Centro De Cuidado Prolongado San Lucas

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview with director of nursing (employee # 8) and record review performed on 3/27/2026 at 11:20 AM, it was determined that the facility failed to ensure reasonable efforts to review or adjust the individual resident's food plan to meet the specific needs of assistance during meals.Findings include:Resident (#10) is a [AGE] year-old male admitted on [DATE] due to Decondition / Weakness. During the interview performed on 3/25/2026 at 9:00 AM, resident stated that he has weakness on both upper and lower extremities and needs assistance during meals. Clinical record shows a document named Hidratacion [NAME] Residente (Resident Hydration) who is documented daily. Data includes intake of the resident per hour (in milliliters), but it does not specify the kind of meal (breakfast, lunch, dinner, snack), type of food (e.g. liquids or solids) nor level of assistance per meal (Ex. Minimal, moderate or complete) needed to meet food intake.

Based on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with resident right to designate a representative in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by state law. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the insititutional program director (employee #6), provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The 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.

Based on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident has the right to be informed of, and participate in his or her treatment. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the insititutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13 page policy were include all 483.10 resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policies and procedures and interview with nursing supervisor (employee #15), it was determined that facility failed to promote the right of each resident to sign the forms stating they understand their condition and the proposed treatment, and that they agree to the treatment. This deficient practice was identified in 2 out of 2 closed records (CR) of residents that receive services at the facility. (CR #3 and CR #4). Findings include: 1.CR#3 reviewed is a [AGE] year-old male resident admitted on [DATE] with a diagnosis of Left Knee Replacement. Resident was admitted receiving services for short term rehabilitation after surgery. During review of the medical record on 09/09/2024 at 2:00 PM it was identified that this resident was alert and oriented when admitted to the facility, however, inform consent authorizing disclosure of information, Health Insurance Portability and Accountability Act (HIPAA) notification and treatment consent did not have the signature of the resident. 2.CR#4 reviewed…

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 the review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the residents' right to self-administer medications if the interdisciplinary team determined that this practice is clinically appropriate. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 am with the institutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13-page…

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 the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to choose his/her attending physician. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 am with the insititutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13 page policy where include all 483.10 resident right statement in one policy.

Based on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to be treated with respect and dignity. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the insititutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13 page policy where include all 483.10 resident right statement in one policy.

Based on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to receive services with reasonable accommodation of resident needs and preferences. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the insititutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13 page policy were include all 483.10…

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 review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to share a room with his or her spouse, with his or her roommate of choice when practicable when residents live in the same facility and receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the insititutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate…

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 review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right refuse to transfer to another room in the facility. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the insititutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13 page policy were include all 483.10 resident right statement in one policy.

Based on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right promote and facilitate resident self-determination through support of resident choice. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the insititutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13 page policy were include all 483.10…

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 the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right provide immediate access to any representative of the State, to resident's individual physician, to any representative of the protection and advocacy systems. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the insititutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The 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.

Based on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to receive visitors of his or her choosing at the time of his or her choosing Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the insititutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13 page policy were include all 483.10 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.

Based on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right inform v and equal visitation privileges. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the insititutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13 page policy were include all 483.10 resident right statement in one policy.

Based on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to organize and participate in resident groups in the facility. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the insititutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13 page policy were include all 483.10 resident right statement…

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 the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to choose or refuse to perform services for the facility. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the insititutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13 page policy were include all 483.10 resident right statement in one…

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 the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to manage his or her financial affairs. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the insititutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13 page policy were include all 483.10 resident right statement in one policy.

Based on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to Accounting and Records of personal funds Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the insititutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13 page policy were include all 483.10 resident right statement in one policy.

Based on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to notice of certain balances. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AMwith the insititutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13 page policy were include all 483.10 resident right statement in one policy.

Based on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to Assurance of financial security. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the insititutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13 page policy were include all 483.10 resident right statement in one policy.

Based on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to not impose a charge against the personal funds of a resident for any item or service for which payment is made under Medicare. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the insititutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a…

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 the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to be informed of his or her rights and of all rules and regulations governing resident conduct and responsibilities during his or her stay. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the insititutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy 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.

Based on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to access personal and medical records pertaining to him or herself. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the insititutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13 page policy were include all 483.10 resident 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.

Based on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to receive notices orally and in writing in a format and a language he or she understands. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the insititutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13 page policy were include all 483.10…

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 review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to post, in a form and manner accessible and understandable to residents, at list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the institutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare…

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 review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to have reasonable access to the use of a telephone, including TTY and TDD services, and a place in the facility where calls can be made without being overheard. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the institutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident 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.

Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the institutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The…

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 review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the institutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident 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.

Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to display in the facility written information, and provide to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the institutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include…

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 review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to notification of changes. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the institutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13-page policy were including all 483.10 resident right statement in one policy.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed (RR), it was found that the facility failed to ensure that resident understand the right to be oriented of the Important Message (IM) at the admission for 2 out of 2 resident discharged home. (RR#3 and RR#4). Findings include: 1. RR. #3 is [AGE] years old admitted on [DATE] with a diagnosis of Left knee replacement (Lt TKR), during RR performed on 09/10/2024 at 3:00PM, it was found that the IM during admission was not sign by the resident or their representative. Resident was discharge on [DATE] and the IM was sign. 2. RR. #4 is a 79 admitted [DATE] with a diagnosis of Right Total Hip Replacement (Rt THR), during the RR performed on 09/10/2024 at 3:00 PM it was found that the IM during admission was not sign by the resident or their representative. Resident was discharge on [DATE] and the IM was sign.

Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to personal privacy and confidentiality of his or her personal and medical records. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the institutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13-page policy were including all 483.10 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.

Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to safe environment. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the institutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13-page policy were include all 483.10 resident right statement in one policy.

Based on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to grievances. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the insititutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13 page policy were include all 483.10 resident right statement in one policy.

Based on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to contact with external entities. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the insititutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13 page policy were include all 483.10 resident right statement in one policy.

Based on the review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to be free from Abuse, Neglect, and Exploitation. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the institutional program director (employee #6) and provide three policy that was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. a. Identifying and Reporting Victims of Abuse/Neglect/Domestic Violence/Rape and Exploitation. b. Victims of abuse/neglect/domestic violence/sexual violence/exploitation/abuse. c. Preventing abuse and neglect. 3. Each of the areas of Resident right must include separate…

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 review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to be free from Abuse, Neglect, misappropriation of resident property, and exploitation. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the insititutional program director (employee #6), and provide three policy that was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. a. Identifying and Reporting Victims of Abuse/Neglect/Domestic Violence/Rape and Exploitation. b. Victims of abuse/neglect/domestic violence/sexual violence/exploitation/abuse. c. Preventing abuse and neglect. 3. Each of the areas 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.

Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to be free from Abuse, Neglect, and Exploitation or involuntary seclusion. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the institutional program director (employee #6) and provide three policy that was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. a. Identifying and Reporting Victims of Abuse/Neglect/Domestic Violence/Rape and Exploitation. b. Victims of abuse/neglect/domestic violence/sexual violence/exploitation/abuse. c. Preventing abuse and neglect. 3. Each of the areas of Resident right must…

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 review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to be free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The policy and procedure title Patient Restriction Guide reviewed on 09/10/2024 at 11:00 AM with the institutional program director (employee #6), provide by the facility guide was hospital based and was addressed to the Episcopal Hospital San [NAME] Metro. 3. The facility failed to develop and implemented a policy and procedure of resident right to be free from chemical restraints.

Based on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to be free from chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The policy and procedure title Patient Restriction Guide reviewed on 09/10/2024 at 11:00 AM with the insititutional program director (employee #6), provide by the facility guide was hospital based and was addressed to the Episcopal Hospital San [NAME] Metro. 3. The facility failed to developed and implemented a policy and procedure of resident right to be free from chemical restraints.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to not employ or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The policy and procedure title Criminal record verification or Background check reviewed on 09/10/2024 at 1:00 PM with the institutional program director (employee #6), provide by the facility guide was hospital based and was addressed to the Episcopal Hospital San [NAME] Metro. 3. The facility failed to develop and implemented a policy and procedure…

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 review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, include training to the skill personnel. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The policy and procedure title Abuse and Neglect Prevention, Identification and Reporting of Victims of Abuse/Neglect/Domestic Violence/Rape/Exploitation and Victims of Abuse/Neglect/Domestic Violence/Rape/Exploitation/Abuse, reviewed on 09/10/2024 at 1:00 PM with the institutional program director (employee #6), provide by the facility was hospital based and was addressed to the Episcopal Hospital San [NAME] Metro.

Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to ensure that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The policy and procedure title Abuse and Neglect Prevention, Identification and Reporting of Victims of Abuse/Neglect/Domestic Violence/Rape/Exploitation and Victims of Abuse/Neglect/Domestic Violence/Rape/Exploitation/Abuse, reviewed on 09/10/2024 at 1:00 PM with the institutional program director (employee #6), provide by the facility was hospital based and was addressed to the Episcopal Hospital San [NAME] Metro not directed to the skilled nursing facility, and not…

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 review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to ensure that all alleged violations are thoroughly investigated, and prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The policy and procedure title Abuse and Neglect Prevention, Identification and Reporting of Victims of Abuse/Neglect/Domestic Violence/Rape/Exploitation and Victims of Abuse/Neglect/Domestic Violence/Rape/Exploitation/Abuse, reviewed 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.

Based on interview with the facility appointed Minimum Data Set (MDS) Coordinator (employee #5), it was determined that facility failed to demonstrate that is capable of transmit to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State. Findings include: 1.On 09/10/2024 at 9:30 AM it was request to the MDS Coordinator (employee #5) an initial connectivity test who evidence facility is capable of transmit data to the CMS System. 2. During interview the MDS Coordinator (employee #5) stated on 09/10/2024 at 9:40 AM that facility had not perform this test. She stated that facility is collecting data on paper based MDS-RAI assessment instrument and they plan to begin with transmission once they had a Medicare provider number. 3. Information related the contact person on the Puerto Rico state agency MDS-RAI automation coordinator was provided on 09/10/2024 at 10:00 AM to promote facility request information of how to perform the test if…

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 two records reviewed R.R.' it was found that the facility failed to ensure that to newly admitted resident was developed and implement a baseline care plan within 48 hours of a resident's admission with the minimum healthcare information necessary to properly care for a resident for 1 out of 2 RR .(RR#101) Findings include: Resident #101 is an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Left Total Hip Replacement (Lt THR). During the record review on 09/10/2024 at 1:08 PM, it was found that no evidence that the facility developed and implement the baseline care plan for the resident within 48 hours of admission with minimum heath care information as initial goals based on admission orders, physician orders, dietary orders, therapy services, social services.

Based on interview with Nursing Supervisor (employee #15) on 09/09/2024 at 9:45 AM, It was determined that the facility failed to ensure it had a policy and procedure that the residents received appropriate treatment and assistive devices to maintain their visual and hearing abilities. Findings include: 1. During the review of the procedures manual, the device to maintain the hearing and vision policy and procedures was not found. The Nursing Supervisor (employee #15) and the Interim Manager (employee #18) were interviewed to see if they could find it in the manual, which they indicated that they did not have it available. The facility did not ensure compliance with maintenance targets for hearing and visual devices.

Based on review of policies and procedures with the Nursing Supervisor (employee #15) on 09/09/2024 at 10:00 AM, it was determined that the facility failed to ensure have a policy and procedure so that residents receive care consistent with the standard of professional practice, necessary care and treatment including medical and nursing care and services when they need a urostomy. Findings include: 1. During the review of the procedure's manual, the policy and procedure with professional standards of Urostomy practice. The Nursing Supervisor (employee #15) was interviewed to see if they could find it in the manual. The facility failed to not ensure that the comprehensive resident-centered care plan, goals and care, necessary treatment, care, medical and nursing services when urostomy care is needed.

Based on review of policies and procedures with the Nursing Supervisor (employee #15) on 09/09/2024 at 10:20 AM, it was determined that the facility failed to ensure that residents who have a prosthetic device receive care and assistance in the resident's goals and preferences in accordance with the comprehensive plan of care for wearing and using the prosthesis. Findings include: 1. During the review of the procedure's manual, the policy and procedure with professional standards of protheses practice. The Nursing Supervisor (employee #15) was interviewed to see if they could find it in the manual. The facility failed to not ensure that it had a standard of practice on the plan of care and goals for getting the patient to use the prosthesis.

Based on review of policies and procedures with the Nursing Supervisor (employee #15) on 09/09/2024 at 10:30 AM, it was determined that the facility failed to ensure that trauma-survivor residents receive competent, trauma-informed care in accordance with professional standards and mitigate triggers that may re-traumatize the resident. Findings include: 1. During the review of the procedure's manual, the policy and procedure with professional standards of trauma informed care practice. The Nursing Supervisor (employee #15) were interviewed to see if they could find it in the manual, to which they indicated that it was not available, did they find any mitigation in the manual. 2. We did not find how staff recognize and respond to the effects of all types of traumas recognizes the pervasive impact and signs and symptoms of trauma on residents and incorporates trauma awareness into plans, policies, procedures, and practices to prevent retraumatization.

