Multy Medical Skilled Nursing Facility

Americo Miranda Ave Entrada Principal Centro, Rio Piedras, PR 00935 · For profit - Corporation · 35 certified beds · (787) 754-0194 Medicare only — no Medicaid

Call the home — (787) 754-0194 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116

Abuse/neglect citations on record (F0600, F0602, F0603) — most recent Sep 2024Resident-funds citations (F0565, F0566, F0567)Behavioral-health or dementia-care citations — no harm found (F0740, F0741)

Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor

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

Worth asking about

it has abuse, neglect, or exploitation citations (F0600, F0602, F0603) — most recent Sep 2024
it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0605, F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
it has citations for mishandling residents’ money or property (F0565, F0566, F0567)
a high number of inspection citations overall (77) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
its independent health-inspection rating is low (1/5)
its payroll-based staffing rating is low (2/5)

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.

1/5

CMS overall

1 of 5

Health inspectionSurveyor-assigned, ranked within your stateInspector-verified	1 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 ↗

Hospital

HOSPITAL PAVIA HATO REY, INC0.9 mi

Emergency dept. usually open 24/7 · ER 24/7

Urgent care / clinic

Gastroenterologia<0.1 mi

816 Torre Axilio Mutuo · (787) 765-6554 · Call to confirm hours

Pharmacy

Walgreens Specialty Pharmacy of Puerto Rico<0.1 mi

576 Calle Cesar Gonzalez · (787) 777-1120 · Call to confirm hours

Grocery

Supermercados Econo Colobos-Canóvanas-Manatí0.2 mi

Ave 65th Infantería Carr #3 Km 14.7 Centro Comercial Los Colobos · (787) 701-6262 · Call to confirm hours

Park

Parque Isabel La Católica0.2 mi

270 Calle Isabel La Catolica · Typically dawn to dusk

Place of worship

Iglesia Cristiana Discípulos de Cristo en University Gardens0.3 mi

273 Columbia,University Gardens · (787) 763-3275

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.

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	0.0%	0.3%	1.4%	better than state — see note marked double-dagger below the table

‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

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.

0.94U.S. median 0.31

Therapy hours / resident / day

0.73hours / resident / day

Physical therapy

0.21hours / resident / day

Occupational therapy

Therapy staffing: this home’s payroll records show 0.94 therapist hours per resident per day in 2026Q1 — more than 96% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 59% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. 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	CMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF	not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.	—
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF	not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.	—
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge	not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.	—
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge	not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.	—
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge	not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.	—
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified	not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality 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 data for this measure is missing or was not submitted. 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	not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.	—
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay	not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.	—
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened	not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.	—
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization	not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.	—
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs	not reported — The data for this measure is missing or was not submitted. 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

1.89

RN hours/ resident / day

0.00

LPN hours/ resident / day

0.00

Aide hours/ resident / day

1.89

Total nurse hours/ resident / day

1.53

RN hoursweekends

—

Total nursing turnover

—

RN turnover

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 1.89 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 1.89 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 1.53 hrs/resident/day on weekends vs 2.04 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 2.04 to 1.53 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

8 ↓

deficiencies at the latest standard inspection (2026-03-26)

at the previous standard inspection (2024-09-25)

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.

ABCDEFGHIJKL

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.

77 citations, most serious first. The 10 most serious are shown; the remaining 67 are one tap away and print in full.

