayline observation in the facility's satellite kitchen, a meal tray for a resident was found to include a Magic cup supplement that was not listed on the physician's order. The resident was supposed to be on a puree nectar thick liquid diet, but the tray ticket incorrectly included a mechanical soft meat. This discrepancy was confirmed by the Regional RD, indicating a failure to adhere to the prescribed dietary orders for the resident.
Infection Control Deficiencies in Hand Hygiene, Laundry, and Water Management
Penalty
Summary
The facility failed to adhere to proper infection control practices, as evidenced by several observations and interviews. In one instance, an occupational therapy (OT) staff member did not perform hand hygiene before and after assisting a resident with meals. The OT staff member was observed putting on gloves without washing hands, feeding the resident, and then removing gloves to open a door for another resident. The OT staff member then put on a new pair of gloves and resumed feeding without washing hands. This was confirmed during an interview with the OT staff member, who acknowledged the lapse in hand hygiene. Additionally, the facility did not ensure proper handwashing practices during medication administration for two residents. Licensed Vocational Nurses (LVNs) were observed not performing hand hygiene before and after administering medications. Interviews with the LVNs and the Director of Nursing (DON) confirmed that handwashing should occur between administering medications to different residents, but this was not followed. The facility's policy on administering medication and hand hygiene emphasizes the importance of handwashing to prevent infection spread, yet these practices were not adhered to. The facility also failed to maintain infection control in the laundry area, where personal clothing was stored with clean pillows, as verified by the Maintenance Director. Furthermore, the facility did not have an established and implemented water management program to prevent Legionella growth. The Maintenance Director and other staff were unable to provide documentation of regular testing or specific control measures for Legionella prevention. Interviews with the Director of Staff Development/Infection Preventionist (DSD/IP) and the Administrator confirmed the lack of a comprehensive water management program, posing a risk for the spread of Legionella and other pathogens.
Failure to Monitor Antibiotic Use According to McGeer's Criteria
Penalty
Summary
The facility failed to monitor and address the use of antibiotics according to McGeer's criteria for two residents, which could lead to inappropriate antibiotic use and the development of antibiotic-resistant bacteria. The facility's Antibiotic Stewardship Program, dated June 2021, requires that antibiotics be prescribed only when clinical definitions of active infection or suspected sepsis are met, and pathogen susceptibility is confirmed. However, the Infection Preventionist (IP) did not track or review whether McGeer's criteria were met before prescribing antibiotics to Resident 7 and Resident 10. Resident 7 was admitted with a cough and was prescribed azithromycin, but the surveillance log did not confirm if McGeer's criteria were met. Similarly, Resident 10 received Bactrim DS for recurrent pneumonia prophylaxis, but the records did not show if the infection met McGeer's criteria. Interviews with the Director of Staff Development/Infection Preventionist (DSD/IP) and the Director of Nursing (DON) confirmed these findings, indicating a lapse in the facility's antibiotic stewardship practices.
Failure to Monitor Freezer Temperature and Address Ice Buildup
Penalty
Summary
The facility failed to ensure the freezer compartment inside the medication refrigerator in Medication Room A was free of ice buildup and did not monitor or record the freezer temperature in the temperature log. During an inspection and interview with the DON, it was observed that the freezer compartment had ice buildup and contained ice packs, but lacked a thermometer. The facility's policy required verification and documentation of refrigerator, freezer, and room temperatures twice daily, with any deviations reported to the Nurse Leader or Health Care Administrator. However, the temperature log for November 2024 showed no documentation of freezer temperature monitoring, with horizontal lines recorded from November 1 through November 14, 2024. The DON confirmed that the freezer temperature should have been monitored and recorded twice daily, and the ice buildup should have been addressed.
Failure to Conduct Accurate Entrapment Assessments for Bed Rails
Penalty
Summary
The facility failed to ensure accurate and complete entrapment assessments for a resident using bed rails, which could lead to potential entrapment, serious injury, or death. The deficiency was identified through observation, interviews, and document reviews, revealing that the entrapment zones for the resident's bed were not properly measured. Specifically, the entrapment zones 1, 2, 3, and 4 for the right side rail, as well as zones 6 and 7 for both side rails, were not assessed. This oversight was confirmed by the Maintenance Director, who admitted to not being aware of the resident's use of bilateral grab rails and failing to measure the necessary zones. The resident involved was observed with elevated bilateral grab rails, and the facility's policy requires that all bed systems leave no gap wide enough to entrap a resident's head or body. The Maintenance Director, responsible for conducting these assessments, acknowledged the failure to measure the entrapment zones as required. The Director of Nursing was informed and verified the findings, highlighting a lapse in the facility's adherence to its own policies and procedures regarding bed safety and entrapment risk assessments.
