Ryder Memorial Hospital INC
355 Ave Font Martelo, Humacao, PR 00792 · Non profit - Corporation · 62 certified beds · (787) 716-7977 Medicare only — no Medicaid
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (41) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (69%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | Not rated |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | Not rated |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Short-stay residents who newly got an antipsychotic medication | 1.5% | 0.3% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 99.5% | 97.9% | 79.4% | better |
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
63.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 73 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 11.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 43 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.97 therapist hours per resident per day in 2026Q1 — more than 97% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 37% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 63.5%CMS range 56.2–72.1 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.0%CMS range 7.6–16.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 11.6% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 39.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 9.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 0.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 85.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.8%CMS range 3.1–13.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 62 beds and averages 38.8 residents a day — about 63% occupied, or roughly 23 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.07 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 1.88 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 0.00 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.29 hrs/resident/day on weekends vs 3.38 on weekdays — 32% thinner on weekends — a notable drop. RN hours go from 2.15 to 1.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 69% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
41 citations, most serious first. The 10 most serious are shown; the remaining 31 are one tap away and print in full.
- Potential for harm · Fcited before2025-03-26 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on dining observations, review of policies procedures and facility staff interview performed on 03/24/2025 through 03/26/2025 from 8:00 AM through 3:30 PM, it was determined that the facility failed to ensure that each resident (R), receives and the facility provides food and drink that is palatable, attractive, and at a safe and appetizing temperature. This deficiency affects 1 out of 12 residents admitted receiving services (R #268). Findings include: 1. Resident interview #268 is a [AGE] year-old male admitted on [DATE] with a diagnosis of lumbar discitis osteomyelitis. -During the initial pool process on 03/24/2025 at 8:21 AM resident #268 indicated that when food is brought in sometimes there are foods that are not to his liking, when this happens the staff does not offer him some substitute food to ensure he has adequate food intake. -Record reviewed conducted on 03/24/2025 at 1:44 PM noted that the dietician made an estimate of the resident's tastes and needs, and these went to the kitchen for…
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.
- Potential for harm · Fcited before2025-03-26 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 03/24/2025 from 8:00 AM through 3:30 PM, it was determined that the facility failed to comply with the required sink compartment sanitations. This deficient practice could affect 24 out of 24 residents admitted receiving care at the facility. Findings include: Review of facility's policy and procedure Lavado, Enjuage y Saneamiento, Cleaning and Disinfection of three compartment Sinks regarding the process of cleaning and sanitization of kitchen equipment was reviewed on 03/24/2025 at 11:30 AM and it says that compartment one (1) must have a temperature of 110º F, on compartment two (2) and on compartment three (3) utensils should be for 30 seconds with a sanitizing solution concentration of 200 ppm.Test strip container was verified and stated that concentration testing should be taken with a temperature of 75 degrees Fahrenheit. 1.During the visual inspection and staff interview it was noticed that 3 compartment sinks were not prepared as stated in the facility policies and…
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.
- Potential for harm · Fcited before2025-03-26 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation during medication pass performance on 03/25/2025 from 8:22 AM till 9:30 AM, it was determined that the facility failed to ensure establish and maintain an infection prevention and control program relate to hand washing during the drug pass and failed to ensure establish and maintain an infection prevention and control program related to changing gloves in bed baths in 1 out of 1 resident observed (RR #215) Findings include: 1. During the drug past performance on 03/25/2024 from 8:22 AM till 9:30 AM, it was observed two register nurses in the process medication administration, and it was found the following. a. On 03/25/2025 at 8:55 AM RN #10 failed to follow appropriate hand washing process during the medication administration and failed to hand wash 1 out to 7 opportunities for hand wash 14.28%. b. On 03/25/2025 at 8:22 AM RN #11 failed to follow appropriate hand washing process during the medication administration and failed to hand wash 9 out to 11 opportunities for hand wash 81.81%. 2.…
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.
- Potential for harm · Fcited before2025-03-26 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working safely.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations performed on 03/24/2025 from 8:30 AM through 3:30 PM, it was determined that the facility failed to maintain all patient care equipment in safe operating condition. This deficient practice affects 24 out of 24 residents admitted receiving treatment at the facility. Findings include: 1. During a visual inspection of the equipment in the physical therapy area, it was observed that of 7 wheelchairs observed, 3 of these had peeling paint and signs of rust, and clinical tape on the arm rests. 2. It was also observed that of 15 walkers available, 5 of them showed signs of rust and wear and tear. 3. Two (2) out of two (2) of pedal floor exerciser were observed with signs of rust.