Potential for harm · F2026-03-26 · tag F0761 — failed to label and store drugs safely — widespread
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, review of logs, policies and procedures and interview, it was determined that the facility failed to ensure that the medication room conserves adequate temperature levels and relative humidity. This deficiency affects 17 out of 17 residents in the facility.Findings include:The facility policy named Control de Temperatura y Humedad - Cuarto de Medicamentos Temperature Control and Humidity- Medication Room was reviewed on 03/26/2026 at 11:31AM and states The room temperature must be maintained between 72 and 78 degrees Fahrenheit ( F), and the relative humidity between 20% and 60%. If either of these readings is outside the specified range at the time of measurement, this must be reported, and the corrective actions taken must be documented. The medication room was visited on 03/26/2026 at 8:44AM and it was noted that the temperature was 71.9 F and the relative humidity was 72%.The temperature and relative humidity logs from December 2025 through March 2026 were reviewed on 03/26/2026 at 1:27PM and the following was noted:On January 2026 the temperature was over…
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.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Potential for harm · Fcited before2026-03-26 · tag F0851 — widespread
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — the official record, unedited, may be distressing
Based on staff interview, it was determined that the facility failed to ensure the submission if Payroll-Based Journal (PBJ) data to CMS.Findings include:On 03/25/2026 at 2:20 PM, an interview was conducted with the Director of Nursing (DON) (employee #1) to determine who was responsible for completing and submitting the Payroll-Based Journal (PBJ). The DON stated that she was not responsible for this task.1.At 2:42 PM, an interview was conducted with the Director of Compliance, who reported that PBJ reporting had been the responsibility of the administrator's resignation, PBJ data had not been submitted and the facility had recently become aware that no one had been assigned to continue this responsibility.2.This finding indicates the facility failed to ensure ongoing compliance with federal requirements for PBJ data submission.
Administration Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2026-03-26 · tag F0867 — failed to act on quality-improvement findings — widespread
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of Quality Assessment Performance Improvement- QAPI and interview with facility compliance officer (employee #2 ) on 03/26/2026, it was determined that the facility failed to consider residents feedback as quantifiable data to enhance care and ensure safety. Findings include:1.Review of QAPI activities of year 2025 and first quarter of year 2026 on 03/26/2026 at 10:30 AM, the following was identified:A. Administration clerk officer ( employee #6 ) present on 03/26/2026 at 9:50 AM information collected during year 2025 related with resident satisfaction surveys.B. Accordingly with information provided by facility compliance officer (employee #2 ) on 03/26/2026 at 11:55 AM facility collect on an ongoing basis resident experience while receiving services at the facility in a satisfaction survey questionnaire. He explain that this information is not discussed as part of QAPI committee meeting and activities.C. Facility failed to align healthcare services provided considering resident needs and expectations in order to identify areas where they can improve their services.
Administration Deficiencies · Deficient, Provider has date of correction
Potential for harm · Fcited before2026-03-26 · tag F0868 — widespread
Have 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 and interview with facility compliance officer (employee #2 ) on 03/26/2026, it was determined that the facility failed to maintain a QAPI committee with the participation of administrator, owner, a board member or other individual in a leadership role; in each committee meeting.Findings include:1.Review of quarterly QAPI committee meeting 2025 and 2026 on 03/26/2026 at 10:20 AM, the following was identified:A. QAPI committee meeting performed on January 14, 2026 did not evidence the participation of administrator, owner, a board member or other individual in a leadership role.B. QAPI committee meeting of the first quarterly of year 2025. January, February and March 2025 attendance list did not demonstrate participation of administrator owner, a board member or other individual in a leadership role.C. Review of QAPI rules and regulation updated on 01/08/2026 with QAPI compliance officer (employee# 2) on 03/26/2026 at 11:35 AM did not include in the section of governance and leadership that the Administrator or…
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.
Administration Deficiencies · Deficient, Provider has date of correction
Potential for harm · Fcited before2026-03-26 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
Make 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
