Inspection Reports for
San Juan Care Center
806 W MAPLE STREET, FARMINGTON, NM, 87401
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% better than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 13, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to ensure proper notification, discharge planning, and confirmation of resident receipt of discharge notice for resident #68, which potentially led to an unsafe discharge.
Complaint Details
The complaint investigation found that resident #68 was discharged without proper notification and discharge planning. The resident was arrested and discharged while in jail, and the facility could not confirm the resident received the discharge notice. The resident did not receive medications upon discharge, and no discharge plan was created. Interviews with the Director of Nursing, Administrator, and Regional Nurse Consultant confirmed these failures.
Findings
The facility failed to meet regulatory requirements when discharging resident #68 by not providing proper notification, not conducting discharge planning, and not confirming the resident received the discharge notice. The resident was discharged after unsafe behavior, but the discharge process lacked appropriate documentation and planning, increasing the risk of harm.
Deficiencies (1)
Failure to ensure proper notification was given to the resident, conduct discharge planning, and confirm resident receipt of discharge notice during discharge of resident #68.
Report Facts
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding discharge process failures for resident #68 |
| Administrator | Administrator | Interviewed regarding discharge notice delivery and facility decision to deny reentry |
| Regional Nurse Consultant | Regional Nurse Consultant | Interviewed regarding expectations for discharge planning for resident #68 |
| Medical Director | Medical Director | Documented resident was no longer safe to remain in the facility |
| Assistant Director of Nursing | Assistant Director of Nursing | Involved in incident leading to resident discharge |
Inspection Report
Routine
Deficiencies: 6
Date: Jun 13, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory standards related to resident care, safety, medication management, environment, and infection control.
Findings
The facility was found deficient in multiple areas including maintaining dining room linens in good repair, ensuring cleanliness of grounds and trash removal, proper use and documentation of psychotropic medications, creation of baseline care plans within 48 hours of admission, securing treatment carts, proper food safety practices related to ice machine drainage, and pest control measures such as window screens.
Deficiencies (6)
Dining room linens were stained and had holes, and the facility grounds contained trash and debris visible from resident areas.
Residents received psychotropic medications without proper 14-day stop dates or documentation of rationale for extension.
Baseline care plan was not created within 48 hours of admission for a resident with complex needs.
Treatment cart was left unlocked and unattended, risking resident access to medical supplies.
Ice machine did not drain through an air gap, risking foodborne illness.
Facility failed to utilize screens on all windows to prevent pest entry; wasp nests and flies were observed.
Report Facts
Number of stained tablecloths observed: 6
Number of tablecloths with holes: 1
Number of windows without screens: 7
Number of residents affected by psychotropic medication deficiency: 1
Number of residents affected by baseline care plan deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Registered Nurse | Entered hospice orders into electronic health record without 14-day stop dates for psychotropic medications |
| Director of Nursing | Director of Nursing | Stated expectation for 14-day stop dates on psychotropic medications and locking treatment carts |
| Head of Housekeeping | Head of Housekeeping | Interviewed regarding condition of dining room linens |
| Administrator | Facility Administrator | Provided statements regarding expectations for linens, grounds cleanliness, pest control, and maintenance rounds |
| Hospice Medical Director | Hospice Medical Director | Interviewed regarding expectations for stop dates on psychotropic medication orders |
| Corporate Maintenance Director | Corporate Maintenance Director | Interviewed regarding ice machine drainage requirements |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 4, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the failure to ensure a working call light system in a resident's bathroom and bathing area, which led to a resident falling in the shower room.
Complaint Details
The complaint investigation found that the shower room call light was not functional at the time Resident #1 fell on 12/28/24. The complaint was substantiated with findings that maintenance inspections did not reliably cover the shower room call lights and staff did not verify call light functionality before resident use.
Findings
The facility failed to ensure the shower room call light was functional when Resident #1 bathed herself, resulting in an unwitnessed fall. Maintenance inspections of call lights were inconsistent and documentation was incomplete. Staff assumed call lights were functional without verifying before resident use.
Deficiencies (1)
Failure to ensure a working call light was available in Resident #1's shower room, leading to inability to request immediate assistance.
Report Facts
Date of resident fall: Dec 28, 2024
Number of call light inspections by Maintenance Director in 2024: 12
Number of resident room call lights inspected on 12/28/24: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Documented Resident #1's fall and condition in Progress Notes. | |
| Director of Nursing | Director of Nursing | Interviewed regarding call light functionality and staff assumptions. |
| Maintenance Director | Maintenance Director | Interviewed about call light inspections and maintenance practices. |
| Administrator | Administrator | Interviewed about expectations for call light maintenance and incident. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 9, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify the Power of Attorney (POA) of a resident's significant change in condition involving low oxygen saturation and the need for supplemental oxygen.
Complaint Details
The complaint investigation found that the facility did not notify the resident's family member/POA of the resident's change in condition on 12/10/24 despite the resident having low oxygen saturation and requiring supplemental oxygen. Interviews with the family member and staff confirmed the lack of notification. The complaint was substantiated.
Findings
The facility failed to notify the POA of Resident #1's low oxygen saturation and subsequent need for supplemental oxygen and hospital transfer. Documentation and staff interviews confirmed no notification was made to the family member prior to the resident's change in condition.
Deficiencies (1)
Failure to notify the resident's Power of Attorney of a significant change in condition involving low oxygen saturation and supplemental oxygen use.
