Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Nursing Home Inc during CMS and state inspections, most recent first.
Failure to Complete Significant Change MDS Assessments: The facility did not complete Significant Change in Status MDS assessments for three residents after major changes in condition, including hospice admission, new diagnoses such as UTI, DNR status, pleural effusion, and worsening respiratory symptoms with cough, congestion, SOB, oxygen use, and suctioning. Records showed no significant change assessments were completed, and interviews with MDS and nursing leadership reflected inconsistent tracking and completion of these assessments.
Failure to Refer Residents for PASRR Review: The facility did not coordinate PASRR assessments for several residents with dementia, psychotropic medication use, behavioral symptoms, or newly identified mental health diagnoses. Five residents had negative Level I PASRRs or no follow-up PASRR review despite diagnoses such as mood disorder, psychotic disorder, major depressive disorder with psychotic symptoms, bipolar disorder, delusional disorder, and severe cognitive impairment. Interviews showed staff were unclear on PASRR responsibility, no one was tracking referrals, and PASRR training had not been provided for years.
Food Service Sanitation and Storage Failures: Surveyors observed flaking non-stick pans, damaged spatulas, buildup on a steam table shelf, mold-like substance on bread refrigerator gaskets and doors, and spoiled or improperly stored food in the walk-in refrigerator and freezer. Interviews showed confusion about responsibility for damaged equipment and food storage, and the DM stated the cleaning schedule had not been followed properly for over nine months. Record review showed limited sanitation check-offs despite facility policies requiring daily and weekly inspections.
Unlocked Nurse Medication Cart Left Accessible: An unlocked nurse med-cart was observed unattended in a Wing 1 hallway with the keys hanging from the lock and all drawers accessible. The cart contained medications, including narcotics. LVN-D stated she forgot to lock the cart and remove the keys before walking away, and the DON and Administrator stated it was the nurse's responsibility to keep the cart locked and maintain the keys.
QAPI plan lacked a process for conducting QAA/QAPI activities, including how to identify and correct quality deficiencies and how to handle change in condition assessments. The ADM and DON stated nurses were documenting progress notes for resident changes or injuries but were not completing focused assessments, SBARs, or significant change assessments, and significant changes were not being tracked or trended. The MDS Coordinator stated she only signed off that MDS assessments were completed and did not verify accuracy or whether the proper assessments had been done.
Infection control failures occurred during wound care for a resident with a Stage IV pressure ulcer and multiple chronic conditions. An LPN removed gloves and put on new gloves without hand hygiene, then used a wooden applicator from an open shared container instead of a sterile, individually wrapped applicator. The facility also lacked an established Legionella prevention and surveillance process, and leadership stated no water-system prevention measures had been implemented.
The facility failed to label and discard expired medical supplies in accordance with professional principles. An observation revealed expired dressings in the medication storage room, posing a risk to residents. Interviews with staff, including an LVN, ADON, and DON, indicated a lack of systematic checks and no specific policy for handling expired items.
A facility failed to include a dementia diagnosis in a resident's care plan, despite severe cognitive impairment and dependence on staff for ADLs. Staff interviews revealed oversight in updating the care plan, with the DON acknowledging the need for comprehensive care planning.
A resident with multiple health conditions was not provided oxygen at the prescribed rate, receiving 3 LPM instead of the ordered 2 LPM. Staff interviews revealed inconsistencies in monitoring and adjusting the oxygen flow rate, with the DON stating that checks should occur at least twice daily. The facility's policy on oxygen administration was not followed, potentially risking respiratory distress for the resident.
Failure to Complete Significant Change MDS Assessments
Penalty
Summary
The facility failed to complete Significant Change in Status MDS assessments within 14 days after significant changes in condition for 3 of 5 residents reviewed. The report identified failures for a resident admitted to hospice services, a resident with multiple new diagnoses including Klebsiella pneumoniae, UTI, DNR status, and pleural effusion, and a resident whose cough, congestion, and shortness of breath progressively worsened over time. For the resident admitted to hospice, the record showed diagnoses including CHF, AFib, and palliative care, and a physician order to admit the resident to hospice with CHF. The care plan included hospice interventions such as coordinating with hospice, keeping the resident comfortable, and monitoring for changes in condition. The electronic record did not show that a Significant Change in Status MDS assessment was completed after hospice admission, and none were found for the resident during the entire stay. For the resident with multiple new diagnoses, the record showed new findings and orders related to Klebsiella pneumoniae, UTI treatment, a change in code status to DNR, and a pleural effusion. The care plan included DNR interventions, respiratory monitoring for shortness of breath, and infection monitoring. The electronic record did not show a Significant Change in Status MDS assessment after these changes, and none were found for the resident during the entire admission. For the resident with worsening respiratory symptoms, the record showed repeated progress notes for cough and congestion, use of cough medication, chest percussion and deep suctioning without success, oxygen use for low saturations, audible crackles, and a STAT chest x-ray and lab work ordered with continued albuterol treatments. The annual MDS did not reflect oxygen therapy or suctioning, and the electronic record did not show a Significant Change in Status MDS assessment after the resident progressively worsened. Interviews with MDS and nursing leadership indicated confusion and inconsistency about tracking and completing significant change assessments.