Based on the observations and interviews conducted, it was determined that the facility failed to provide a safe environment, specifically regarding the bathrooms in the residents' rooms. This deficiency was observed in 5 of the 16 residents interviewed.Findings include: During the initial pool interviews 5 residents were interviewed (75, 76, 77, 78 and 79) and the 5 residents stated that the water came out of the bathroom when they were showering. Also, they state that the nursing staff instructed all the resident to put the bed sheets on the bathroom floor when they are going to take a shower, so the water does not go out of the bathroom.The resident #76 was visited on 03/25/2026 at 9:15AM and it was noted that she just came out of the shower and there was water under the bed that came from the bathroom when she was showering. A nurse came in the room and asked the resident if she put the bed sheets on the floor before showering but the resident didn't.The resident #76 was visited on 03/25/2026 at 8:10AM and it was noted that she was getting out of the shower again. This time 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.
Environmental Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2026-03-26 · tag F0924 — widespread
Put firmly secured handrails on each side of hallways.
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 interview, the facility failed to maintain the physical environment in a safe and functional manner to ensure resident safety. Specifically, handrails were not maintained in good repair.Findings Include:During a tour of the facility on 03/26/2026, observation of handrails located in corridors revealed the following:Handrails with loose corner sectionsHandrails with uneven surfaces, creating irregular gripping areasThese conditions were observed in the following locations: Next to room [ROOM NUMBER]Next to room [ROOM NUMBER]Next to room [ROOM NUMBER]Next to room [ROOM NUMBER]Next to room [ROOM NUMBER]Next to room [ROOM NUMBER]Next to room [ROOM NUMBER]Next to room men visitors bathroomInterview with the engineer (employee #3) confirmed that the handrails were not in good repair and no immediate corrective action had been taken at the time of survey. Handrails that are loose or have uneven surfaces may not provide adequate support for residents, increasing the risk of slips, trips, 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.
Environmental Deficiencies · Deficient, Provider has date of correction
Potential for harm · Dcited before2026-03-26 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
Honor 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 resident interview, record review, and staff report, it was determined that the facility failed to ensure a safe, comfortable, and adequately accessible bathroom environment for 1 out of 1 sampled resident (resident #88). Findings include: Resident #88 is a 59-years-old female admitted on [DATE] with a diagnosis of Left Total Knee Replacement (TKR). During an interview conducted on 03/25/2026 at 9:42 am, the resident reported that the bathroom space was very uncomfortable and difficult to use. She stated that during a recent bathroom use with assistance from nursing staff, she became entangled between her walker and the commode, causing her to slide to the floor. The resident further stated that nursing staff attempted to assist her in maintaining a standing position but were unable to prevent the fall. The resident expressed that the bathroom should be more comfortable and accessible for safe use. Review of facility documentation revealed that on 03/22/2026 at 11:30 AM, an incident/accident report was…
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.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0550 — failed to protect resident dignity and rights — widespread
Honor 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 review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with resident right and Exercise of right. Findings include: During the survey process it was requested 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 were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident rights and Exercise facility policy and procedure Manual was requested to the facility on [DATE] at 10:00 AM and no evidence was provided. The facility provides different policy and procedure related to resident right that was in English language only as: a. Policy #4000 Resident Care policies that were in the administrative Manual. b. Policy #4005 Resident Right policies, 2 pages that were in the administrative Manual. c. Policy #4010 Access Visiting policies 3 pages that was in 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.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0553 — failed to let residents help plan their care — widespread
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of policy and procedure with the facility Administrator (employee #3), 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 requested 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 were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right to participate in the planning care facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0554 — widespread
Allow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the residents' right to self-administer medications if the interdisciplinary team has determined that this practice is clinically appropriate. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The resident right to self-administer medications facility policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
Resident Rights Deficiencies · Deficient, Provider has date of correction