Based on review of policies and procedures with the Nursing Supervisor (employee #15) on 09/09/2024 at 10:42 AM, it was determined that the facility failed to ensure the risks and benefits of bedrails for residents. The facility must ensure the proper installation, use and maintenance of bedrails. Findings include: 1. During the review of the procedure's manual, the policy and procedure with professional standards of bedrails practice. The Nursing Supervisor (employee #15), was interviewed to see if they could find it in the manual. The facility did not ensure that the handrail restrictions included risk review and consent to meet the resident's needs.

Based on review of policies and procedures, records reviewed, and interview, with Administrator (employee #10), it was determined that the facility failed to have an organized behavioral health care and services program, to promote the maintenance of highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care to residents with mental and substance use disorders. Findings include: On survey procedures behavioral health care and services program policies and procedures were requested to the facility Administrator. As part of the behavioral health care and services program structure facility present a contract with information who defines who facility is expected to do to comply with this requirement. This contract address provisions to be taken when behavior and mental health conditions were presented by residents receiving services at the facility. The contract stipule that if necessary and based on the assessment performed by health care personnel in charge of the residents, those cases were transferred to a…

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 review of policies and procedures, record review, and interview, with Administrator (employee #10), it was determined that the facility failed to have staff who provide direct services to residents with the appropriate competencies and skills through an organized behavioral health care and services program, to promote the maintenance of highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care to residents with mental and substance use disorders. Findings include: On survey procedures behavioral health care and services program personnel roster with schedule were requested to the facility Administrator (employee #10). Facility Administrator (employee #10) was asked by the surveyor during interview on 09/10/2024 at 10:10 AM how facility plan to provide health care and services as an integral part of the person-centered environment at the facility with an interdisciplinary approach to care. He was asked also how facility plan to have available qualified staff to provide those services as part of a…

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 interview with administrator (employee #10) and review of facility policies and procedures, it was determined that facility failed to determine if they are going to have a relationship with any laboratory services (by contract) in order to provide those services at the facility. Findings include: 1. Facility administrator (employee #10) was interview on 09/10/2024 at 11:15 AM and it was requested information to him in relation of a laboratory services as an option to be provided by their facility. 2. Facility administrator (employee #10) stated on interview on 09/10/2024 at 11:28 AM that at the moment facility did not have any contract with a laboratory service in order to make available laboratory services in according to the scope permitted to a SNF. He said that since the facility is hospital base they use the Episcopal San [NAME] Metro Hospital laboratory that is Joint Commission Accredited and Medicare certified facilities to offer these services.

Based on interview with administrator (employee #10) and review of facility policies and procedures, it was determined that facility failed to determine if they are going to have a relationship with any blood bank services (by contract) in order to provide those services at the facility. Findings include: 1. Facility administrator (employee #10) was interview on 09/10/2024 at 11:15 AM and it was requested information to him in relation of a laboratory services as an option to be provided by their facility. 2. Facility administrator (employee #10) stated on interview on 09/10/2024 at 11:28 AM that at the moment facility did not have any contract with a laboratory service in order to make available blood bank services in according to the scope permitted to a SNF. He said that based on the fact that the facility is hospital base they use the Episcopal San [NAME] Metro Hospital laboratory services and blood blank that was Joint Commission accredited and Medicare certified facilities to offer these services. 3. The institutional program director (employee #6) provide the Transfusion…

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 interview with administrator (employee #10) and review of facility policies and procedures, it was determined that facility failed to determine if they are going to have a relationship with any radiology and other diagnostic services (by contract) in order to provide those services at the facility. Findings include: 1. Facility administrator (employee #10) was interview on 09/10/2024 at 11:15 AM and it was requested information to him in relation of a laboratory services as an option to be provided by their facility. 2. Facility administrator (employee #10) stated on interview on 09/10/2024 at 11:28 AM that at the moment facility did not have any contract with a radiology service in order to make available radiology services in according to the scope permitted to a SNF. He said that since the facility is hospital base, they use the Episcopal San [NAME] Metro Hospital radiology services.