- Potential for harm · Ecited before2025-03-26 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and eighteen records reviewed (RR) on 03/24/2025 through 03/26/2025 from 9:00 AM to 3:00 PM, it was determined that the facility did not ensure providing in making decisions regarding medical care and treatment with the resident or representative in advance directives 2 out of 18 records reviewed. (R.R #106 and #108). Findings include: 1. During the evaluation of the records review on 03/25/2025, the following was found: a. R.R #215 is a [AGE] year-old male admitted [DATE] with Infected Sacral Ulcer. Noted in the record review on 03/26/2025 at 10:13 AM, the advance directive was observed without the signature of the resident or representative. b. R.R #217 is a [AGE] year-old male admitted on [DATE] with Amputation of the First Toe of the Right Foot. Noted in the record review on 03/25/2025 at 2:10 PM, that the resident was on Family Department Service and that the advance directive was not signed by a proxy. It was verified that the resident had signed an X on the advance directive document.…
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.
- Potential for harm · Ecited before2025-03-26 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with residents, facility administrator and physical environment personnel during the survey for the physical environment, it was determined that the facility failed to ensure that resident's sleeping rooms have comfortable and safe temperature levels and room environment is not homelike. This deficient practice was identified in 5 out of 20 residents' rooms. Findings include: 1. During the tour of physical environment with a nurse, performed on 03/25/2025 at 10:30 AM all residents' sleeping rooms were visited. Residents located in room [ROOM NUMBER], 106 and 114 referred that room temperature was very cold. Those residents were observed covered with blankets and complained about low temperatures. 2. Resident located in rooms # 105,# 106 and # 114 stated during individual interviews on 03/25/2025 from 10:30 AM through 11:00 AM they would prefer warmer temperatures. It was identified that those rooms did not have a thermostat to be used to regulate the temperature of the room.…
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.
- Potential for harm · Ecited before2025-03-26 · tag F0655 — patternCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of twelve medical records, resident interview and interview with the Administrator (employee #1) performed from 03/24/2025 thru 03/26/2025, from 8:00 AM thru 3:30 PM, it was determined that the facility failed to develop and implement baseline care plan within 48 hours of a resident's admission in order to promote the continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services. This deficient practice was identified in 2 out of 12 cases reviewed. (RR #265, #266) and fail to update information based on the comprehensive care plan identified on 5 out of 6 records reviews. (Residents #6, # 7, #10, #13 and #108 ). Findings include: 1.Record Review #265 is an [AGE] year-old female admitted on [DATE] with a diagnosis of decondition. -The resident was admitted…
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.
- Potential for harm · E2025-03-26 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #4 is a [AGE] year-old female admitted [DATE] with osteomyelitis sacral ulcer stage 4, according to the information collected in the medical record. a. On 3/24/2025 at 1:20 PM, it was noted in the medical record that the interdisciplinary care plan was not completed by recreational therapy, nutrition and pharmacy staff. The interdisciplinary care plan in the expected outcomes on the evaluation date there was no continuity or outcomes according to the care plan. On 03/25/2025 at 9:03 AM, medication pass nurse #11, referred that they discuss the interdisciplinary care plan every Tuesday with the nursing staff. On 03/25/2025 at 10:05 AM, employee #12, MDS coordinator, was interviewed and stated that cases are evaluated individually in the first seven days when they are completing the MDS, but officially the interdisciplinary group has not met since the pandemic. 3. Resident #217 is a [AGE] year-old male admitted with amputation of the first toe of the right foot according to the information collected in…
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.
- Potential for harm · E2025-03-26 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations performed on 03/24/25 through 03/26/25 from 8:30 AM till 4:00 PM and interview with Nursing personnel (employee #16), and Administrator (employee #1) it was identified that facility failed to develop and implement comprehensive person-centered care plan for a resident who is identified with social service's needs and failed to guarantee participation of the interdisciplinary group in the comprehensive care plan meetings This deficient practice affects 1 out of 12 residents included in the sample selection. (Resident #3). Findings include: 1. The following information was identified while reviewing the medical record of resident #3 with the Nursing personnel (employee #16), on 03/25/2025 at 9:15 AM: a.RR #3 is an 80 male resident admitted on [DATE] with a diagnosis of Right Femur Fracture. Accordingly with information documented on the medical record Social Worker Initial Assessment resident lives alone in an independent elderly apartments complex. Apparently, the resident begins 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.