Show the remaining 67 citations

Potential for harm · F2024-09-25 · tag F0558 — failed to accommodate residents' needs and preferences — widespread
Reasonably accommodate the needs and preferences of each resident.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident has the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: The resident right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences facility policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0559 — widespread
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the residents' right to share a room with his or her spouse, share a room with his or her roommate of choice when practicable 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 requested 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 were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident has the right to share a room with his or her spouse, share a room with his or her roommate of choice when practicable facility policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0560 — widespread
Protect a residents' right to refuse some types of non-requested transfers within the nursing home.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident rights to refuse to transfer to another room in the facility. Findings include: During the survey process it was requested 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. The resident right to refuse to transfer to another room facility policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0561 — failed to honor residents' choices — widespread
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed 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 requested 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. The resident right to promote and facilitate resident self-determination through support of resident choice facility policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0562 — widespread
Provide immediate access to any resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident right to 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 requested to the facility the resident's rights manual, and it was found the following: 1. The residents right to immediate access to any representative of the State, to resident's individual physician, to any representative of the protection and advocacy systems policies and procedures were requested to the facility Administrator (employee #3). As part of the Resident Right structure facility present on 09/25/2024 at 11:55 AM policies and procedures written in English. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with resident right to be provided to residents. The policies and procedures do not include the date when…
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.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0563 — failed to protect the right to visitors — widespread
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that the 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 requested to the facility the resident right manual, and it was found the following: 1. The resident has the right to receive visitors of his or her choosing at the time of his or her choosing, policies and procedure were requested to the facility Administrator (employee #3). As part of the Resident Right structure facility present on 09/25/2024 at 11:55 AM policies and procedures written in English. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with resident right to be provided to residents. The policies and procedures do not include the date when each policy was created or the approval of the governing body. 2. The resident's right to receive visitors of his or her choosing at the time…
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.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0564 — widespread
Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident right to be informed of his or her visitation rights and equal visitation privileges. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The resident right to be informed of his or her visitation rights and equal visitation privileges policies and procedure were requested to the facility Administrator (employee #3). As part of the Resident Right structure facility present on 09/25/2024 at 11:55 AM policies and procedures written in English. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with resident right to be provided to residents. The policies and procedures do not include the date when each policy was created or the approval of the governing body. 2. The resident's right to be informed of his or her visitation rights and equal…
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.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0565 — failed to support the resident council — widespread
Honor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the review of policy and procedure with the facility Administrator (employee #3), 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 requested to the facility the resident right manual and it was found the following: 1. The resident right to organize and participate in resident groups in the facility policies and procedure were requested to the facility Administrator (employee #3). As part of the Resident Right structure facility present on 09/25/2024 at 11:55 AM policies and procedures written in English. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with resident right to be provided to residents. The policies and procedures do not include the date when each policy was created or the approval of the governing body. 2. The resident right to organize and participate in resident groups in the facility policies and procedures did 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.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0566 — widespread
1) Protect residents from being forced to work at the nursing home, or 2) let residents work if they want to.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident has the right to choose or refuse to perform services for the facility. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The resident right to choose or refuse to perform services for the facility policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0567 — failed to protect residents' money held by the home — widespread
Honor the resident's right to manage his or her financial affairs.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident has the right to manage his or her financial affairs. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The resident right to manage his or her financial affairs policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0572 — widespread
Give residents a notice of rights, rules, services and charges.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident has the 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 in the facility. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. 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 in the facility policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0573 — widespread
