Inspection visit
Inspection
Citations
23 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0026GeneralS&S Cno actual harm
Establish roles under a Waiver declared by secretary.
- 0345GeneralS&S Epotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0347GeneralS&S Dpotential for harm
Properly provide smoke detection systems in areas open to corridors.
- 0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Epotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F554 - The right to self-administer medications if the interdisciplinary team, as
Allow residents to self-administer drugs if determined clinically appropriate.
F625 - Transfer and discharge-
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.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F679 - Activities
Provide activities to meet all resident's needs.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F758 - Medication Errors
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.
F761 - Labeling of Drugs and Biologicals
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.
F801 - Staffing
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.
F802 - Staffing
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F813 - Food Safety Requirements
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
F909 - Conduct Regular inspection of all bed frames, mattresses, and bed
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.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the November 17, 2023 survey of SAN JUAN HILLS HEALTHCARE CENTER?
This was a inspection survey of SAN JUAN HILLS HEALTHCARE CENTER on November 17, 2023. The surveyor cited 23 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SAN JUAN HILLS HEALTHCARE CENTER on November 17, 2023?
Yes, 23 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Establish roles under a Waiver declared by secretary."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.