- Potential for harm · Ecited before2025-03-26 · tag F0756 — failed to review each resident's drug regimen — patternEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations performed on 03/24/25 through 03/26/25 from 8:30 AM till 4:00 PM and interview with Nursing personnel (employee #16), it was identified that facility failed to evidence that identify irregularities in the medication review were documented, reported and if necessary to the attending physician and pharmacist. This deficient practice affects 3 out of 12 residents included in the sample selection. (Resident #67, #265 and #268). Findings include: 1.The following information was identified while reviewing the medical record of resident #67 with the Nursing personnel (employee #16), on 03/26/2025 at 9:00 AM: a.RR #67 is a 45 male resident admitted on [DATE] with a diagnosis of Right Knee Replacement. According to the information documented in the medical record this resident had history of Anxiety Disorder and Depression (other than bipolar ). b. When the resident was admitted to the facility on [DATE] nursing personnel perform medication reconciliation. During medication reconciliation 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.
Show the remaining 31 citations
- Potential for harm · D2025-03-26 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the observations made through the initial pool process and the request for policies and procedures to the administrative staff conducted on 03/24/2025 through 03/26/2025 from 8:00 AM to 3:30 PM, it was determined that the facility failed to provide a respectable service where the residents' dignity was maintained. This deficiency was identified in 1 out of 24 cases reviewed during the initial pool process (Resident #265). 1. Resident #265 is an [AGE] year-old female admitted on [DATE] with a diagnosis of decondition. The resident was observed on 03/24/2025 at 10:11 AM leaving the scale with no pants or sheets covering her legs so she was exposed to view. On 03/25/2025 at 9:15 AM a policy was requested from the facility regarding the procedure for female wheelchair use and was not provided. The facility failed to treat each resident with respect and dignity and provide care and services in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing…
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.
- Potential for harm · D2025-03-26 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of 12 medical records reviewed (RR) and interviews performed on 03/24/2025 through 03/26/2025 from 8:00 AM through 3:30 PM, it was determined that the facility failed to promote mechanisms to identify the psychotropic drugs are not given unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. This deficient practice was identified in 2 out of 12 active records reviewed. (R.R. #265 and #268). Findings include: 1. Resident #265 is an [AGE] year-old female admitted on [DATE] with a diagnosis of decondition. Record review conducted on 03/24/2025 at 2:25 PM, it was noted that the resident has high risk medications orders: Eliquis 2.5 milligrams (mg) 1 tab orally (PO) two times per day (BID), Lasix 40mg PO Daily and Seroquel 25mg tab PO hour of sleep (HS). No evidence was found that the License Pharmacist performed a Medication Regimen requirement to identify the psychotropic drugs are not given these drugs unless the medication is necessary…
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.
- Potential for harm · Dcited before2025-03-26 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on dining observations, review of policies procedures and facility staff interview performed on 03/24/2025 through 03/26/2025 from 8:00 AM through 3:30 PM, it was determined that the facility failed to ensure that each resident receives food that accommodates resident allergies, intolerances, and preferences. This deficiency was identified in 1 out of 12 residents of the sample selection (Resident #268). 1. Resident interview #268 is a [AGE] year-old male admitted on [DATE] with a diagnosis of lumbar discitis osteomyelitis. -During the initial pool process on 03/24/2025 at 8:21 AM resident #268 indicated that when food is brought in sometimes there are foods that are not to his liking, when this happens the staff does not offer him some substitute food to ensure he has adequate food intake. -Record reviewed conducted on 03/24/2025 at 1:44 PM noted that the dietician made an estimate of the resident's tastes and needs, and these went to the kitchen for preparation. The facility failed to ensure that…
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.
- Potential for harm · F2024-05-15 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations and interview with the Dietitian (employee #2) performed from 05/13/2024 thru 05/15/2024, from 8:00 AM thru 5:00 PM, it was determined that the facility failed to provide sufficient support for personnel safely and effectively carry out the functions of the food and nutrition service. Findings include: During an interview with the Dietitian performed on 05/14/2024 she stated that the facility did not have all the necessary personnel in the kitchen. A kitchen personnel pattern was requested to the kitchen manager by the surveyor and it was noticed that the pattern revealed 5 more employees were needed for optimal operation.
- Potential for harm · Fcited before2024-05-15 · tag F0802 — failed to prepare enough nourishing food — widespreadProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on dining observations, review of policies procedures and facility staff interview performed on 05/13/2024 through 05/15/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to ensure that residents needs and preferences related with food services are met. This deficiency was identified in 3 out 13 sample cases reviewed (Resident #116, #120 and #121). Findings include: Facility policy Title: Food Services to Residents was reviewed on 05/13/2024 at 11:35 AM with Dietitian (employee #2) Policy clearly stated on the procedures that every resident's breakfast must be delivered between 7:00 AM-8:15 AM. 1. During initial pool process residents located in room [ROOM NUMBER]-A, #116-A and #117-A stated that breakfast did not arrive at a time in the morning that best suits their needs. a. Resident sample # 116 stated in the interview on 05/13/24 at 8:40 AM that breakfast has arrived for the past four days after 8:30 AM. She stated that she was admitted on [DATE] due to status post right…
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.
