San Juan Hills Healthcare Center

Inspectors wroteBased on interview, closed medical record review, and facility P&P review, the facility failed to to provide reasonable accommodations to meet the needs for one of four sampled residents (Resident 1). * The facility failed to ensure the facility's staff assisted Resident 1 to the bathroom on the day she was admitted to the facility. This failure had the potential to negatively impact the resident's psychosocial well-being or result in a delay of care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to meet the resident's care needs for one of four sampled residents (Resident 2). * The facility failed to complete a Change of Condition (COC) report and corresponding documentation related to Resident 2's new physician's order for the intravenous fluids due to poor oral intake. This failure had the potential for the resident to not receive adequate and timely care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure medications were not left unattended at the bedside for one of four sampled residents (Resident 1. * Multiple medications including oral, topical, and subcutaneous medications were left unattended at Resident 1's bedside without authorization for beside storage. This failure had the potential for Resident 1 to inaccurately self-administer the medications.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the DHPPD nurse staffing forms were accurate and posted daily. * The facility failed to ensure the DHPPD staffing information was posted daily on 5/22 and 5/26/26, and failed to complete and obtain required signatures on the forms dated 5/20 and 5/22/26. These failures had the potential to result in inaccurate staffing information provided to the public.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure information regarding the administration of psychotherapeutic medications was provided for one of eight sampled residents (Resident 1). * Resident 1's psychotherapeutic drug informed consent form for Depakote (anticonvulsant) was incomplete and inaccurate. * Resident 1's psychotherapeutic drug informed consent form for mirtazapine (antidepressant) was incomplete. * Resident 1's psychotherapeutic drug informed consent form for seroquel (antipsychotic) was incomplete * Resident 1's psychotherapeutic drug informed consent form for olanzapine (Zyprexa Zydis, antipsychotic) was incomplete 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.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure food safety and sanitation requirements were met in the kitchen. * The facility failed to ensure the proper labeling and dating of the food items in the main kitchen and satellite kitchen. * The facility failed to ensure the expired food items in the main & satellite kitchen were discarded. * One of one ice machine was not clean. * The facility failed to ensure a dry food storage container was properly sealed. * The facility failed to ensure the food preparation equipment were in good condition. * The facility failed to ensure the cutting board was kept in a sanitary condition. * The kitchen utensils and dishware were not stored in a sanitary condition. * The facility failed to ensure the food preparation equipment were properly air dried prior to storage. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the infection control practices designed to provide the safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to implement the infection control surveillance program for the months of January 2025 through August 2025. The facility conducted surveillance of resident infections only when the residents were prescribed antimicrobial medications and/or if the residents were diagnosed with an infection. The facility failed to determine whether the residents who exhibited signs and symptoms of infection and were not prescribed antimicrobial medications, or had not been diagnosed with an infection, met the facility's criteria for infection (utilizing McGeer's Criteria). [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one non-sampled resident (Resident 68) was assessed, had a care plan and a physician's order to self-administer the medications. * Resident 68's bedside table had Neosporin (antibiotic medication) ointment. There were no assessment, care plan or physician's order to self-administer this medication. This failure had the potential for the resident to administer the medication inaccurately and negatively impact the residents' physiological well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop a resident-centered care plans to reflect the individual care needs for two of 12 final sampled residents (Residents 67 and 72). * The facility failed to develop a comprehensive person-centered care plan to address Resident 67's right upper arm midline catheter and the administration of Dextrose - NaCl solution 5-0.45% (an IV fluid used for hydration and electrolyte replenishment). * The facility failed to develop a comprehensive person-centered care plan to address Resident 72's use of siderails. These failures had the potential risk of not providing appropriate, consistent, and individualized care to these residents.