Failure to Refer Residents for PASRR Review
Penalty
Summary
The facility failed to coordinate assessments with the PASRR program to the maximum extent practicable for 5 of 16 residents reviewed. Residents with incorrect PASRR Level I coding or with newly identified mental health diagnoses were not referred for PASRR Level II assessment or review, and no additional PASRR screenings were found in their records. The deficiency involved Residents #2, #7, #8, #9, and #11. Resident #2 was admitted with diagnoses including unspecified dementia, mood disorder due to a known physiological condition, anxiety disorder due to a known physiological condition, and cognitive communication deficit. His MDS showed moderate cognitive impairment, dependence for all ADLs, bowel incontinence, a urinary catheter, a feeding tube, progressive neurological conditions, diabetes, stroke, anxiety disorder, bipolar disorder, and psychotropic medication use. His PASRR Level I was negative for MI, ID, or DD, and the record contained no other PASRR screening. Resident #7 had diagnoses including Parkinson's disease, psychotic disorder with hallucinations due to a known physiological condition, unspecified dementia, depression, and functional quadriplegia. Her MDS showed severely impaired cognition, no functional abilities, dependence for all ADLs, bowel incontinence, a urinary catheter, a feeding tube, antidepressant and antipsychotic use, and continuous oxygen therapy. Her PASRR Level I was negative for MI, ID, or DD, and there were no other PASRR screenings. Resident #8 was admitted with unspecified dementia, anxiety, depression, Parkinson's disease, and lack of coordination, and later was diagnosed with mood disorder due to a known physiological condition, delusional disorders, and insomnia. His MDS showed severely impaired cognition, behavioral symptoms toward others, dependence for all ADLs, bowel and bladder incontinence, non-Alzheimer's dementia, mood disorder, progressive neurological conditions, stroke, Parkinson's, anxiety, depression, psychotic disorder, heart failure, psychotropic medication use, and oxygen therapy. His PASRR Level I was negative for MI, ID, or DD, with no other PASRR screenings. Resident #9 was admitted with unspecified dementia, anxiety disorder, major depressive disorder, and insomnia, and later was diagnosed with major depressive disorder, recurrent, severe with psychotic symptoms. Her MDS showed no impaired cognition, use of a manual wheelchair, independence with most ADLs except for setup and cues, occasional bladder incontinence, and diagnoses including non-Alzheimer's dementia, progressive neurological conditions, anxiety, depression, respiratory failure, end stage renal disease, and heart failure. She was on dialysis and oxygen therapy. Her PASRR Level I was negative for MI, ID, or DD, and there were no other PASRR screenings. Resident #11 had diagnoses including anxiety disorder, diabetes, arthritis, heart failure, anemia, major depressive disorder, mood disorder due to a known physiological condition, vascular dementia, depression, bipolar disorder, and delusional disorders. Her MDS showed severely impaired cognition, dependence for all ADLs, bowel and bladder incontinence, anemia, heart failure, progressive neurological conditions, diabetes, non-Alzheimer's dementia, anxiety disorder, bipolar disorder, psychotic disorder, asthma, antianxiety medication use, oxygen therapy, and hospice care. Her PASRR Level I was negative for MI, ID, or DD, and a physician-signed form 1012 was present but never filed; no other PASRR screenings were found. During interviews, the MDS staff and administration gave inconsistent descriptions of who was responsible for PASRR and stated that no one was tracking it. The MDS coordinator said he had not followed up with PASRR since Covid and had never received PASRR training. The DON stated the MDS coordinator was responsible for referrals when residents had newly evident qualifying diagnoses. The ADM said the facility had not had PASRR training for years and did not know the PASRR process or when a form 1012 should be used. The facility policy stated that residents with newly evident or possible serious mental disorder, intellectual disability, or related condition were to be referred promptly for Level II review, but the records for these residents did not show that occurred.