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident has the right to access personal and medical records pertaining to him or herself. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The resident right to access personal and medical records pertaining to him or herself policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0574 — widespread
The resident has the right to receive notices in a format and a language he or she understands.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0575 — widespread
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
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 review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident has the right that the facility 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 requested to the facility the resident right manual, and it was found the following: 1. During the tour to the facility 09/24/2024 at 9:15 AM, no evidence was observed that the facility 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 2. The residents have the right to be inform in a form and manner accessible and understandable to residents, resident representatives of a list of names, addresses (mailing 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.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0577 — widespread
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident has the 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 requested to the facility the resident right manual, and it was found the following: 1. 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 policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0579 — widespread
Provide information about how to apply for and use Medicare and Medicaid benefits.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident has the 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 requested to the facility the resident right manual, and it was found the following: 1. The resident right to the facility displays inwritten information, and provides 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 policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0580 — failed to tell family and doctor about changes — widespread
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the residents has the right to notify changes. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The resident right to notification of changes policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0582 — widespread
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the residents has the right to be Inform in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The resident right to be informed in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · Fcited before2024-09-25 · tag F0584 — failed to keep a safe, clean, comfortable home — widespread
Honor 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 — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the residents has the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The resident right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0586 — widespread
Not prohibit or in any way discourage a resident from communicating with federal, state, or local officials.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the residents have the right to contact with external entities. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The resident right to contact external entities policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0600 — failed to protect residents from abuse and neglect — widespread
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident right to be free from Abuse, Neglect. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The facility Elder/ Dependent Adult abuse #4015, State Operation Manual Guidance- Abuse and Neglect #4015.1, Abuse Reporting/posting #4015.3 and Abuse and Neglect -Definition #4015.4 policy and procedure provided by the facility Administrator (employee #3) on 09/25/2024 at 11:55 AM. As part of the Resident Right structure facility present policies and procedures written in English base on the State operations Manual. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with resident rights and be provided to residents. The policies and procedures do not include the date when each policy was created or the approval of the governing body. 2. 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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0602 — failed to protect residents from theft of their belongings — widespread
Protect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the review of policy and procedure with the facility Administrator (employee #3), 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 requested to the facility the resident right manual, and it was found the following: 1. The facility Elder/ Dependent Adult abuse #4015, State Operation Manual Guidance- Abuse and Neglect #4015.1, Abuse Reporting/posting #4015.3 and Abuse and Neglect -Definition #4015.4 policy and procedure provided by the facility Administrator (employee #3) on 09/25/2024 at 11:55 AM. As part of the Resident Right structure facility present policies and procedures written in English base on the State operations Manual. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with resident rights and be provided to residents. The policies and procedures do not include the date when each policy was created or…
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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0603 — failed to not confine residents against their will — widespread
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the review of policy and procedure with the facility Administrator (employee #3), 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 or involuntary seclusion. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The facility Elder/ Dependent Adult abuse #4015, State Operation Manual Guidance- Abuse and Neglect #4015.1, Abuse Reporting/posting #4015.3 and Abuse and Neglect -Definition -Definition 4015.4 policies and procedure provided by the facility Administrator (employee #3) on 09/25/2024 at 11:55 AM. As part of the Resident Right structure facility present policies and procedures written in English base on the State operations Manual. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with residents' rights and be provided to residents. The policies and procedures do not 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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0604 — failed to not use physical restraints improperly — widespread
