San Juan Hills Healthcare Center

In the surveyor’s words

From the most serious findings on record at San Juan Hills Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 12, 2023

  Intakes: 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. […]

• No harm, potential for more than minimal, widespreadF812Nov 17, 2023

  Based 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. […]

• No harm, potential for more than minimal, patternF812Jan 22, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF880Jan 22, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF812Nov 15, 2024

  Based 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 Findings: Review of the Residents' Order Summary Report dated 11/12/24, showed 41 of 42 residents received meals prepared in the facility's kitchen. 1. On 11/12/24 at 0750 hours, an inspection of the facility's satellite kitchen was initiated. The following findings were observed: - a plastic see through container of juice was observed defrosting under running water in the hand wash sink of the satellite kitchen. The sink was observed with yellow and black stains, and a piece of wet paper towel in it. […]