San Juan Care Center

Inspectors wroteBased on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR; a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was accurate for 1 (R #1) of ( R #1) resident reviewed for PASARR accuracy. This deficient practice is likely to result in the facility not providing the services needed by residents who are identified in the screening process for additional care and services.

Inspectors wroteBased on observation and interview, the facility failed to ensure the ice machine drained through an air gap. This deficient practice is likely to affect all residents in the facility. If staff do not maintain the ice machine drain air gaps, then residents are at risk of foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to utilize screens in all windows of the facility to prevent pest from entering the facility. This failure had the potential to affect all residents in the facility. If the facility does not use screens in the windows, then pest could enter the facility and harm or annoy the residents.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to: - Ensure dining room linens remained in good repair and free from stains and holes. - Maintain the facility trash and debris free. This deficient practice had the potential to affect residents who utilized the main dining area and various courtyards in the facility. If the facility fails to maintain the facility in a homelike manner, then residents may experience a diminished environment that negatively impacts their dignity and quality of life.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception) unless the medication was medically necessary for 1 (R #94) of 1 (R #94) resident reviewed for unnecessary medications, when staff failed to ensure the resident's as needed (PRN) psychotropic medications were not prescribed for longer than 14 days without documentation in the resident's medical record of the rationale to extend beyond 14 days. These deficient practices could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result).

Inspectors wroteBased on record review, observation, and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #20) of 1 (R #20) resident. If the facility fails to implement a baseline care plan within 48 hours of admission for residents with complex needs, staff may lack necessary guidance to provide appropriate care which could lead to an adverse event (undesirable experience, preventable or non-preventable, that causes harm to a resident because of medical care or lack of medical care).

Inspectors wroteBased on observation and interview, the facility failed to protect a treatment cart (a movable piece of equipment used in healthcare facilities to store, transport, and dispense treatment supplies and tools) from unauthorized access when staff failed to lock the treatment cart when they left it unattended. This deficient practice had the potential to affect all residents on the 300 Unit. If staff fail to lock an unsupervised treatment cart, then residents could obtain medical equipment which could result in injury or death.

Inspectors wroteBased on interview and record review, the facility failed to meet regulatory requirements when discharging 1 (R #68) of 1 (R #68) resident when staff failed to ensure proper notification was given to the resident, conduct discharge planning, and confirm of resident receipt of the discharge notice. These failures had the potential for an incomplete and unsafe discharge and increase risk of resident harm.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a call light was in working order for 1 (R #1) of 1 (R #1) resident, when the staff failed to make sure the shower room call light was functional before R #1 bathed herself. If the facility is not ensuring a working call light system, then residents are unable to request immediate assistance when needed.

Inspectors wroteBased on record review and interview, the facility failed to notify the Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care) when R #1's oxygen saturation (the amount of oxygen in the blood) was low and required supplemental oxygen (oxygen therapy; a therapy treatment which provides extra oxygen) through a nasal cannula (a small, flexible tube that delivers oxygen to the nose through soft prongs) for 1 (R #1) of 3 (R #1, #2, and #3) residents reviewed for change in condition. If the facility is not notifying the POA when there is a change in condition then the POA is unable to make decisions related to treatment and advocate for the resident's care.

Inspectors wroteBased on observation and interview, the facility failed to safeguard (secure or protect) clinical record information by leaving protected health information (PHI; personal identifying information) unattended. The deficient practice has the potential to affect all residents on the 100 and 400 hall (residents were identified by the Resident Census List provided by the Administrator on 02/26/24). If the resident's clinical information is not adequately safeguarded, resident's PHI is likely to be accessed (obtained or examined) by unauthorized (not having permission or approval) residents, visitors, and or staff.

Inspectors wroteBased on observations and interviews the facility failed to ensure all medication carts were locked when not in use and ensure eye drops were dated when opened and not stored at the bedside for 1 (R #21) of 1 (R #21). These deficient practices will likely to result in 41 residents, identified on the census list provided by the Executive Director (ED) on [DATE], receiving expired medication and allowing access to medication carts to unauthorized personnel.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for 1 (R #71) of 3 (R #53, R #66, and R #71) residents reviewed for care plans by not following a planned schedule for dialysis care and by failing to include resident specific information in a goal. This deficient practice could likely result in residents not receiving the care needed to reach their highest practicable level of well-being.