- Potential for harm · F2024-05-15 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on dining observations, review of policies procedures and facility staff interview performed on 05/13/2024 through 05/15/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to ensure that input received from residents and preferences related with food services are met. This deficiency affects 4 out of 13 cases reviewed during initial pool process (Resident #108, #116, #120 and #121). Findings include: The facility policy Title: Nutritional Needs last updated in January 2024, was reviewed on 05/15/2024 at 3:05 PM with Dietitian. Policy clearly stated the procedures that for every resident admitted to the facility food will be provided considering each resident preference. 1. During initial pool process residents located in room [ROOM NUMBER]-A, #116-A and #117-A stated that food brought by the kitchen personnel had items that they do not like in their breakfast, lunch, and dinner. a.Resident sample #116 stated in an interview on 05/13/24 at 8:40 AM that she receives in her…
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.
- Potential for harm · Fcited before2024-05-15 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on dining observations, review of policies procedures and facility staff interview performed on 05/13/2024 through 05/15/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to ensure that each resident receives, and the facility provides food and drink that is palatable, attractive, and at a safe and appetizing temperature. This deficiency affects 5 out of 13 cases admitted receiving services (Resident #108, #111, #116, #120 and #121). Findings include: Facility policy Title: Nutritional Needs last updated in January 2024, was reviewed on 05/15/2024 at 3:05 PM with Dietitian. Policy clearly stated the procedures that for every resident admitted to the facility food will be provided considering each resident preference. 1. During initial pool process residents located in room [ROOM NUMBER]-A, #116-A and #117-A, stated that food brought by the kitchen personnel is not palatable, appetizing and at appetizing temperature. a. Resident sample # 116 stated in an interview on 05/13/24…
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.
- Potential for harm · Fcited before2024-05-15 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 05/13/2024 from 8:00 AM through 4:00 PM, it was determined that the facility failed to comply with the required sink compartment sanitations. Findings include: Review of facility's policy and procedure Lavado, Enjuage y Saneamiento, Cleaning and Disinfection of three compartment Sinks regarding the process of cleaning and sanitization of kitchen equipment was reviewed on 05/13/2024 at 11:30 AM and it says that compartment one (1) must have a temperature of 110º F, on compartment two (2) and on compartment three (3) utensils should be for 30 seconds with a sanitizing solution concentration of 200 ppm. 1. During the visual inspection and staff interview it was noticed that 3 compartment sink was not prepared as stated in the facility policies and procedures. It was observed that the staff working the sink did not have knowledge of the temperatures required in the different sinks' compartments. It was requested that the concentration of sanitizer be taken on the third…
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.
- Potential for harm · F2024-05-15 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of Quality Assessment Performance Improvement ( QAPI) activities and interview with facility administrator (employee #1) performed on 05/13/24 through 05/15/24 from 8:00 AM till 4:30 PM it was determined that facility failed to ensure the participation of all required members on the Quality Assessment Performance Improvement (QAPI) committee meetings. Findings include: 1. During review of facility committee meetings of QAPI during year 2023 and the months of January 2024 and April 2024 the following was identified: Upon review of facility rules and procedures related with QAPI program committee meeting activities last reviewed on July 15, 2016, it was identified that rule did not establish that the Infection Preventionist must participate in every QAPI committee meeting. a. There is no evidence of participation of facility Infection Preventionist on QAPI committee meetings performed on April 19, 2023, July 20, 2023, October 25, 2023, January 30, 2024, and April 17, 2024. b. During interview on 05/15/24 at 1:00 PM facility administrator (employee #1) stated that…
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.
- Potential for harm · Fcited before2024-05-15 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working safely.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 05/13/2024 through 05/15/2024 from 8:00 AM through 5:00 PM, it was determined that the facility failed to maintain all patient care equipment in safe operating condition. This deficient practice had the potential to affect 21 out of 21 residents. Findings include: During observational tour the following was observed related with equipment in the facility: 1. 10 out of 15 wheelchairs in the Physical Therapy area were observed with rust. 2. 1 out of 2 walking canes in the Physical Therapy area were observed with rust. 3. 5 out of 10 walkers in the Physical Therapy area were observed with rust. 4. The parallel bars and steps showed rust in some of their parts.
