Ponce Health and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to ensure residents received an accurate Preadmission Screening and Resident Review (PASRR) Level I screening and a Level II screening for one (Resident 91) out of two residents reviewed. Resident 91 did not receive a PASSAR Level II after admission to the facility. There were a total of 139 residents residing in the facility at the time of this survey. The findings included: Record review of the Preadmission Screening and Resident Review (PASSR) Policy and Procedure (reviewed January 2025) documented: Policy-The facility ensures that a all residents admitted to the facility has PASSR Level I done prior to admission to facility or Level II as indicated by resident's condition and diagnosis of resident. Procedure: 1) Prior to admission, the admission department including nurse navigator must ensure that hospital or another nursing home facility has completed PASSR Level I for new residents prior to admittance to facility and 2) Upon receipt…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interview and record review, the facility's quality assurance and assessment committee failed to demonstrate an effective plan of action was implemented to correct an identified quality deficiency in the problem area related to repeated deficient practice for F645- PASARR Screening for Mental Disease (MD) and Intellectual Disability (ID). As evidenced by: F645 was cited during a Recertification survey ending 12/21/23 when the facility failed to ensure a level 1 Preadmission Screening and Resident Review (PASRR) was completed accurately prior to admission and failed to revise the screening following admission for four (4) Residents This repeated deficient practice has the potential to affect any of the 139 residents residing in the facility at the time of the survey. The findings included: Record review of the facility's survey history revealed, during a recertification conducted on December 18, 2023, through December 21, 2023, at the facility. F645-PASRR Screening for Mental Disease (MD) and Intellectual Disability (ID) was cited as the facility failed to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to follow infection prevention and control procedures for Residents ( #13, #106, #129, #234). As evidenced by Residents # #13, # 106, #129, and #234 Incentive Spirometer were observed stored at bedside with no protective covering. There were 139 residents residing in the facility at the time of the survey. The findings included: Resident #13 During an observation on 05/12/25 at 06:51 AM Resident #13 was in bed asleep, an Incentive Spirometer was on the bedside table with no protective covering (Photo Evidence) On 05/13/25 at 08:21 AM Resident # 13 was observed in bed awake, eating breakfast, an Incentive Spirometer was being stored on bedside table with no protective covering. On 05/14/25 at 11:20 AM Resident # 13 was sitting on side of bed, receiving therapy provided by rehab staff, no distress noted, the Incentive Spirometer not in the room. Review of the medical records for Resident # 13 revealed the resident was admitted to the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. On 12/18/23 at 09:17 AM, Resident # 48 was observed seated in a wheelchair in front of a table in the Activities room well-groomed and smiling. Two staff members were present, encouraged resident to participate in games and praised her efforts. On 12/19/23 at 08:10 AM, Resident # 48 was observed in activities room playing a game, smiling, and responded to greetings. On 12/20/23 at 09:23 AM, Resident # 48 was observed teary. Staff reassured the resident and assisted resident to Activities room. Record Review of Resident # 48's Level I PASARR (Preadmission Screening and Resident Review) documented Section I: PASARR Screen Decision Making: A: MI or suspected MI (check all that apply) - bipolar disorder was not checked off. Does individual have validating documentation to support dementia or related neurocognitive disorder - no. Section III Not a provisional admission. Section IV No diagnosis or suspicion of SMI or ID indicated. Level II PASARR evaluation not required. PASARR Level I was completed by Director of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the safety of vulnerable residents for one out of two sampled residents (Resident #88) for smoking. As evidenced, Resident #88 was smoking out in the smoking area with no staff supervision. This deficient practice has the tendency to affect all 7 residents who smoke at the facility at the time of the survey. The findings included: On 12/19/2023 at 11:14 AM, during an interview with Staff B, a Certified Nurse Assistant, she stated that she was the one who watches the residents when they go to smoke. She stated most residents come 2 or 3 times a day, and a staff is always present at the smoking area to supervise them. Observation on 12/20/2023 at 08:10 AM showed Resident #88 was at the smoking area by himself with a cigarette in his hand smoking, no staff was around. Observed Resident #88 finished smoking at 08:14 AM and still no staff was present. Further observation showed Resident #88 was very hard to hear. Review of Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to ensure an accurate count on the narcotic sheet (Resident #71) on one cart and failed to ensure medications were securely stored as evidenced by four loose medication pills found on two carts out of three carts checked. The findings included: On [DATE] at 01:09 PM, in an observation of the third-floor medication cart two with Staff C, RN (Registered Nurse). It was revealed that Resident #71's narcotic count sheet for Tramadol 50 milligrams stated there were 16 remaining, but 15 were remaining in the bingo card. When checking the medication cart, two white loose pills (337 & ET/59) were found. In an interview with Staff C, R.N., when shown that the narcotic count sheet was incorrect. Staff C R.N. stated, I charted the medication that it was given in the electronic medication record. I needed to put the time, which is 8:18 AM that it was given on the narcotic sheet. At that time, a resident called 911 due to shortness of breath. I had to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews. The facility failed to ensure privacy of confidential information by leaving unlocked unattended computer screens with residents' information visible for two out of three medication carts observed. The facility has a total of six medication carts. This deficient practice has the potential to affect all 140 residents in the facility at the time of this survey. The findings included: 1) During a medication administration observation conducted with Staff I, a Registered Nurse (RN ) on 10/18/22 at 5:17 PM, Staff I left the computer on top of the medication cart on (logged into the electronic charting system) and unattended, facing out into the main hallway while she entered room [ROOM NUMBER] to administer medications to a resident. 