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to ensure the comprehensive plan of care was revised to reflect the resident's current care needs and interventions for one of 12 final sampled residents (Resident 64).* Resident 64's care plan for alteration in functional mobility and presence of pain related to nondisplaced type III odontoid (neck bone) fracture was not revised to address the use of the neck collar brace as ordered by the physician. This posed the risk of not providing the resident with individualized and person-centered care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of one final sampled resident (Residents 67) reviewed for IV care. * The facility failed to ensure Resident 67's parenteral fluids were administered in accordance with the physician's order, and the right upper arm midline catheter was changed as per the facility's P&P. These failures had the potential for Resident 67 to not maintain adequate hydration and/or electrolyte levels and delay the identification of catheter related complications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the respiratory services for two of two final sampled residents (Residents 12 and 63) reviewed for respiratory care. * The facility failed to ensure Resident 12's nasal cannula tubing was changed as per the facility's P&P. In addition, the facility failed to ensure the nasal cannula tubing was stored in a set-up bag when not in use. * The facility failed to ensure Resident 63's nebulizer tubing and mask were changed every week as per the facility's P&P. These failures posed the risk of complications and negative health outcomes to Resident 12 and 63.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the monitoring of output and fluid restriction were followed for two of two final sampled residents (Residents 71 and 72) reviewed for dialysis. * The facility failed to ensure the output was properly monitored for Resident 71. * The facility failed to ensure the physician's order for 1500 ml of fluid restriction was followed and carried out accordingly for Resident 72. These failures had the potential of not identifying potential negative outcomes for the dialysis residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three final sampled residents (Resident 72) reviewed for the use of bed rails remained free from accident hazards associated with the use of elevated bed rails. * The facility failed to ensure the physician's order was obtained for the use of the right upper bed rail for Resident 72. In addition, an IDT assessment was not conducted prior to the use of the right upper bed rail. This failure had the potential to put the resident at risk for serious injuries.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food items were served in the appetizing and safe temperatures. * The food temperatures were above the recommended temperature for cold desserts. This failure posed the risk of not providing safe food for the residents receiving a meal tray from the kitchen.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the Facility Assessment was complete. * The facility failed to ensure the Facility Assessment addressed or included the active involvement of required individuals in developing the Facility Assessment and resources necessary to care for residents including weekends. This failure had the potential not to meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were completed and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of side rails for two of three final sampled residents (Residents 72 and 75) reviewed for side rails use. * The facility failed to ensure the entrapment assessment of bed rails were completed for Residents 72 and 75. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs of one of 12 final sampled residents (Resident 62). * The facility failed to ensure the call light for Residents 62 was within the residents' reach. This failure had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to dispose and store trash in a sanitary manner. * One of four dumpsters was overflowing with garbage which prevented the lid to be fully closed. This failure posed the risk for the development of odors, attract and harborage or breeding place of insects and rodents, and a possible source of contamination of food, equipment, and utensils.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to notify the physician when the resident had a change in condition for one of three sampled residents (Resident 1). * The facility failed to notify the physician when Resident 1 had low blood pressure readings. This had the potential for a delay in the physician prescribing necessary treatments and interventions for the resident.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services for one of four sampled residents (Resident 1). * The facility failed to properly assess Resident 1's bowel function and provided the timely interventions as ordered by the physician when Resident 1 had no bowel movement. This failure posed a risk for the resident not to receive the necessary care and interventions to maintain the resident's normal bowel function.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the care plan reflected the individual care needs for one of four sampled residents (Resident 1). * The facility failed to develop a care plan to address Resident 1's change of condition when Resident 1 had nausea/vomiting and diarrhea (frequent, loose, or watery stools). This failure posed the risk of not providing the appropriate, consistent, and resident-centered care to the resident.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the care plan was revised to reflected the individual care needs for one of four sampled residents (Resident 1). * The facility failed to develop a different interventions in Resident 1's care plan to prevent constipation. This failure posed the risk of not providing the appropriate, consistent, and resident-centered care to the resident.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record was complete and accurately maintained for one of three sampled residents (Resident 1). * Resident 1 had a blood sugar level of 58 mg/dL. There was no documentation a COC was initiated for the blood sugar level of 58 mg/dL. Additionally, there was no documentation the resident's representative was notified of the low blood sugar. * Resident 1's vital signs were documented as taken after the resident had already been discharged from the facility. These failures had the potential for not providing the necessary care and services due to incomplete medical record information.

Inspectors wroteBased on observation and interview, the facility failed to ensure the sanitary conditions in the satellite and main kitchens. This failure posed the risk of food services not meeting professional standards

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the self-administration of medications was safe for one of 14 final sampled resident (Resident 132) and one nonsampled resident (Resident 14). This failure had the potential to negatively impact the residents' physiological well-being and administer the medications inaccurately.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to address the concerns brought forth in the resident council meetings (a group of residents gathered to discuss interest and issues noted in the facility) and failed to notify two nonsampled residents (Residents 12 and 137) who filed the grievances regarding the outcomes of investigation. These failures had the potential for the residents' identified issues to go uncorrected.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of one final sampled resident (Resident 16) who had a mental disorder was referred to state PASARR representative for Level II evaluation and determination screening process. This failure pose risk for the resident not to receive adequate level of services, comprehensive assessment, intervention, and evaluation for conditions related to mental disorder.