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident's 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 requested to the facility the resident right manual, and it was found the following: 1. The facility Restraint -Physical, 4040 policies and procedure provided by the facility Administrator (employee #3) on 09/25/2024 at 10:55 AM. As part of the Resident Right structure facility present policies and procedures written in English base on the State operations Manual. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with resident rights and be provided to residents. The policies and procedures do not include the date when each policy was created or the approval of the governing body. 2. The resident right to be free from…
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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0605 — failed to not use drugs as a restraint — widespread
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident's right to be free from chemicals restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms that can affect 8 out of 8 admitted residents. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The facility Restraint -Psychotropic Drug #4041 policies and procedure provided by the facility Administrator (employee #3) on 09/25/2024 at 10:55 AM. As part of the Resident Right structure facility present policies and procedures written in English base on the State operations Manual. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with residents' rights and be provided to residents. The policies and procedures do not include the date when each policy was created or the approval 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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0607 — failed to have anti-abuse policies — widespread
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that the 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, including training to the personnel. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The facility Elder/ Dependent Adult abuse #4015, State Operation Manual Guidance- Abuse and Neglect #4015.1, Abuse Reporting/posting #4015.3 and Abuse and Neglect -Definition #4015.4 policies and procedure provided by the facility Administrator (employee #3) on 09/25/2024 at 10:55 AM. As part of the Resident Right structure facility present policies and procedures written in English base on the State operations Manual. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with resident rights and be provided to residents. The 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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0610 — failed to investigate and act on abuse reports — widespread
Respond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the review of policy and procedure with the facility Administrator (employee #3), 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 requested to the facility the resident right manual, and it was found the following: 1. The facility Elder/ Dependent Adult abuse #4015, State Operation Manual Guidance- Abuse and Neglect #4015.1, Abuse Reporting/posting #4015.3 and Abuse and Neglect -Definition #4015.4 and Unusual Occurrence Reporting #4021policie and procedure provided by the facility Administrator (employee #3) on 09/25/2024 at 10:55 AM. As part of the Resident Right structure facility present policies and procedures written…
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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0620 — widespread
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the Admissions policy. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The facility admissions policy and procedure were requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0622 — widespread
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the Transfer and discharge. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The facility Transfer and discharge policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0623 — widespread
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the Notice before transfer. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The facility Notice before transfer policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0624 — widespread
Prepare residents for a safe transfer or discharge from the nursing home.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the Orientation for transfer or discharge. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The facility Orientation for transfer or discharge policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0625 — widespread
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the Notice of bed-hold policy and return. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The facility Notice of bed-hold policy and return policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0626 — widespread
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the Permitting residents to return to facility. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The facility Permitting residents to return to facility policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0727 — failed to provide required RN coverage — widespread
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — the official record, unedited, may be distressing
Based on interviews with the Director of Nursing (DON) (employee #6) and Human Resources Officer (employee #5), on 09/24/2024 through 09/25/2024 at 9:00 AM through 4:00 PM, it was determined that the facility failed to ensure to appoint the services of a full-time Director of Nursing. Findings include: 1. During the interview with the DON (employee #6) on 09/24/2024 at 1:30 PM, she stated that two weeks ago she had been promoted to director of nursing, previously she was a nursing supervisor. 2. The Human Resources Officer (employee #5) on 09/24/2024 at 2:57 PM was interviewed and stated that the employee had been appointed DON, the employee's file was reviewed, and it was noted that she had not been appointed DON, but nursing supervisor on 01/17/2024. The facility failed to designate a registered nurse (RN) to act as a full-time DON.
Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0740 — failed to provide behavioral / mental-health care — widespread
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interview and review of policies and procedures performed during the survey process from 09/24/2024 thru 09/25/2024 from 8:30 AM thru 4:30 PM, it was determined that the facility failed to demonstrate that has 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: 1. On survey procedures behavioral health care and services program policies and procedures were requested to the facility Administrator (employee #3). As part of the behavioral health care and services program structure facility present on 09/25/2024 at 3:55 PM policies and procedures written in English. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with behavioral health care services to be provided to residents. The policies and procedures do not include the date when each policy was…
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.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0741 — failed to have staff trained for behavioral health — widespread