- Potential for harm · Fcited before2024-05-15 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations of the physical environment and facility staff interview performed on 05/13/2024 through 05/15/2024 from 8:00 AM through 5:00 PM, it was determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. This deficient practice had the potential to affect 21 out of 21 residents. Findings include: During observation tour with Safety Officer (employee #6) the following was observed: 1. Rust particulate in the air conditioner vents was observed in rooms #103, #104, #108, #117, #119 2. Excessive dust behind patients beds and closet doors on rooms #102, #108, # 112, # 113, #115, #117, #119, #120. 3. Peeling paint was observed in rooms #108 and #119 4.Water and humidity stains on ceiling tiles were observed in rooms #104, #107, #108, #114, #117, #118. 5. Bathroom curtain pole were found unsecured in 11 rooms, this represents a fall risk for residents.
- Potential for harm · Fcited before2024-05-15 · tag F0924 — widespreadPut firmly secured handrails on each side of hallways.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 05/13/2024 through 05/15/2024 to from 8:00 AM through 5:00 PM, it was determined that the facility failed to equip corridors with firmly secured handrails on each side. This deficient practice had the potential to affect 21 out of 21 residents. Findings include: Loose handrail was observed in corridor in front of room [ROOM NUMBER] close to the corner.
- Potential for harm · Fcited before2024-05-15 · tag F0925 — failed to control pests — widespreadMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations of the kitchen and physical environment performed on 05/13/2024 through 05/15/2024 from 8:00 AM through 5:00 PM, it was determined that the facility failed maintain an effective pest control program so that the facility is free of pests. This deficient practice had the potential to affect 21 out of 21 residents. Findings include: 1. During the flash kitchen tour a live spider and spider webs were obvserved in the dry food storage. 2. Spiders were observed on the lightning fixtures in main corridor. 3. Spiders and spider webs were observed in residents rooms near glass windows leading to main corridor.
- Potential for harm · Ecited before2024-05-15 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed (RR), residents' interview and registered nurse (RN) interview and policy and procedure review, it was found that the facility failed to ensure that patient right to request and formulate advance directive auto determination for 3 out of 18 resident record review. (Resident #105, #111 and #124) Findings include: Facility policy and procedure number 4.9 update on 7/14/16 title: Advance Directive Auto determination evaluate on 05/14/24 at 01:56 PM refer in the item #1 and #2 that the physician during the initial evaluation must oriented the resident related to his right to auto determine his treatment and answer to the resident if have any advance directive formulated. The physician completes the sheet of the resident orientation about the auto determination indicating if have or not any advance directive. 1. Resident #105 is a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Diabetes Mellitus and Right Total Knee Replacement. During the record review performed…
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.
- Potential for harm · Ecited before2024-05-15 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 05/13/2024 through 05/15/2024 from 8:00 AM through 5:00 PM, it was determined that the facility failed to promote the resident right to receive services in a safe, clean, comfortable, and homelike environment. Findings include: During observational tour the following was observed related with environment in the facility: 1. Room headlights are missing lightbulbs or one light not working on room [ROOM NUMBER], #103, #117 2. The room temperatures were not within the parameters established by the institution's Politica de Temperaturas en Habitaciones de Pacientes policy which states room tempertures must be between 68 and 72 degrees farenheit . Some residents reported feeling hot temperaures and even waking up at night sweaty. When taken, the temperature in room [ROOM NUMBER] was 83 degrees farenheit and room [ROOM NUMBER] was 82 degrees farenheit. 3. Wooden closets were observed with dust and…
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.
- Potential for harm · Ecited before2024-05-15 · tag F0806 — failed to honor food preferences — patternEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on dining observations, review of policies procedures and facility staff interview performed on 05/13/2024 through 05/15/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to ensure that each resident receives food that accommodates resident allergies, intolerances, and preferences. This deficiency was identified in 1 out of 13 residents of the sample selection receiving services (Resident #108). Findings include: Facility policy Title: Nutritional Needs last updated in January 2024, was reviewed on 05/15/2024 at 3:05 PM with Dietitian. The policy clearly stated on the procedures that for every resident admitted to the facility food will be provided considering each resident preferences and food intolerances. 1. Resident #108 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Right Total knee Replacement. During the interview 05/13/2023 at 10:00 AM, she states that she likes some days with a sandwich for breakfast and Lactose Free milk, that she…
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.