Inspectors wroteBased on observation, interview, medical record review, facility's P&P review, and facility document review, the facility failed to provide the safe environment free from potentially serious accident hazards for two of two final sampled residents (Residents 383 and 432) who smoked in the facility. - Resident 383 was not accurately and thoroughly assessed to determine if they required supervision or any adaptive equipment while smoking, nor if they could safely store their own cigarettes or lighters. - Resident 432's smoking paraphernalia was left unsupervised. The residents who were assessed as requiring supervision or those with a history of non-compliance with the facility's smoking P&P were permitted to keep the cigarettes, lighters, and other smoking materials in their possession. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of 14 final sampled residents (Resident 285) and one nonsampled resident (Resident 436) to maintain or restore their bladder functions. * The facility failed to provide a bladder retraining for Resident 285 as identified in the care plan and facility's P&P. * The facility failed to ensure Resident 436 was placed on toileting program and a care plan to address Resident 436's toileting needs was developed. These failures posed the risk for these residents to lose their bladder control.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of two final sampled residents (Residents 132 and 282) reviewed for respiratory care were provided with the appropriate respiratory care. * The facility failed to ensure Residents 132 and 282's physician's order for administration of oxygen was clarified with the physician for continuous or PRN use. This failure had the potential to effect the respiratory health and well-being of the residents.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided when: * The facility failed to ensure all controlled medications were accurately accounted for and documented for one of 14 final sampled residents (Resident 432). * The medications received from pharmacy were accounted and signed for by the licensed staff who received the medications at the facility. * The facility failed to ensure the proper disposal of medications was followed. These failures posed the risk of drug diversion.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the orthostatic blood pressure monitoring was accurately performed as ordered by the physician related to the use of antipsychotic medication for one of one final resident (Resident 132) reviewed for antipsychotic medications. This failure had the potential for the resident to have adverse complications from the medication and the potential of not providing the correct data to the prescriber to adjust the dose of the psychotropic medication for the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 7.14% One licensed nurse (LVN 4) was found to have made error during the medication administration. * Resident 134 had a physician's order for Calcium Carbonate Tablet Chewable 500 mg one tablet by mouth one time a day for indigestion, chew and swallow. LVN 4 did not administer the medication as ordered by the physician. * Resident 4 had a physician's order for Effexor XR (medication to treat depression) Oral Capsule Extended Release 24 hour 75 mg one capsule by mouth one time a day for depression m/b persistent expression of hopelessness, give with food. LVN 4 did not administer the medication with food as ordered by the physician. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper medication storage. * The facility failed to ensure the expired treatment medications were removed from the medication cart. * The facility failed to ensure to separate the externally and internally medications from the medication cart and Medication Room A. * The facility failed to ensure proper storage of feeding formula and temperature monitoring. These failures had the potential to negatively impact the residents' well-being, and medication errors. Findings Review of the facility's P&P titled Medication Storage in the Facility dated 4/2008 showed orally administered medications are kept separate from externally used medication, such as suppositories, liquids and lotion. 1.a. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the dietary staff were competent in the skills needed to carry out the functions of the food and nutrition services. This failure posed the risk of the residents not receiving appropriate food and nutrition services.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the menu and diet orders were followed as evidenced by: * Chicken salad was not documented on the cool down log. * The kitchen staff did not use the correct serving size scoop. * The temperatures for milk and cottage cheese were not taken at the tray line. Cottage cheese was not maintained at the acceptable temperature. * Plates of dessert were near the dirty sink. * Tray ticket was inaccurate for one of 14 final sampled resident (Resident 383) * Food item was not served as per the tray ticket for one nonsampled resident (Resident A). * The lunch tray included a food item not appropriate for the resident's prescribed diet order for one nonsampled resident (Resident 136). * The facility failed to ensure the menu and diet order were followed for one of 14 final sampled residents (Resident 9). [...]

Inspectors wroteBased on observation and interview, the facility failed to follow the puree recipe for seven residents on puree diet. This failure posed the risk of the residents not receiving foods prepared by methods that conserve nutritive value.