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interview and review of policies and procedures performed during the survey process from 09/24/2024 thru 09/25/2024 from 8:30 AM thru 4:30 PM, it was determined that the facility failed to demonstrate that has an organized program with sufficient staff assigned to provide direct services to residents to promote the maintenance of highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care to resident's with mental and substance use disorders. Findings include: 1. On survey procedures behavioral health care and services program contract with a psychiatrist was presented by the facility Administrator (employee #3) on 09/25/2024 at 3:55 PM. 2. Psychiatrist contract was presented by facility Administrator (employee #3) on 09/25/2024 at 11:00 AM to comply with provisions §483.40 Behavioral Health program, including general information related to contractual agreement with a psychiatrist. 3. Facility did not present information related to the mechanism to be implemented if a resident 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.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0756 — failed to review each resident's drug regimen — widespread
Ensure 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 2. R.R #52 is a [AGE] year-old female admitted on [DATE] for Left total hip replacement. Review record on 09/24/2024 at 9:03 AM, it was found that he is using Elequis 2.5 mg one tablet twice daily (BID) per physician's order. The medication regimen documented by the pharmacy staff was not found in the medical record. 3. R.R # 102 is a [AGE] year-old female admitted on [DATE]f for Right total replacement. Review record on 09/24/2024 at 10:08 AM, it was found that the medication regiment documented by the pharmacy staff was not found in the medical record. The facility failed to ensure that the pharmacy staff performed the medication regimen with the objective of minimizing adverse consequences and potential risks associated with the medications. 4. Resident #51 is a [AGE] years old female admitted to the facility on [DATE] with a diagnosis of Lumbar interbody Fusion. During record review performed on 09/24/24 02:41 PM, no evidence was found that the pharmacist performed the medication regimen review (MRR). During…
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.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0800 — widespread
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on an observational tour of the facility's kitchen performed from 09/24/2024 through 09/25/2024, from 8:30 AM through 4:30 PM and interview with Administrator (employee #3) , it was identified that the facility failed to maintain kitchen production area in good condition in order to promote sanitary conditions and the prevention of foodborne illness. This deficient practice has the potential to affect 8 out of 8 admitted residents. (R#1 through #8). Findings include: 1. On 09/24/2024 from 8:30 AM through 4:30 PM during the observational tour to the kitchen it was determined the following: a. The kitchen area is observed in bad condition. B. Poor condition in which the kitchen equipment and environment it does not promote that high standards of cleanliness are maintained. ac. Kitchen equipment and environment conditions were discussed with facility Administrator (employee #3) on 09/24/2024 from 11:30 AM. The Administrator (employee #3) stated that the kitchen is managed by an outside contractor company. She stated that based on the fact that they are at a hospital facility,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations, staff interview and review of policies and procedures performed during the survey process from 09/24/2024 thru 09/25/2024 from 8:30 AM thru 4:30 PM, it was determined that the facility failed to ensure that food and drink are in an appetizing temperature. Findings include: During test tray performed by surveyors it was noticed that temperatures on food brought by the diet department were not up to standards.
Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0812 — failed to store, cook, and serve food safely — widespread
Procure 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 08/24/2024 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 09/24/2024 at 9:30 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.
Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0814 — failed to dispose of garbage properly — widespread
Dispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based upon a Physical Environment survey performed on 09/24/24 at 8:00 AM through 4:00 AM, to evaluate facility, it was determined that the facility failed to dispose of garbage and refuse properly. Findings include: During the observation of the kitchen area, it was noticed that a tilt truck was overflowed with trash, cardboard boxes and bags on floor located on an area were kitchen utensils were kept.
Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0841 — widespread
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical records obtained on [DATE], it was determined that the facility failed to secure designate a physician to serve as medical director. Findings include: 1. During the review of the medical faculty file on [DATE] at 9:15 AM in the medical director's file (employee #4), a medical faculty appointment was found at the hospital's rehabilitation center as category: Active Medical Staff, but not as medical director. 2. On [DATE] at 9:20 AM, the medical director's file contained a criminal record that expired on [DATE]. The facility failed to make the appointment with its job description as medical director.
Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0880 — failed to prevent and control infections — widespread
Provide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews and review of policies and procedures performed during the survey process from 09/24/2024 through 09/25/2024 from 8:30 AM through 4:30 PM it was determined that the facility failed to establish and 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. Findings include: During the review of infection control program created on June 2024, content and components on 09/25/2024 at 8:55 AM till 10:00 AM during observational tour and evaluation of policies and activities performed by the infection control program officer (employee #1) the following was identified: 1. Infection control program policies and procedures manual did not have a table of contents who gives the reader an overview of the manual contents. 2. Infection control program policies and procedures manual does not include the date when each policy was created and the approval of the governing body or infection control committee.…
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.
Infection Control Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2024-09-25 · tag F0887 — widespread
