San Juan Villa

The facility failed to notify the resident's representative and physician in a timely manner after finding a resident in another resident's bed.

Fire department hydrostatic test overdue (last date 6/20/2020), sprinkler gauges need testing/replacement, sprinkler head in kitchen dishwashing area loaded with debris, and freezer sprinkler head loaded with ice.

Missing annual inspection, hydrostatic tests required on various extinguishers, and Kitchen K extinguisher mounted over 5 feet high.

Failed to provide annual fire alarm report and fire alarm electrical breaker needs a lock.

Facility failed to provide annual fire door inspection report.

Deficiency previously cited was corrected.

Facility failed to ensure confidentiality of resident records for medication cart trash and medication cart computer. PHI was found in unsecured trash and unattended computers.

Facility failed to ensure 5 of 5 sampled staff received TB tests within required time frames.

Facility failed to provide Medicaid Policy to 4 of 7 sampled residents, and agreements were missing or unsigned.

Failure to ensure proper hand hygiene, cleaning procedures, and food storage. Observations included unsanitary handling of food, mold/residue in ice machines, and dirty kitchen vents.

Facility failed to have Registered Nurse (RN) delegation services and documentation in place for a resident requiring assistance with medications.

Facility failed to notify residents when food substitutions were made.

Facility failed to ensure background check authorizations were submitted before initiation of employment for 2 of 4 sampled staff.

Facility failed to obtain medications for 3 of 7 sampled residents (R1, R2, R3, R4) in a timely manner, putting residents at risk.

Facility failed to complete ongoing assessments focused on identified problems for 3 of 7 sampled residents (R1, R3, R7).

Facility failed to ensure 3 of 3 sampled staff completed required continuing education units (CEU).

Facility failed to monitor and document resident well-being after residents R2 and R3 did not receive prescribed medications/treatments.

Facility failed to ensure R1 received medications as prescribed, specifically failing to hold blood pressure-related medications when vital signs were out of parameters.

Facility failed to notify the physician when R3 consistently refused medications, placing the resident at risk.

Facility failed to provide care as agreed upon for R2, R4, and R7, including failures to supply oxygen tanks and perform medical device assessments.

The licensee failed to notify the physician when one resident refused their medications, which was an uncorrected deficiency previously cited on November 8, 2024.

Missed nocturnal shift fire drills (Q1 2023) and swing shift fire drills (Q4 2022). Corrected as of 12/14/2023.

Failed to provide documentation showing fire/smoke damper 4-year inspection. Corrected as of 12/14/2023.

Failed to provide forward flow test and 5-year fire department connection hydrostatic test documentation. Escutcheon plate in dining room separated from ceiling.

Failed to provide documentation showing kitchen suppression system technician holds ICC/NAFED certification.

Failed to provide documentation of second semi-annual kitchen suppression system inspection.

Failed to provide documentation of annual replacement of fusible links for kitchen suppression system.

Extinguishers need annual servicing.

Failed to provide documentation of annual fire alarm system inspection. Deficiency note: Sprinkler heads overdue for sample testing and painted sprinkler head found.

Failed to provide documentation showing testing and maintenance of carbon monoxide detectors.

Failed to maintain 2 exit signs in inner courtyard; signs do not illuminate when button is pressed.

Staff failed to follow infection control practice standards and remove soiled PPE prior to exiting residents' rooms during an active infectious disease outbreak.

Staff failed to follow infection control standards and remove soiled Personal Protective Equipment (PPE) prior to exiting residents' rooms during a viral infection outbreak.