Food Service Sanitation and Storage Failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen and in a nutrition room. During an initial tour of the kitchen, surveyors observed 4 of 7 non-stick frying pans with flaking coating, including 3 pans that were completely bare except for the sides. Two large spatulas in the use bin had chunks of plastic missing around the edges. The underside of the shelf directly over food on the steam table had removable red, brown, and black substances on it. Surveyors also observed food storage problems in the refrigerators and freezer. There was a removable fuzzy black substance on and around the gaskets and doors of the 2-compartment bread refrigerator. Tomatoes with fuzzy black spots were leaking juices in the walk-in refrigerator, and 7 large limp carrots with fuzzy black spots were inside a box touching more carrots. An unsealed zip-type bag of cut cabbage was open to air in the walk-in refrigerator. In the walk-in freezer, a large open plastic bag labeled sausage slices was observed, and the sausage slices had ice on them. In interviews, the DA, cooks, DM, DON, MDS, and ADM gave differing descriptions of who was responsible for damaged equipment, food storage, and nutrition room oversight. The DM stated he was responsible for everything in the kitchen, that the cleaning schedule had not been followed properly for over nine months, and that staffing shortages had caused some tasks to be cut out. Record review showed a 4-page cleaning schedule for 2025, but there were no check-offs for any days in December 2025 and only limited check-offs in prior months. Facility policies required food to be stored, prepared, distributed, and served in accordance with professional standards, required daily inspection of refrigerators and freezers, and required weekly sanitation inspections by the dietary manager.
Unlocked Nurse Medication Cart Left Accessible
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in locked compartments for 1 of 6 medication carts reviewed. During observation on 12/09/2025 at 9:42 AM, an unlocked nurse medication cart was found parked down from the nurse's station in the long hall on Wing 1 with no nurse or other staff nearby. The keys were hanging from the lock, the cart lock was popped out, and all drawers could be opened and accessed. The cart contained medications, including narcotics, and residents were seen walking and passing by the cart. In an interview at the time of the observation, LVN-D stated the cart was hers and that she had forgotten to lock it and remove the keys before walking away. She stated the cart should always be locked when not in use because residents or anyone else could get into it and remove medications that did not belong to them. She also stated the key ring contained the regular med-cart key, the narcotic box key, a key to the medication room, a key to the lock box in the medication room, and other keys she was unsure about. The DON and Administrator later stated it was the nurse's responsibility to keep the cart locked and maintain the keys, and the facility policy required carts and compartments containing drugs and biologicals to be locked when not in use.
QAPI Plan Lacked Process for Change in Condition Tracking and Deficiency Correction
Penalty
Summary
The facility failed to develop a QAPI plan that described the process for conducting quality assessment and assurance activities, including how the committee would identify and correct quality deficiencies and how it would conduct change in condition assessments for 3 of 16 residents. During interview, the ADM stated that a significant change was a deviation from a resident’s baseline that would require treatment or monitoring, but also stated that if an injury or accident occurred, nurses would document a progress note and not complete an actual assessment. The ADM further stated that floor nurses should be completing assessments such as a focused assessment or SBAR with resident changes, but was unsure whether they were doing so, and stated that because significant changes were not being made, the facility was not able to track and trend resident changes and it was not part of QAPI. The DON stated that when a resident had a change in condition, floor nurses assessed the situation and documented it in a progress note, but did not complete an actual focused assessment or SBAR assessment for the change in condition, although he acknowledged those assessments would be needed. The DON stated the nurses should have been completing focused assessments, SBARs, or significant change assessments to trigger MDS significant change in condition assessments, but they were not being done, and significant changes were not being tracked and trended. The MDS Coordinator stated she had been trained on MDS assessments and forms, but she did not actually check for accuracy or verify that the proper assessments were completed, and said her role was only to sign off that the MDS had been completed. She also stated that administration met twice a week to discuss issues in the facility and with residents, but they were not tracking or trending significant changes or monitoring them. Record review of the facility’s QAPI policy dated 02/12/25 showed that the QAPI plan was to address tracking and measuring performance, establishing goals and thresholds, identifying and prioritizing quality deficiencies, and developing corrective action or performance improvement activities, and that data from all departments was to be collected and used to develop and monitor performance indicators.