Inspectors wroteBased on record review and interview, facility failed to ensure quality of care for 1 (R #53) of 2 (R #53 and R #71) residents reviewed by not following physician's orders to obtain weekly weights. This deficient practice could likely result in residents not receiving the care and services ordered.

Inspectors wroteBased on observation, record review, and interview, the facility failed to meet professional standards of care for 1 (R #63) of 3 (R #63, R #49, and R #32) residents reviewed for respiratory care by not properly dating the oxygen tubing for the resident. This deficient practice could likely lead to respiratory infections by the oxygen tubing becoming clogged due to condensation (a process where water vapor becomes liquid) or becoming dirty, leading to the reduced oxygen flow.

Inspectors wroteBased on record review and interview, the facility failed to obtain a physician's order for dialysis (clinical purification of blood as a substitute for the normal function of the kidney) access site assessment and monitoring (ensuring the site used for dialysis remains free of complications related to excessive bleeding or closing) for 1 (R #71) of 1 (R #71) residents reviewed for dialysis care. This deficient practice could likely result in residents not receiving dialysis care and monitoring they need after dialysis treatment.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff maintained accurate medical records for 2 (R #1 and R #3) of 3 (R #1, R #2 and R #3) residents reviewed for pressure ulcers (injuries to the skin and underlying tissue resulting from constant pressure on the affected body part). This deficient practice could likely result in residents not receiving the care and services they need.

Inspectors wroteBased on record review and and interview, the facility failed to develop a comprehensive care plan for 1 (R #2) of 3 (R #1, R #2 and R #3) residents reviewed for pressure ulcers (injuries to the skin and underlying tissue resulting from constant pressure on the affected body part). This deficient practice could likely result in residents not receiving the care and treatment needed to reach their highest well-being.

Inspectors wroteBased on record review, observation, and interview the facility failed to ensure that the ice-making machine was maintained in a clean and sanitary condition. This deficient practice could likely affect all 86 residents identified on the Facility Matrix provided by Administrator on 11/14/22 by not storing ice in a machine that is free from contamination and allowing the spread of bacteria and viruses.

Inspectors wroteBased on interview, record review, and observation, the facility failed to ensure that proper infection control practices were consistently followed. The following deficient practices could likely affect any of the 86 residents identified on the Facility Matrix provided by Administrator on 11/14/22 by allowing the spread of infectious agents [bacteria and viruses]. 1. Catheter tubing dragging on the ground under residents wheelchairs for R #'s 21, 64 and 70. 2. Catheter bag being placed on floor for R #50. 3. Laundry room not maintained in sanitary condition. 4. Residents room not sanitary after laundry

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure quality care for 3 residents (R #'s 50, 59 and 72 ) of 3 (R #'s 50, 59 and 72) reviewed for diets, catheter care (a catheter is a hollow tube, inserted within the bladder and is an aid to help you pass urine and must have the tubing changed and the area kept clean to prevent infection) and restorative care (designed to improve or maintain the functional ability of residents). This deficient practice could likely cause: 1. R #50 to receive the wrong diet that may likely result in difficulty swallowing, chocking on food or aspiration [breathing into airway, food or liquid] pneumonia [a lung infection]. 2. R #59 an infection could occur if there are no orders for catheter care. 3. R #72 to have deterioration in his ability to maintain or improve his ability to walk.

Inspectors wroteBased on observation and interview the facility failed to maintain a process that would ensure that oxygen tubing, humidifier (a device used to add moisture to the air) bottles and aerosol (high flow of oxygen) mask reviewed for respiratory care: 1. Were dated when changed for 2 (R# 23, 66) of 2 (R #23, 66) residents 2. Aerosol mask to be replaced weekly as ordered by a physician R #66. These deficient practices could likely lead to confusion amongst the staff as to when the oxygen tubing, humidifier bottles and aerosol masks are due to be changed to prevent infection as a result of unsanitary (dirty or unhealthy and therefore likely to cause disease) conditions.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the care plan had been revised for 1 (R #57) of 1 (R #57) resident reviewed by not updating a care plan to reflect discontinuation of medication and blood drawn for laboratory tests. This deficient practice could likely cause staff to be unaware of current resident needs and impair the safety of the resident by staff administering medications and performing blood draws for laboratory testing that was discontinued by a physician.