St. Juanita Retirement and Rehab

In the surveyor’s words

From the most serious findings on record at St. Juanita Retirement and Rehab, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF727Aug 17, 2026

  Based on observation, interview, and record review, the facility failed to provide the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week in that: The facility had no RN coverage on 8/15/21 and 8/16/21. This failure could affect residents by putting them at risk of poor nursing care and assessment. The findings were:Observation on 8/15/26 at 2:38 p.m. through 8/15/26 8:20 p.m. revealed no RN in the building. Observation on 8/16/26 at 10:24 a.m. through 1:36 p.m. revealed no RN in the building. Interview on 8/15/26 at 3:27 p.m. CNA A stated there were two nurses on the day shift, but there was not an RN on duty. Interview on 8/15/26 at 3:58 p.m. CNA B stated the only RN the facility had was the DON. Interview on 8/16/26 at 12:02 p.m. […]

• No harm, potential for more than minimal, patternF880Aug 17, 2026

  Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #1) observed for infection control. The facility failed to ensure LVN C and CNA D used the required PPE (gown) for Resident #1 who was on enhanced barrier precautions due to her pressure ulcer wound care on 8/15/26.LVN C failed to provide wound care to Resident #1 in a manner that prevented cross-contamination by failing to use any hand hygiene, placing the uncovered wound on the bed, going over the wound multiple times while cleaning, and using the same gloves the entire wound… […]

• No harm, potential for more than minimal, patternF552Jul 12, 2026

  Based on interview, and record review, the facility failed to allow the resident the right to be informed of, or participate in, his or her treatment for 3 (Resident #3, resident #4, Resident #6) of 6 residents reviewed for resident rights.The facility failed to inform the resident (Resident #6) and/or their RP/POA (Resident # 3, Resident #4), in advance, of the care to be furnished and the professional that would furnish the care.The facility failed to inform the resident (Resident #6) and/or their RP/POA (Resident # 3, Resident #4), in advance, by the physician or professional of the risks and benefits of proposed care, of treatment alternatives or treatment options he or she prefers.The facility failed to protect, promote, and respect the rights of each resident (Resident #3, Resident… […]

• No harm, potential for more than minimal, patternF812Dec 23, 2025

  Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to prevent dishes and utensils from being stored face up (open to air contamination).The facility failed to remove potatoes in the dry storage when they were beginning to show signs of rot.These failures could place residents who received prepared meals from the kitchen at risk of food borne illness and cross-contamination. The findings included:During the initial tour of the kitchen on 12/23/25 at 8:15 AM the following observations were revealed: The top plate in the plate warmer faced up and was not covered. […]

• No harm, potential for more than minimal, isolatedF842Aug 17, 2026

  Based on interview and record review the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 2 of 5 residents (Resident #1, Resident #2) reviewed for medical records. The facility failed to ensure wound care assessments were completed for Resident #1 and Resident #2 The facility failed to document changes in condition for Resident #1's development of an ulcer and keeping the family informed. These failures could place residents at risk of records being inaccurate and not receiving potentially needed services due to documentation errors. […]