- Potential for harm · E2024-05-15 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During review of record review of case #105 it was identified that facility nursing personnel receive telephonic orders on 05/09/24 at 9:00 PM, and on 05/11/24 at 9:13 PM by the physician. No authentication, sign, or confirmation of those telephone orders by the physician was evidenced on 05/13/24. 3. During the record review of case #108 it was identified that facility nursing personnel receive telephonic orders on 05/10/24 at 9:00 PM, and on 05/12/24 at 9:00 PM by the physician. No authentication, sign, or confirmation of those telephone order by the physician was evidenced on 05/13/24. Based on review of thirteen medical records on 05/13/24 through 05/15/24 from 8:00 AM till 4:30 PM and interview with facility nursing supervisor (employee #3), it was determined that facility failed to ensure that telephone orders taken by nursing personnel were signed and authenticated accordingly with facility policies and procedures. This deficient practice was identified in 3 out of 13 cases reviewed. (Case RR#105, #108…
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.
- Potential for harm · E2024-05-15 · tag F0919 — failed to provide a working call system — patternMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations of the physical environment and facility staff interview performed on 05/13/2024 through 05/15/2024 from 8:00 AM through 5:00 PM, it was determined that the facility failed to maintain adequately equipped rooms to allow residents to call for staff assistance . This deficient practice had the potential to affect 4 out of 21 residents. Findings include: Rooms #102 and #106 nurse call were found not working.
- Potential for harm · D2024-05-15 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on thirteen records reviewed (R.R.), and interview with the nursing supervisor (employee #3), it was determined that the facility failed to ensure that treatment and care provided to residents' place priority on identifying health identified concerns. This deficiency affects 1 out of 13 records reviewed. (Resident #120). Findings include: Sample selection resident #120-A is a [AGE] year-old female resident admitted on [DATE] with a diagnosis of Left Knee Replacement. On 05 /10/22 at 8:25 AM during initial pool process resident was interview and stated that she had diabetes disease history and that since admission facility is monitoring her sugar levels with Dextrostix every 6 hours and if sugar levels are out of expected range personnel will administer to her regular insulin to control them. Review of medical record on 05/13/24 evidence that physician order subcutaneous insulin protocol on 05/10/24 at 10:00 PM to monitor resident blood sugar levels however did not select on the standing order the type 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.
- Potential for harm · D2024-05-15 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on dining observations, review of policies procedures, thirteen records reviewed (RR) and facility staff interview performed on 05/13/2024 through 05/15/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to ensure that kitchen personnel follow therapeutic diet specifications consistent with the resident's comprehensive assessment. This deficiency affects 1 out of 13 records reviewed. (Resident #55). Findings include: Facility policy Title: Nutritional Needs was reviewed on 05/15/2024 at 3:05 PM with Dietitian. Policy clearly stated on the procedures that for every resident admitted to the facility and accordingly with a comprehensive assessment therapeutic diet specifications must be followed accordingly with resident's needs. 1. RR# 55 is a male [AGE] year-old resident admitted on [DATE] with a diagnosis of Fracture on Left Femur. This resident case was consulted with the Speech Language Pathology (SLP) on 05/13/24 at 9:00 PM because resident was presenting difficulty 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.
- Potential for harm · Fcited before2023-04-05 · tag F0802 — failed to prepare enough nourishing food — widespreadProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on recertification survey and interview with kitchen manager (employee #8) and clinical dietitian (employee #1) on 04/03/2023 through 04/05/2023 to from 8:30 AM through 4:00 PM, it was determined that the facility failed to provide information related with the kitchen staffing pattern. This deficient practice had the potential to affects 22 out of 22 residents admitted receiving at the facility. Findings include: 1. On 04/03/2022 at 3:50 PM during the recertification survey, the kitchen manager (employee #8) was asked by the surveyor to provide the kitchen staffing pattern, but this document was not provided. Kitchen manager (employee #8) stated in an interview on 04/04/2023 at 3:50 PM that she does not have the staffing pattern calculation, and that they are not short of employees at that time. The facility failed to provide the kitchen staffing pattern. 2. On 04/04/2022 at 11:50 AM the clinical dietitian (employee #1) provides a handwritten sheet of paper with the staff calculation of the kitchen staffing pattern. Clinical dietitian (employee #1) stated on interview on…
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.
- Potential for harm · Fcited before2023-04-05 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a recertification survey, observations and facility staff interview performed on 04/03/2023 through 04/05/2023 to from 8:30 AM through 4:00 PM, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice affects 22 out of 22 residents admitted receiving services at the facility. Findings include: 1. Ultra-High Temperature (UHT) milk boxes were observed stored at the kitchen area at the right side of the kitchen dishwashing area. During an interview on 04/03/2023 at 3:30 PM kitchen manager (employee #8) stated that UHT milk was stored outside dry food storage area because in dry food storage area there is not enough space. Dry food storage located inside the kitchen area is observed in need of cleaning and maintenance. The floor had tiles broken, air condition vents cover is incorrectly positioned, and entrance door does not closed properly and had chipped wood on the surface. Windows located at the top area behind tray washing machine were observed in need…
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.
