Health inspection·June 2, 2023

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop a base line care plan that included instructions needed to provide effective and person-centered care of the resident for 1 resident (Resident #117) of 17 residents reviewed for base line care plans. The facility did not develop a base line care plan for Resident #117 that addressed Resident #117's use of antipsychotic medication. This failure could place resident receiving antipsychotic medications of not receiving the necessary care required to maintain psychosocial well-being. The findings were: Record review of Resident #117's Physician's Orders dated 05/30/23 revealed Resident #117 was an [AGE] year-old female who was admitted to the facility on [DATE] with admitting diagnosis of Alzheimer's disease, Type 2 Diabetes Mellitus, and generalized anxiety disorder. Record review of Resident #117's Interim Care Plan (base line care plan) revealed the section for antipsychotics/psychotropics was blank. Record review of Resident #117's Physician's Orders dated 05/30/23 revealed an order for Olanzapine oral tablet 5 mg, give one tablet orally one time a day for anxiety. Record review of Resident#117's e-MAR revealed Resident #117 was administered Olanzapine tablet 5mg on 05/30/23, 05/31/23, and 06/01/23 at 6:30 PM. In an interview on 06/02/23 at 09:45 AM, Resident #117 said she did feel anxiety at times, but she felt well now. Resident said she took her medication. Resident said she only felt anxious when she had a problem and would feel nervous then. Resident said she has not seen her family member in years, and she hoped that her family member was alive. Resident said when she was thinking of her family member, she began to feel nervous. Resident said she did not know if she was taking the medication for anxiety. In an interview on 06/02/23 at 09:57 AM, LVN A said, Resident #117 received the Olanzapine in the evenings. Resident #117 had not had any signs of anxiety. In an Interview on 06/02/23 at 12:37 PM, MDS/LVN B said the Interim Care Plan had to be completed (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 455484 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Nursing Home Inc 300 N Nebraska San Juan, TX 78589 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)