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Deficiency Records for San Juan Hills Healthcare Center
A list of the most recent deficiencies for San Juan Hills Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for San Juan Hills Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-12 | 2024-01-02 | Y |
| Keep all essential equipment working safely. | Health | 2023-11-17 | 2023-12-17 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-11-17 | 2023-12-15 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-11-17 | 2023-12-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-17 | 2023-12-15 | N |
| Provide activities to meet all resident's needs. | Health | 2023-11-17 | 2023-12-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-17 | 2023-12-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-17 | 2023-12-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-17 | 2023-12-15 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-11-17 | 2023-12-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-11-17 | 2023-12-15 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-11-17 | 2023-12-15 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-11-17 | 2023-12-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-17 | 2023-12-15 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-11-17 | 2023-12-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-17 | 2023-12-15 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-11-17 | 2023-12-15 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-11-17 | 2023-12-15 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-11-20 | 2023-12-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-20 | 2023-12-07 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-11-20 | 2023-12-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-20 | 2023-12-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-11-20 | 2023-12-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-20 | 2023-12-07 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-10-20 | 2022-11-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-20 | 2022-11-10 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-10-20 | 2022-11-10 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-10-20 | 2022-11-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-20 | 2022-11-10 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-10-20 | 2022-11-10 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-10-20 | 2022-11-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-10-20 | 2022-11-10 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-10-20 | 2022-11-10 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-10-20 | 2022-11-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-20 | 2022-11-10 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-10-20 | 2022-11-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-20 | 2022-11-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-24 | 2022-11-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-24 | 2022-11-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-24 | 2022-11-04 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-10-24 | 2022-11-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-24 | 2022-11-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-10-24 | 2022-11-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-04-08 | 2022-04-18 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-09-10 | 2019-11-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-09-10 | 2019-11-22 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-09-10 | 2019-11-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-10 | 2019-10-23 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-09-10 | 2019-10-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-10 | 2019-10-23 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-09-10 | 2019-10-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-10 | 2019-10-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-10 | 2019-10-23 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-09-10 | 2019-10-23 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-09-10 | 2019-10-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-10 | 2019-10-23 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-09-10 | 2019-10-23 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-09-10 | 2019-10-23 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-09-10 | 2019-10-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-10 | 2019-10-23 | N |
| Dispose of garbage and refuse properly. | Health | 2019-09-10 | 2019-10-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-10 | 2019-10-23 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-09-10 | 2019-10-23 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-10-02 | 2019-10-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-02 | 2019-10-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-02 | 2019-10-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-10-02 | 2019-10-22 | N |
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