San Juan Nursing Home, Inc.

In the surveyor’s words

From the most serious findings on record at San Juan Nursing Home, Inc., in the surveyor’s own words.

• No harm, potential for more than minimal, patternF637Dec 11, 2025

  Based on interview and record review the facility failed to complete a significant change MDS assessment within 14 days after a significant change in the resident's mental and physical condition for 3 of 5 residents (Resident #12, #4, and #2) reviewed for assessments.1. The facility failed to complete a Significant Change in Status MDS Assessment after Resident #12 admitted to hospice services on [DATE].2. The facility failed to complete a Significant Change in Status MDS Assessment after Resident #2 had four new diagnoses changes: Klebsiella Pneumoniae ([DATE]), Urinary Tract Infection (UTI [DATE]), Do Not Resuscitate (DNR [DATE]), and Pleural Effusion ([DATE]).3. […]

• No harm, potential for more than minimal, patternF644Dec 11, 2025

  Based on interviews and record review, the facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort for 5 of 16 residents reviewed for PASRR. (Residents #2, 7, 8, 9, and 11) 1. The facility failed to refer Resident #2 for PASRR Level II assessment when the facility incorrectly coded his PASRR Level I assessment. 2. The facility failed to refer Resident #7 for PASRR Level II assessment when the facility incorrectly coded her PASRR Level I assessment. 3. The facility failed to refer Resident #8 for PASRR review following new mental illness diagnosis. […]

• No harm, potential for more than minimal, patternF812Dec 11, 2025

  Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed and 1 of 1 nutrition rooms for storage, preparation, and sanitation. The facility failed to discard damaged pans and utensils. The facility failed to keep food products in the refrigerators and freezers sealed properly. The facility failed to follow a cleaning schedule. These failures could place residents at risk for food contamination and foodborne illness. Findings include: Initial tour and observation of the kitchen on 12/09/24, beginning at 8:15 am revealed 4 of 7 non-stick type coated frying pans were flaking. Three of the pans were completely bare, except for the sides. […]

• No harm, potential for more than minimal, patternF761Sep 6, 2024

  Based on observation, interview and record review the facility failed to ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable in 7 of 12 boxes of medical supplies (200 hallway) reviewed for medication storage and labeling. The facility failed to ensure7 boxes of medical supplies in the medication storage room, on the 200 hallway, had current usage dates and expired supplies were stored along with current medications/supplies. This failure could place residents at risk of receiving expired medical supplies, wound dressings that past expiration date would not have the intended therapeutic level or effect on a resident's wound. […]

• No harm, potential for more than minimal, isolatedF659Jun 18, 2026

  Based on interview and record review, the facility failed to ensure that care and services were provided by qualified persons in accordance with the written plan of care for 1 or 3 residents (Resident #1) reviewed for qualified persons.The facility failed to provide direct supervision to a student nurse while the student nurse administered a gastrostomy tube bolus feeding. This failure could place residents with a G-tube at risk of abdominal discomfort, aspiration, and decreased quality of life.Findings included: Record review of Resident #1's admission record dated 06/17/26 revealed an original admission date of 02/01/22 and admission date of 04/08/24. […]