Inspectors wroteBased on observation and interview, the facility failed to ensure the therapeutic diets were served as prescribed by the residents' physicians for one of 14 final sampled resident (Resident 16) and one nonsampled resident (Resident 284). * Resident 284 was not served the prescribed diet. * Resident 16 was served Magic cup (supplement) but not listed on the physician's orders. These failures had the potential for the residents not meeting the therapeutic needs.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were followed for two of 14 final sampled residents (Resident 132 and 435) and one nonsampled resident (Resident 134); in the laundry area; hand washing; and preventing Legionella. * The facility failed to perform handwashing before and after assisting Resident 435 with meals * The facility failed to perform handwashing before and after medication administration for Residents 132 and 134. * The facility failed to ensure infection control practices was maintained in the facility's laundry room when a facility staff personal clothing was stored with the rack of clean pillows. [...]

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to monitor and address the use of antibiotics when the resident's condition did not meet McGeer's criteria (a set of specific definitions to identify true infections in long term nursing facilities) for two residents (one discharged resident, Resident 10; and one nonsampled resident, Resident 7) on the surveillance log. This failure had the potential for antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the freezer compartment inside the medication refrigerator inside Medication Room A was free of ice buildup. In addition, the facility failed to ensure the freezer temperature was monitored and recorded in the temperature log. These failure had the potential for not maintaining the acceptable temperature for medication storage in the refrigerator.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate and complete, and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed rails for one of 14 final sampled residents (Resident 132). This failure had the potential to negatively impact the resident resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on observation, medical record review, and interview, the facility failed to provide an equal access to nutritional services for one nonsampled resident (Resident 25). This failure posed the risk of the resident's rights not being honored.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure two final sampled residents (Residents 132 and 285) and four nonsampled residents (Residents 2, 26, 135, and 436) who attended the resident council meeting were informed of their rights and given information on how to formally complain to the State Agency about the care they received. This failure posed the risk of the residents and/or their legal representatives to not receive the necessary services.

Inspectors wroteBased on interview and medical record review, the facility failed to provide the necessary care and services to ensure one of 14 final sampled residents (Resident 132) attained and maintained their highest practicable physical well-being. * The facility failed to ensure Resident 132's physician's order to discontinue the use of sling for the right shoulder was carried out. This failure created the risk of not providing appropriate and consistent care to the resident.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the medical record was accurately documented for one of 14 final sampled resident (Resident 132). This failure had the potential for the residents' care needs not being met as their medical information was inaccurate.