- Potential for harm · F2023-04-05 · tag F0813 — widespreadHave a policy regarding use and storage of foods brought to residents by family and other visitors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a recertification survey, observations and facility staff interview performed on 04/03/2023 through 04/05/2023 to from 8:30 AM through 4:00 PM, it was determined that the facility failed to have in place a policy regarding use and storage of food brought to residents by family and other visitors to assure safe and sanitary storage and handling before consumption was not performed. This deficient practice affects 22 out of 22 residents admitted receiving at the facility. Findings include: 1.Policies and procedures were requested by the surveyor on 04/05/2023 at 10:39 AM for food brought to residents by family and other visitors. to assure safe and sanitary storage and handling before consumption was Nursing supervisor (employee #9) stated on interview on 04/05/2023 at 10:39 AM that if a resident, resident relative or visitor brings food or drink items, the nursing personnel were instructed to put the item in a plastic zip lock bag with residents' name and room number and store in a refrigerator located behind the nursing station. She also stated that once the food or drink…
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.
- Potential for harm · Fcited before2023-04-05 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a recertification survey, observations, review of policies procedures and facility staff interview performed on 04/03/2023 through 04/05/2023 to from 8:30 AM through 4:00 PM, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections related to lack of handwashing procedures implementation before the use of gloves and failure to provide clean and safe environment at the linen washing and drying laundry area. This deficient practice affects 22 out of 22 residents admitted receiving at the facility. Findings include: 1. On 04/03/2023 at 11:59 AM the following was observed when a kitchen personnel (employee #3 and employee #4) provide the lunch tray during dining procedures observations: a. kitchen personnel (employee #3) were observed giving residents lunch trays in rooms 113 through room [ROOM NUMBER]. This…
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.
- Potential for harm · Fcited before2023-04-05 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a recertification survey, observations performed on 04/03/2023 through 04/05/2023 to from 8:30 AM through 4:00 PM, it was determined that the facility failed to maintain all patient care equipment in safe operating condition. This deficient practice affects 22 out of 22 residents admitted receiving at the facility. Findings include: 1. During a visual inspection of the equipment in the physical therapy area, it was observed that of 19 wheelchairs observed, 12 of these had peeling paint and signs of rust, three of them had duct tape on the arm rests. It was also observed that of 21 walkers available, 14 of them showed signs of rust and wear and tear. Of 3 canes observed, two of them were observed with signs of rust. 2. Kitchen During initial brief tour performed on 04/03/2023 and follow up visit performed on 04/04/2023 to the kitchen, four ovens were observed with out of order sings, an additional electric oven also was rotulated as out of service. Evaluation of the use of the three-compartment sink was carried out, the PPM test was carried out for the chemical sanitation…
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.
- Potential for harm · Fcited before2023-04-05 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a recertification survey, observations, review of policies procedures performed on 04/03/2023 through 04/05/2023 to from 8:30 AM through 4:00 PM, it was determined that the facility failed to promote the resident right to receive services in a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. This deficient practice affects 22 out of 22 residents admitted receiving at the facility. Findings include: a. During observation inspection with Safety Officer (employee #6 ) a connected line water heater was observed connected an functioning on the men's bathroom of the physical therapy area. The electrical equipment was placed on the floor unattached to the wall and right next to the bathroom sink exposing it to be in contact to falling water. This is a potential risk to patients and staff. Acoustic tile When asked the Safety Officer replied that he did not have knowledge of the precedence of the equipment. b. During visual inspection of patients sleeping rooms water…
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.
- Potential for harm · Fcited before2023-04-05 · tag F0925 — failed to control pests — widespreadMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a recertification survey, observations, and review of policies procedures and pest control documents on 04/03/2023 through 04/05/2023 to from 8:30 AM through 4:00 PM, it was determined that the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents. This deficient practice affects 22 out of 22 residents admitted receiving at the facility. Fndings include: 1. During visual inspection of the facility a two bulb UV light insect machine was observed with only one of the bulb functioning. 2. During visual inspection of the facility outside corridors were observed with spiderwebs and spiders between the upper part of walls and acustic ceiling tiles. Evidence of pest control was requested by surveyors, administrator first provided a in house log of fumigator visits to facility, surveyor solicited a breakdown of services rendered by company and materials used in visit and administration could not provide this information. Administrator informed they will ask for breakdown of service from now on. No licence number of supplier…
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.