Failure to Follow Puree Recipe for Residents
Penalty
Summary
The facility failed to adhere to the puree recipe for seven residents on a puree diet, which posed a risk of not conserving the nutritive value of the food. During an observation of puree meal preparation, Cook 1 was seen adding chicken broth to cooked peas instead of using the liquid from the cooked peas as specified in the recipe. Additionally, Cook 1 added multiple tablespoons of thickener to the food items, deviating from the recipe instructions that called for one and one-half tablespoons of thickener. These actions were verified with the Registered Dietitian (RD).
Inaccurate Medical Record Documentation for Resident with Fracture
Penalty
Summary
The facility failed to ensure accurate documentation in the medical record of a resident, identified as Resident 132, which had the potential to impact the resident's care needs. Resident 132 was admitted with a diagnosis of a right humerus fracture and had a fluctuating capacity to understand and make decisions. Despite this, the medical records showed that blood pressure readings were consistently taken from the resident's right arm, which was the site of the fracture. This was observed over a series of dates, with multiple blood pressure readings documented from the right arm. During an observation on November 13, 2024, a Licensed Vocational Nurse (LVN) attempted to take the resident's blood pressure from the right arm, but the resident refused. In a subsequent interview, the LVN confirmed that the blood pressure should not have been taken from the right arm due to the fracture. The Director of Nursing (DON) was informed of the situation and acknowledged that taking blood pressure from the right arm could cause pain and worsen the fracture. This oversight in documentation and practice highlights a deficiency in the facility's adherence to professional standards for safeguarding resident care.
Failure to Provide Equal Access to Nutritional Services
Penalty
Summary
The facility failed to provide equal access to nutritional services for a resident, identified as Resident 25, which posed a risk to the resident's rights. Resident 25, who was admitted with diagnoses including dementia and chronic kidney disease, was observed during a lunch meal waiting 40 minutes for her meal tray while other residents were already eating. The lunch was scheduled to be served at 1215 hours, but Resident 25 did not receive her meal until much later. A review of the facility's PCC list of diets did not include Resident 25's name, and staff, including the Director of Nursing, were unable to explain the delay in serving her meal.
Failure to Inform Residents of Complaint Procedures
Penalty
Summary
The facility failed to ensure that residents were informed of their rights and provided with information on how to formally complain to the State Agency about the care they received. During a resident council meeting, six residents expressed that they were unaware of the contact information for the State Licensing and Certification Office and did not know how to file a formal complaint. Instead, they mentioned that they would typically talk to the nurses if they had grievances or complaints. Interviews with the Activity Director and the Admissions Director confirmed that the residents were not provided with the necessary information on how to contact the State Agency. Although the State Agency's contact information was posted on the facility's consumer board, it was not included in the admission packet. The Admissions Director acknowledged that the information was not mentioned to the residents unless they specifically asked for it, and it was not part of the documents provided during admission.
Failure to Discontinue Sling Use as Ordered
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident attained and maintained their highest practicable physical well-being. Specifically, the facility did not carry out a physician's order to discontinue the use of a sling for the resident's right shoulder. The resident was observed wearing the sling during an initial tour of the facility, despite an order to discontinue its use being written on the same day. The order was noted without a time or signature from the licensed staff, and the Director of Nursing (DON) confirmed that the order was not executed. The Director of Staff Development (DSD) also verified that the order to discontinue the sling was not carried out as it should have been.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 884 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Juan Capistrano
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Capistrano Beach Care Center | 3.7 mi | ★★★★★ | 34 | 0 |
| Orchards Skilled Nursing | 3.8 mi | ★★★★★ | 0 | 0 |
| Palm Terrace Healthcare & Rehabilitation Center | 7.5 mi | ★★★★★ | 27 | 0 |
| Villa Valencia Healthcare Center | 8 mi | ★★★★★ | 7 | 0 |
| Laguna Hills Health And Rehabilitation Center | 8.1 mi | ★★★★★ | 49 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.