Infection Control Failures During Wound Care and Legionella Prevention
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for Resident #5, a female with hypertension, type 2 diabetes, end stage kidney disease, and cerebral infarction, who also had a Stage IV pressure ulcer and a BIMS score of 00. During wound care observation, LVN A sanitized the wound care tray, removed gloves, and put on new gloves without sanitizing or washing hands. LVN A later removed gloves again after preparing the wound care supplies and put on new gloves without sanitizing or washing hands. During the same wound care observation, LVN A removed a wooden applicator from a shared cup on the medication cart and placed it on the tray for use with Resident #5's wound. The applicators were stored together in an open container, were not individually wrapped, and were not sterile. LVN A stated he had forgotten some steps, acknowledged that hand hygiene was important after glove removal to prevent cross-contamination, and stated he probably should have used an individual sealed applicator because it would be sterile. He also stated that using a non-sterile wooden applicator could possibly cause the wound to not heal or become infected. The facility also failed to maintain an infection prevention and control program that included a system for preventing and controlling Legionella. The Maintenance Director stated he had not established any prevention measures to monitor and prevent Legionella and that nothing had been done to the water system other than replacement of three water heaters. The IP stated she was aware of Legionella but was not trained on its prevention, and the DON stated the facility needed monitoring and prevention strategies in place to prevent Legionella. The facility's policies reflected hand hygiene requirements after glove removal and use of sterile applicators for wound care, as well as a Legionella surveillance policy with water management controls.
Failure to Properly Label and Discard Expired Medical Supplies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled according to currently accepted professional principles, including appropriate accessory and cautionary instructions and expiration dates. During an observation of the medication storage room on the 200 hallway, it was found that seven out of twelve boxes of medical supplies contained expired items. Specifically, there were two boxes of collagen dressings and three boxes of silicone super-absorbent dressings with expiration dates that had already passed, as well as two boxes of Allevyn Adhesive dressings with an upcoming expiration date. This oversight could potentially place residents at risk of receiving expired medical supplies, which may not provide the intended therapeutic effect. Interviews with facility staff, including an LVN, the ADON, and the DON, revealed a lack of a systematic process for checking and discarding expired medications and supplies. The LVN mentioned that expired medications were placed in a box for disposal by the ADON, DON, and pharmacist, but was unsure of the frequency of these checks. The ADON admitted to conducting random checks every 2-3 months but acknowledged that some expired items might have been overlooked. The DON confirmed that everyone with access to the medication room was responsible for discarding expired items and maintaining organization, but there was no specific policy in place for handling expired medications and supplies.
Failure to Include Dementia in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident diagnosed with dementia. The resident, a female with unspecified dementia and depression, was found to have a care plan that did not reflect her dementia diagnosis. The resident's quarterly MDS indicated severe cognitive impairment and dependence on staff for activities of daily living and mobility. Despite these findings, the care plan dated August 21, 2024, lacked focus, goals, or interventions related to her dementia diagnosis. Interviews with facility staff revealed a lack of responsibility and oversight in updating the care plan to include the dementia diagnosis. MDS staff acknowledged the oversight, noting that the dementia diagnosis was mentioned only in the context of ADLs but not specifically care planned. The Director of Nursing confirmed that the dementia diagnosis should have been included in the care plan, emphasizing the collaborative nature of care planning and the importance of addressing all resident needs comprehensively.
Failure to Administer Prescribed Oxygen Rate
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically by not administering oxygen at the prescribed rate. The resident, a 90-year-old female with multiple diagnoses including Alzheimer's Disease, Parkinsonism, hypertensive heart disease with heart failure, and vascular dementia, was prescribed oxygen therapy to maintain oxygen saturation above 92%. However, during an observation, it was noted that the resident was receiving oxygen at 3 liters per minute (LPM) instead of the prescribed 2 LPM. Interviews with staff revealed that the oxygen flow rate was not consistently monitored or adjusted according to the doctor's orders. An LVN admitted to adjusting the flow rate after noticing it was set incorrectly and suggested that the concentrator might have been bumped, causing the change. The Director of Nursing (DON) stated that floor nurses were responsible for ensuring accurate oxygen flow rates and that these should be checked at least twice a day during shift changes. Despite this, the resident was found to be receiving more oxygen than prescribed, which could lead to potential health risks. The facility's policy on oxygen administration, dated October 2010, outlines the procedure for safe oxygen administration, including starting the flow at 2 to 3 LPM unless otherwise ordered and ensuring the proper flow is maintained. However, the policy was not adhered to in this instance, as evidenced by the incorrect oxygen flow rate being administered to the resident. This oversight in following the prescribed oxygen rate could place residents at risk for respiratory distress.
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 178 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — 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
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Heights Of Alamo | 2.7 mi | ★★★★★ | 2 | 0 |
| Windsor Las Palmas Nursing And Rehabilitation Cent | 3.4 mi | ★★★★★ | 1 | 0 |
| Mcallen Transitional Care Center | 3.5 mi | ★★★★★ | 5 | 0 |
| Mcallen Nursing Center | 3.9 mi | ★★★★★ | 4 | 0 |
| Colonial Manor Advanced Rehab & Healthcare | 4.1 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for San Juan Nursing Home Inc.
100% money-back within 48 hours.
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.