Based on interview with administrator (employee #10) and review of facility policies and procedures, it was determined that facility failed to determine if they are going to have a relationship with any dental services in obtaining routine and 24-hour emergency dental care (by contract) in order to provide those services at the facility. Findings include: 1. Facility administrator (employee #10) was interview on 09/10/2024 at 11:15 AM and it was requested information to him in relation of a dental services as an option to be provided by their facility. 2. Facility administrator (employee #10) stated on interview on 09/10/2024 at 11:28 AM that at the moment facility did not have any contract with a dental services in order to make available dental services in according to the scope permitted to a SNF. 3. Facility provide evidence of a dental contract with a physician dentist that provideservice monday to friday from 8:00 AM till 4:00 PM in their office and not meet with Skill Nurse Facility regulation 483.55 Dental Services.

Based on observations of the physical environment, with Engineering Director(employee #13) and Safety Officer (employee #2) performed on 09/09/2024 through 09/10/2024 from 8:00 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 deficiency can affect all residents. Findings include: During visual inspection of the Diet Department it was observed that the walls of the dry warehouse almacen seco showed signs of humidity and water marks. This can affect the integrity of the food within this warehouse.

Based on observations and interview with administrative dietitian (employee #3), it was determined that the facility failed to have in place a policy regarding use and storage food brought to residents by family and other visitors. Findings include: 1. A mechanism to ensure that facility establish their responsibility to store food brought by resident family members or visitors to assure safe and sanitary storage and handling before consumption was not performed accordingly with the following findings identified during survey procedures on 09/09/2024 at 3:20 PM. 2. Administrative dietitian (employee #3), stated on interview on 09/09/2024 at 3:30 PM that facility had a refrigerator located at the back area of the nursing station, where if a resident, resident relative or visitor brings food or drink items personnel nursing were instructed to put the item in a plastic zip lock bag with residents' name and room number. 3. Administrative dietitian (employee #3), stated on interview on 09/09/2024 that once the food or drink item is stored on daily basis nursing personnel advice the…

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 interview with the Physical Therapy Supervisor (employee #16) on 09/10/2024 at 11:00 AM through 12:00 PM, it was determined that the facility failed to secure that speech-language pathology services were not available are required in the resident's comprehensive plan of care. Findings include: 1. During the interview with the Physical Therapy Supervisor (employee #16) on 09/10/2024 at 11:35 AM, she stated that an unsigned contract for speech therapy is pending. She also stated that to date he has not received residents who have needed speech therapist services.The facility failed to not provide specialized speech therapy services to all residents who require it during the time assessed in their comprehensive care plan.

Based on interview with administrator (employee #10) and review of facility policies and procedures, it was determined that facility failed to determine if they are going to have a relationship with any hospice facility (by contract) in order to provide those services at the facility. Findings include: 1. Facility administrator (employee #10) was interview on 09/10/2024 at 11:15 AM and it was requested information to related to hospice care as an option to be provided by their facility. 2. Facility administrator (employee #10) stated on interview on 09/10/2024 at 11:28 AM that at the moment facility did not have any contract with a hospice facility in order to make available hospice services in according to the scope permitted to a SNF. He said that based on the fact that the corporation who owns the SNF offer hospice services and had Medicare certified facilities to offer these services he understand that there is a possibility that those services must be included as an option to be provided by their facility.

Based on interview with administrator (employee #10) and review of Payroll Based Journal reporting system policies, procedures it was determined that facility failed to establish the structure to comply with the mandated electronically submission of data required by Center for Medicare and Medicaid Services (CMS). Findings include: 1. Facility had not shown evidence the development of structure to comply with the mandatory submission of staffing information based on payroll data in a uniform format as required by CMS. 2. Facility administrator (employee #10) was interview on 09/10/2024 at 10:55 AM and it was requested information in relation of the process that facility is going to implement to comply with the Payroll Based Journal reporting system. The administrator stated that facility plan to assign this process to a department named Point click care who is a private company who will oversee all facility software and computer transmission requirements. However, no information related with the process that facility is going to use to electronically submit to CMS complete 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.

Based on reviewed of the quality assessment performance improvement (QAPI) program conducted on 09/10/2024 from 8:00 AM to 4:00 PM and interview with Quality and Service Coordinator to Client (employee #17), it was determined that the facility did not demonstrate Nursing Director participation in its quality assurance committee. Findings include: 1. During the interview and observation on 09/10/2024 at 2:00 PM to 4:00 PM, the following was found: a. On 09/10/2024 at 2:35 PM, the Quality and Service Coordinator to Client (employee #17) was interviewed and said that the quality council is made up of the executive director, medical director, nursing manager, directors, managers and supervisors of departments and services, quality coordinator, infection control coordinator or members whose presence is necessary. During the interview with the coordinator, the nursing director was not mentioned as part of the quality council. b. On 09/10/2024 at 2:45 PM, it was observed in the quality improvement manual that the quality council was not made up of the nursing director and that the…