Inspectors wroteIntakes: CA00872022 Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residen (Resident 1) remained free from accident hazards. * Resident 1 sustained 6 falls while having resided in the facility. Resident 1 sustained the falls on 9/15 (twice), 9/21, 9/26, 10/11, and 10/24/23. After Resident 1 ' s fourth fall in the facility, the facility ' s IDT recommended and implemented the 1 to 1 staff supervision on Resident 1. However, the 1 to 1 supervision was not always provided to Resident 1. As a result, Resident 1 sustained another fall on 10/24/23, resulting in multiple fractured ribs which required the ORIF surgery for Resident 1 ' s right seventh through 10thribs.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen when: * Time/Temperature Control for Safety (TCS) foods (food that require time and temperature controls to limit the growth of illness causing bacteria) were not accurately monitored to ensure proper cool down process was followed. * The thawing process for meats was not performed as per the facility's P&P. * The expired food item in the kitchen was not discarded and was consumed by the resident. * One kitchen staff and one maintenance staff did not perform proper hand hygiene in the kitchen. * The handwashing sink was used for duties other than handwashing. * Trash was stored inappropriately in the kitchen. * Two kitchen staff and one non-staff personnel did not don hair or beard coverings in the kitchen. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to determine if it was safe for one of 12 final sampled residents (Resident 580) and one nonsampled resident (Resident 22) to self-administer the medication left at the bedside. * Resident 22 was observed with clobetasol propionate ointment (corticosteroid medication used to treat skin conditions) medication at bedside. Resident 22 did not have the assessment, physician's order, and care plan problem addressing the resident's self-administration of medication. * Resident 580 was observed with one bottle of Systane (eye drop lubricant) medication left unattended at bedside. Resident 580 did not have a physician's order, assessment, and care plan for self-administration of medications. These failures had the potential for Residents 22 and 580 to administer the medications inaccurately.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of three closed record sampled residents (Resident 8) and/or their representative were provided with the written information regarding the facility's bed-hold policy when the resident was transferred to the acute care hospital. This failure had the potential for Resident 8 and/or their representative to be unaware of their rights to request a bed hold and return to the first available bed should the resident's hospital stay exceed the seven-day bed-hold period.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop and implement the comprehensive person-centered care plan for one of the 12 final sampled residents (Resident 332). * The facility failed to implement the plan of care to provide the padded side rails for Resident 332. This failure posed the risk of not providing appropriate, consistent, and individualized care to Resident 332.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to provide the individualized and ongoing activity program to meet the needs and interests of one of 12 final sampled residents (Resident 6). * The facility failed to provide activities for Resident 6 to meet the resident's identified interests. Resident 6 was provided with the children's coloring page, connect the dot activity sheet, and [NAME] sheet. This failure had the potential for Resident 6 to experience feelings of social isolation and frustration.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure monitoring of the neurological status was conducted after a fall with head injury for one of 12 sampled residents (Resident 17). This failure had the potential for Resident 17 to not receive the necessary care and services.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care for two of 12 final sampled residents (Residents 1 and 581). * The facility failed to ensure Resident 1's nebulizer mask (a mask connected to a nebulizer machine used to deliver a liquid/ solution medication via inhalation directly into the lungs) was stored in the set-up bag when not in use and changed weekly as per the facility's P&P. In addition, the facility failed to ensure Resident 1's nasal cannula tubing was stored in the set-up bag when not in use as per the facility's P&P. * The facility failed to ensure Resident 581 received oxygen as ordered. These failures had the potential for these residents to not receive appropriate respiratory care, and for increased risks of infection and respiratory distress.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, * The facility failed to ensure the narcotic disposition bin was securely locked and sealed. Furthermore, the narcotic disposition bin included whole pills of disposed controlled medications not fully dissolved. * The facility failed to ensure the controlled medications signed out of the controlled medication report was accurately reflected on the eMAR for one nonsampled resident (Residents 9). * The facility failed to ensure LVN 1 administered albuterol-ipratropium solution as ordered for one of 12 final smapled residents (Resident 1). These failures had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of 12 final sampled residents (Resident 17) was free from unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior). * The facility failed to ensure nonpharmacological interventions were implemented for depression behaviors exhibited by Resident 17. This failure had the potential to place the resident at risk for receiving unnecessary medications and increased risk of serious medication adverse reactions.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to store medications, biologicals, and medical supplies in a safe manner. The facility also failed to replace three of four E-Kits (emergency medications in a portable sealed containers) within 72 hours of opening as required by the facility's P&P. * The facility failed to ensure the expired medications and medical supplies were not available for resident use. This failure had the potential for the outdated medications and medical supplies to be accidentally administered and/or used and the IV medical supplies not maintaining sterility (free from germs). * The facility failed to replace the IV, controlled medication, and oral E-kits within 72 hours of opening the kits. These failures had the potential for the medications not to be available when needed for the residents, resulting in poor resident outcomes.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the following: 1. Federal regulations related to the oversight of food service operations were followed when the facility did not employ of a full-time qualified individual, defined as 35 hours per week, to manage and oversee food operation services for the skilled nursing facility. 2. The Certified Dietary Manager who was responsible to oversee the main kitchen which produced food for the skilled nursing facility was competent in managing the day-to-day functions of the food services department. Failure to employ staff with the skills and abilities to effectively implement departmental processes in accordance with standards of practice, may jeopardize the health and well-being of the 33 residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, facility document, and P&P review, the facility failed to ensure the kitchen staff had the skill set necessary to safely perform manual dishwashing in the event of an emergency when one of one diet aides was not competent to describe or demonstrate the manual dishwashing process used in an emergency. This failure had the potential for resident dishes to not be washed correctly in an emergency which could lead to sanitation concerns.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to ensure the food items brought to the facility for the residents were stored or reheated for future resident consumption; and failed to ensure education was provided to staff and family/visitor regarding safe handling of the food brought into the facility. These failures had the potential to limit the residents' rights and enjoyment of food brought in by the family or visitors.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to monitor and address the use of antibiotics when the resident's condition did not meet McGeer's criteria (a set of specific definitions to identify true infections in long term nursing facilities) for one of four nonsampled residents (Resident 632). This failure had the potential for antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the essential equipment were maintained in safe operating condition when: * Two ice machines were not cleaned and/or sanitized as per the manufacturer's guidelines. * The [NAME] dishwashing machine temperature was not monitored as per the dishwashing machine and facility P&P guidelines; and the temperature dial for the dishwashing machine failed to accurately measure the water temperature. These failures had the potential for equipment to not function in the way they were intended to.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate and complete, and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed rails for all three residents with side rails. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the infection control practices were maintained in the facility's laundry room area when employee personal belongings were observed in the clean linen area. This failure posed the risk of contamination of clean linen, transmission of disease-causing microorganisms and infections.