2) During a tour of the facility conducted on 10/19/22 at 5:03 PM, an observation was made of a computer on top of a medication cart that was left on (logged into the electronic charting system) and unattended, facing out into the main…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to address services related to Activities of Daily Living (ADL) related to the grooming of a resident's fingernails; as evidenced by failure to ensure the fingernails were trimmed and cleaned for 1 (Resident # 137) of 1 resident reviewed. The findings included: In an observation conducted on 10/17/22 at 9:30 AM, Resident #137 was noted in bed. Closer observation showed long, thick, sharp-edged, dirty fingernails with some dark, black matter noted at the rim of the nail base/bed. In this observation, Resident #137 was asked if she wanted her fingernails trimmed and she said yes. (Photographic evidence obtained). A chart review showed that Resident #137 was admitted to the facility on [DATE] with diagnoses of Dysphagia, Dementia and Anxiety. The Minimum Data Set (MDS) dated [DATE] showed that Resident #137 had a Brief Interview of Mental Status (BIMS) score of 13 out of 15 which indicate the resident is cognitively intact. The Care Plan dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interviews the facility failed to perform appropriate nutrition monitoring on a resident who was admitted with a stage two pressure ulcer and poor oral intake and failed to provide the appropriate assistance during dining for 1 of 8 sampled residents reviewed for nutritional risk (Residents #490). The findings included: A review of the facility's Nutritional Assessment, revised on 1/18/2022, documented that the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutritional. A chart review showed that resident #490 was admitted to the facility on [DATE] with diagnoses of anorexia, dysphagia, and dementia. The Minimum Data Set (MDS) dated [DATE] revealed that Resident #490 has a Brief Interview of Mental Status (BIMS) score of 04 out of 15 , which indicate the resident has severe cognitive impairment.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed,observations and interviews, the facility failed to assure that enteral nutrition has been followed by the practitioner's order for 1 (Resident #50) of 2 sampled residents reviewed for tube feeding. There were 19 residents receiving tube feeding residing in the facility at the time of this survey. The findings included: A chart review showed that Resident #50 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, Dementia, and Dysphagia. A review of Resident #50's physician orders showed an order for tube feeding Jevity 1.5 (formulary type) at 65 milliliters (ml) an hour times 20 hours to be off at 8:00 AM and on at 12:00 PM. In an observation conducted on 10/17/22 at 9:15 AM, Resident #50 was noted in bed. Closer observation showed a tube feeding bottle with Jevity 1.5 (formulary type) that was started at 5:02 AM on 10/17/22. Closer observation showed that the tube feeding was at the 1500 milliliters (ml) mark out of a 1500 ml capacity bottle. No tube feeding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations and interviews the facility failed to perform adequate tracheostomy care for one (Resident #78) out of one resident residing in the facility with tracheostomy. The findings included: Review of the facility policy titled Tracheostomy Care, revision date January 2022, revealed the following: In the Procedure Guidelines, which spells out each step for the staff to follow during tracheostomy care, this policy specifies the staff is supposed to wash their hands and don (put on) non-sterile exam gloves and remove oxygen tubing from on top of the tracheostomy and remove the old tracheostomy dressings and the disposable inner cannula (the tube that the resident breaths through). The staff is then supposed to remove the non-sterile exam gloves, wash hands, and then open the tracheostomy cleaning kit. While maintaining a sterile field, the staff should set up the supplies which are included in the kit (hydrogen peroxide, normal saline, gauze pads) along with a new tracheostomy inner…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the medication error rate is less than 5%. The facility failed to administer the ordered medication Oxycodone/Acetaminophen 5/325 mg for 81 out of 682 opportunities, (11.88 % error rate) for 1 of 8 sampled residents for medication administration review (Resident #59). The findings included: Observation of medication administration on 10/19/22 07:46 AM for Resident #59 conducted by Registered Nurse (RN), Staff F revealed the following administered medications by mouth: Duloxetine 30 mg (milligrams), aspirin 81 mg EC (Enteric Coated), Oxycodone/APAP 5-325 mg, folic acid 800 mcg (micrograms), Metoprolol tart 25 mg, multivitamin with minerals, vitamin D 25 mcg, ferrous sulfate 325 mg, vitamin C 500 mg, docusate sodium 100 mg, Memantine HCL 10 mg. Record review of Resident #59's clinical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Covid-19, Persistent Mood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews the facility failed to ensure proper storage of medications as evidenced by failure to lock medication carts and secure for 1 out of 2 medication carts observed on the facility's 4th floor. 2) Failed to ensure medication refrigerators are plugged into emergency outlet in event of a power outage. There were 140 residents residing in the facility at the time of this survey. The findings included: During a tour of the facility conducted on 10/18/22 at 4:57 PM, an observation was made of a medication cart that had been left unlocked and unattended in the main hallway of the 4th floor near room [ROOM NUMBER]. Photographic evidence was obtained of this unlocked cart. On 10/18/22 at approximately 5:00 PM, the surveyor asked a passing Certified Nursing Assistant (CNA) which nurse was responsible for the cart, and the CNA replied that it was Staff I, RN. Staff I then came to the surveyor and was notified of her unlocked medication cart. The nurse did not verbally respond but did walk…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.