Report Facts
Oxygen saturation percentage: 66
Oxygen saturation percentage: 47
Oxygen flow rate: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding the resident's condition and notification procedures |
| Director of Nursing | Director of Nursing | Interviewed regarding notification policies for resident change in condition |
Inspection Report
Routine
Census: 41
Deficiencies: 6
Date: Feb 29, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, and facility operations at San Juan Care Center.
Findings
The facility was found deficient in safeguarding residents' personal health information, developing and implementing comprehensive care plans, following physician orders for resident care, ensuring proper respiratory care, obtaining necessary physician orders for dialysis monitoring, and securing medication carts and labeling medications properly. All deficiencies were assessed as causing minimal harm or potential for actual harm.
Deficiencies (6)
Failed to safeguard clinical record information by leaving protected health information unattended on medication cart computers and treatment carts.
Failed to develop and implement a complete care plan for dialysis care and nutrition goals for resident #71.
Failed to follow physician's orders to obtain weekly weights for resident #53.
Failed to properly date oxygen tubing for resident #63, risking respiratory infections.
Failed to obtain a physician's order for dialysis access site assessment and monitoring for resident #71.
Failed to ensure medication carts were locked when not in use and failed to date eye drop medication bottles when opened for resident #21.
Report Facts
Residents affected: 41
Weights recorded: 3
Weight loss percentage: 6.45
Weight loss percentage: 5.09
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed nurses should lock medication cart computers, confirmed weekly weights were not collected, confirmed oxygen tubing should be dated and changed weekly, and confirmed dialysis access site assessments should have physician orders. |
| Registered Nurse #1 | Registered Nurse | Left medication cart computer screen unlocked showing PHI. |
| Registered Dietician | Registered Dietician | Confirmed weights recorded for resident #53 and noted weekly weights were not obtained as ordered. |
| MDS Nurse | MDS Nurse | Stated nutrition goal was a default and should have been completed with resident specific information. |
| Facility Administrator | Facility Administrator | Confirmed medication cart lock was broken and accessible. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 16, 2023
Visit Reason
The inspection was conducted based on complaints regarding failure to develop comprehensive care plans and maintain accurate medical records for residents with pressure ulcers.
Complaint Details
The complaint investigation found substantiated deficiencies related to care planning and medical record accuracy for residents with pressure ulcers.
Findings
The facility failed to develop a complete care plan addressing repositioning for a resident with paraplegia and pressure ulcers, and failed to maintain accurate medical records including proper documentation of pressure ulcer diagnoses for two residents. These deficiencies could result in residents not receiving necessary care and treatment.
Deficiencies (2)
Failed to develop a comprehensive care plan for a resident with pressure ulcers, lacking interventions for repositioning to prevent pressure ulcers.
Failed to maintain accurate medical records for two residents, including omission of pressure ulcer diagnoses on face sheets and care plans.
Report Facts
Residents reviewed for pressure ulcers: 3
Residents affected by care plan deficiency: 1
Residents affected by medical record deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed and confirmed deficiencies related to care planning and medical record documentation. |
Inspection Report
Complaint Investigation
Capacity: 86
Deficiencies: 7
Date: Nov 18, 2022
Visit Reason
The inspection was conducted to investigate complaints related to care plan revisions, catheter care, diet orders, restorative care, respiratory care, infection control, and sanitation at San Juan Care Center.
Complaint Details
The complaint investigation substantiated multiple deficiencies including failure to update care plans, lack of catheter care orders, incorrect diet management, inadequate restorative care, improper respiratory equipment maintenance, unsanitary ice machine, and poor infection control practices.
Findings
The facility failed to revise a resident's care plan after medication discontinuation, lacked physician orders for catheter care, provided incorrect diet textures without proper swallowing evaluations, did not ensure restorative care for ambulation, failed to label and date respiratory equipment, maintained an unsanitary ice machine, and had multiple infection control deficiencies including catheter tubing dragging on the floor, unsanitary laundry conditions, and unclean resident rooms.
Deficiencies (7)
Failed to revise care plan for resident after discontinuation of anticoagulant medication and lab orders.
No physician orders for catheter care for resident with catheter.
Resident received wrong diet texture without swallowing evaluation, causing risk of choking and aspiration.
Restorative care for ambulation not properly ordered or documented for resident.
Oxygen tubing and humidifier bottles not labeled or dated; aerosol mask not replaced as ordered.
Ice-making machine was dirty with black deposits and flakes, not cleaned as required.
Catheter tubing dragging on floor under wheelchairs; catheter bag placed on floor; laundry room and resident rooms unsanitary.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 2
Residents affected: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed failure to revise care plan for resident #57 after medication discontinuation | |
| Center Nurse Executive | Stated catheter care orders should be in place for resident #59 | |
| Unit Manager #1 | Acknowledged lack of catheter care orders for resident #59 and diet order changes for resident #50 | |
| Speech Language Therapist | Revealed no swallowing evaluation had been done for resident #50 | |
| Dietetic Technician | Confirmed diet texture orders must come from physician or speech language pathologist | |
| Director of Rehabilitation | Revealed restorative services referral and issues with documentation for resident #72 | |
| Registered Nurse #6 | Confirmed oxygen tubing and humidifier bottles were not labeled or dated | |
| Central Supply Staff #1 | Confirmed ice machine was dirty and not cleaned recently | |
| Center Nursing Executive | Acknowledged catheter tubing dragging on floor observations | |
| Registered Nurse #5 | Stated catheter tubing should be anchored and not drag on floor | |
| Nursing Unit Manager #2 | Explained resident #50's catheter bag behavior | |
| Laundry Staff Person #1 | Confirmed unsanitary conditions in laundry room | |
| Certified Nurse Assistant | Confirmed unsanitary conditions in resident room |
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