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 review of policies and procedures and interview with infection control officer (employee # 1), it was determined that facility failed to develop and implement policies, procedures and structure to comply with COVID-19 immunizations and other requirements related with COVID-19 immunizations. Findings include: During interview on 09/09/2024 at 3:35 PM the infection control officer (employee #1) stated the following in relation with the compliance of the facility with COVID-19 vaccination: 1. Facility did not have available COVID-19 vaccines. 2. Facility had not had any contract or agreement with another entity to make available COVID-19 vaccines if a resident want to receive the vaccine. 3. No mechanism had been implemented since January of natural year 2024 when facility begun to offer services at the Skilled Nursing Facility (SNF) to residents for screening COVID-19 vaccination status. The medical record did not include documentation that indicates that the resident or resident representative was provided education with COVID-19 virus and vaccination. 4. No mechanism had…

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 interview with administrator (employee #10) and review of facility policies and procedures, it was determined that facility failed to develop and implement a compliance and ethics program, with respect to a facility. Findings include: 1. Facility administrator (employee #10) was interview on on 09/10/2024 at 11:35 AM and it was requested information in relation of the implementation of the compliance and ethics program at the facility. 2. Facility administrator (employee #10) stated on interview on 09/10/2024 at 11:39 AM that facility had not designed, implement, a compliance and ethics program, with respect to a facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of the physical environment, with Infection control officer (employee #1) performed on 09/09/2024 from 9:50 AM through 11:00 AM, it was determined that the facility failed to ensure resident care equipment is in safe operating condition. This deficient practice had the potential to affect 2 out of 2 residents receiving services. Findings include: 1. On rooms #212, #204, #200 the area where the air condition unit is built-in is observed detached from the base. This could promote that the system structural integrity over time be compromised. 2. Bathroom windows curtains located on rooms # 101, # 102, # 103, #105, #106 and # 108 lacks the balance or weight area, this does not permit to close the window in an easy way. 3. This facility had 13 rooms located on the second floor and 12 rooms on the first floor. Every room had two glass windows, one of the windows is located on the bathroom and the other is located at the side of bed located near the wall. All glass windows and other glass…

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 of the physical environment, with Engineering Director (employee #13) and Safety Officer (employee #2) performed on 09/09/2024 through 09/10/2024 from 8:00 AM through 4:00 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 2 out of 2 residents receiving services. Findings include: 1. Hand rail next to smoke barrier double door on main entrance on first floor was found loose and with loose endcaps. 2. Several hand rails on residents room corridor were found loose.

Based on observations of the physical environment, with Engineering Director(employee #13) and Safety Officer (employee #2) performed on 09/09/2024 through 09/10/2024 from 8:00 AM through 4:00 PM, it was determined that the facility failed to maintain an effective pest control program . This deficient practice had the potential to affect 2 out of 2 residents receiving services. Findings include: 1. Dead flying insects were observed on patient rooms and patient room bathrooms luminaries. 2. Cockroach was found in steam cleaning area of the Diet Department.

Based on interview with administrator (employee #10) and review of facility policies and procedures, it was determined that facility failed to develop and implement a compliance and ethics program, with respect to a facility. Findings include: 1. Facility administrator (employee #10) was interview on on 09/10/2024 at 11:35 AM and it was requested information to him in relation of the implementation of the compliance and ethics program at the facility. 2. Facility administrator (employee #10) stated on interview on 09/10/2024 at 11:39 AM that facility had not designed, implement, a compliance and ethics program, with respect to a facility.

Based on interview with the facility human resources personnel (employee #11), it was determined that facility failed to offer behavioral health training to their personnel that provide services at the facility. Findings include: 1. Facility human resources personnel (employee #11) was requested on 09/10/2024 at 1:30 PM with evidence of the behavioral health training that must be offered to the personnel providing services at the facility. 2. During interview on 09/10/2024 at 1:35 PM the Facility human resources personnel (employee #11) stated that training related with care specific to the individual needs of residents that are diagnosed with dementia were not offered to personnel providing services at the facility. 3. Facility human resources personnel (employee #11) was asked on 09/10/2024 at 1:45 PM if facility include in their in service training plan the CMS (CMS Hand in Hand: A Training Series for Nursing Homes that is an example of a training that addresses behavioral health area). Facility human resources personnel (employee #11) stated on 09/10/2024 at 1:47 PM 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.