- Potential for harm · Ecited before2023-04-05 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. During the tour in the residents room from 10:00 AM to 12:00 PM, the following was observed: a. On 4/4/2023 at 10:01 AM residents room [ROOM NUMBER], it was observed the emergency cable tied to the grab bar in the bathroom. b. On 4/4/2023 At 10:05 AM the residents room [ROOM NUMBER], it was observed the toilet with black spots. c. On 4/4/2023 at 10:25 AM the resident room [ROOM NUMBER]-A, it was observed stained floor. d. On 4/4/2023 at 10 :45AM the resident room [ROOM NUMBER]-A, it was observed the bedding with food residues and dirty. e. On 4/4/2023 at 11:02 AM the resident room [ROOM NUMBER]-A. it was observed that the part under the lamp did not work. f. On 4/4/2023 at 11:08 AM the resident room [ROOM NUMBER]-C, it was observed in the upper part of the closet with a white and detached stain. Based on a recertification survey, observations of the physical environment, review of policies procedures and facility staff interview performed on 04/03/2023 through 04/05/2023 to from 8:30 AM through 4:00 PM, it…
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.
- Potential for harm · Ecited before2023-04-05 · tag F0924 — patternPut firmly secured handrails on each side of hallways.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a recertification survey, observations, review of policies procedures performed on 04/03/2023 through 04/05/2023 to from 8:30 AM through 4:00 PM, it was determined that the facility failed to firmly secured handrails on each side. This deficient practice affects 22 out of 22 residents admitted receiving at the facility. Findings include: Eight out of 28 loose handrails were noticed representing potencial fall risk in the following areas: 1. In front of room [ROOM NUMBER] 2. Next to door of room [ROOM NUMBER] 3. Corner in front of physical therapy 4. Front of room [ROOM NUMBER] 5. Front of rooms 103, 104, 105 6. Between 104/105 7. Right side of entry door of room [ROOM NUMBER] 8. Loose rail and missing corner cap next to room [ROOM NUMBER]
- Potential for harm · Dcited before2023-04-05 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a recertification survey twelve records reviewed (R.R.), it was determined that the facility failed to ensure that the Skilled Nursing Facility (SNF) personnel develop a baseline care plan within the first 48 hours of admission which provides instructions for the provision of effective and person-centered care to each resident. This deficiency affects 1 out of 12 record reviews. (Resident #70) Findings include: 1. Resident #70 is an [AGE] year old male admitted on [DATE] with a diagnosis of deconditioning. admitted for rehabilitation with physical Therapy and Occupational Therapy. During the record review performed on 04/05/23 at 11:39 AM, it was found that the Baseline Care Plan was left in blank only have the signature of the caregiver. No evidence was found related to the service that was provided, the goals, medication, nutritionist services that is going to have.
- Potential for harm · Dcited before2023-04-05 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on recertification survey, review of twelve medical records, and interviews conducted 4/3/2023 to 4/5/2023 from 8:00AM to 4:00PM, it was determined that the facility failed to ensure that the resident medication regimen was reviewed in accordance with policy. This deficient practice was identified in 1 out of 12 active cases (Resident Sample #66). Findings include: During the medical records on 04/03/2023 at 8:00AM to 4:00PM, it was observed the medication regimen review of each resident was not performed. 1.Resident Sample #66 is a [AGE] year-old male admitted on [DATE] with diagnosis of Descondition. During the record review performed on 04/03/2023 at 3:11PM provide evidence of physician orders and administer medication Xarelto 10 mg 1 tablet oral daily, Lasix 20 mg 1 tablet oral daily, Jardiace 10 mg 1 tablet oral daily, Neurontin 300 mg 1 tablet oral daily, Midodrine 10 mg 1 tablet oral every eight hours, Toprol XL 25 mg 1 tablet oral daily, Pepcid 20 mg 1 tablet oral daily and Colace 100 mg 1 tablet…
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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| COLON, CARMEN | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | since 02/01/2021 |
| FELICIANO, JOSE | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 02/01/2021 |
| HALLMAN, DEANA | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 05/18/2015 |
| RYDER MEMORIAL HOSPITAL INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNF | since 01/13/1988 |
| BARRETO MARTINEZ, WANDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2015 |
CMS files one row per role, so the 11 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
What families pay in PR
CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Puerto Rico Medicaid page for homes that do.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner. The starred figure is the national median (no state figure published).
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 405018. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-26, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.