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, review of policies procedures and interview with infection control officer (employee # 1), performed during the survey process from 09/24/2024 through 09/25/2024 from 8:30 AM through 4:30 PM, it was determined that facility failed to develop and implement policies, procedures, structure and requirements related to comply with COVID-19 immunizations. Findings include: During the interview on 09/25/2024 at 9:35 AM the infection control officer (employee #1) stated the following in relation with the compliance of the facility with COVID-19 immunizations: 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. The facility did not present policies and procedures developed and implemented to ensure their residents and staff have been educated and offered vaccines for COVID-19 respiratory preventable disease. 4. The facility did not present policies and procedures or structure to ensure that all staff are fully…
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.
Infection Control Deficiencies · Deficient, Provider has date of correction
Potential for harm · Fcited before2024-09-25 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
Make 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 upon a Physical Environment survey performed on 09/24/24 at 8:00 AM through 4:00 AM, to evaluate facility, 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 can affect 8 out of 8 residents and visitors. Findings include: 1.During the observation of the residents' rooms, rust was observed on 12 of 35 beds. 2. During the observation of room [ROOM NUMBER] it was observed that on bed B the head rest of the bed was broken. 3. Some walls were observed with peeled wallpaper 4. Some residents report it takes around 2 minutes for the water in the shower to heat up. 5. During visual observation on residents' rooms bathrooms, 3 out of 25 rooms (810, 811, 812) were observed with a slope exceeding 1/2-inch elevation to enter shower. These thresholds, even at 1/2, can cause trips, slips and falls, as well as potentially preventing life-saving mobility if one of those accidents were to occur. 6. 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.
Environmental Deficiencies · Deficient, Provider has date of correction
Potential for harm · E2024-09-25 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
Develop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, review of policies procedures and interview with infection control officer (employee # 1), performed during the survey process from 09/24/2024 through 09/25/2024 from 8:30 AM through 4:30 PM , it was determined that facility failed to develop and implement policies, procedures and structure to comply with Influenza and pneumococcal immunizations. Findings include: During interview on 09/25/2024 at 9:35 AM the infection control officer (employee #1) stated the following in relation to the compliance of the facility with influenza and pneumococcus immunizations: 1. Facility did not have available Influenza vaccines. 2. Facility did not have available Pneumococcus vaccines. 3. The facility did not present policies and procedures developed and implemented to ensure their residents and staff have been educated and offered vaccines for potentially respiratory preventable diseases. 4. Facility had not have any contract or agreement with another entity to make available influenza and pneumococcus vaccines and to vaccinate the residents if they want to receive 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.
Infection Control Deficiencies · Deficient, Provider has date of correction
Potential for harm · D2024-09-25 · tag F0578 — failed to honor advance directives / code status — isolated
Honor 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 — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on nine records reviewed on 09/24/2024 at 9:00 AM to 12:00 PM, it was determined that the facility failed to ensure the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive 1 out of 9 records reviewed. (R.R # 102). Findings include: 1. During the evaluation of the records review on 09/24/2024 at 10:05 AM, the following was found: a. R.R #102 is a [AGE] year-old female admitted on [DATE] for left total hip replacement. Noted in the record review on 09/24/2024 at 10:08 AM, no Advance Directive sheet was found. The facility failed to establish in writing the right of residents to formulate advance directives, including the right to accept or refuse medical or surgical treatment, and to ensure that staff follow such policies and procedures.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · D2024-09-25 · tag F0655 — isolated
Create 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 observations, records reviewed (RR), staff interview and review of policies and procedures performed during the survey process from 09/24/2024 thru 09/25/2024 from 8:30 AM thru 4:30 PM, it was determined that the facility failed to provide the resident and their representative with a summary of the baseline care plan within 48 hours of the resident's admission This deficient practice was identified in 1 out of 8 residents receiving services at the facility (RR #51). Findings include: 1. RR# 51 is [AGE] year-old female resident admitted on [DATE] with a diagnosis of General Weakness after a Cerebro Vascular Accident, Hyperlipidemia, Coronary Artery Disease and Chronic Kidney Disease Stage 4. Initial pool process was performed on 09/25/24 from 8:45 AM through 10:00 AM on the first day of the survey, screening residents, to identify the resident sample pool and seeking information related with choices residents have with regard to their daily life, any activities they partake in, and other issues revolving…
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.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
No harm found · Ccited before2026-03-26 · tag F0732 — widespread
Post nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on staff interview, it was determined that the family failed to maintain posted daily nurse staffing information for the required retention period of at least 18 months. Findings include:On 03/25/2026 at 3:15 PM, requested the facility's posted daily nurse staffing information for the previous 18 months. The facility was only able to provide documentation from 10/01/2025 to the present.During an interview conducted on 03/25/2026, the Director of Information Technology (employee #4) stated that attempts were made to retrieve prior staffing postings; however, these efforts were unsuccessful.This finding indicates the facility failed to retain posted nurse staffing information in accordance with federal requirements.
Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
No harm found · C2024-09-25 · tag F0609 — failed to report abuse allegations — widespread
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the review of policy and procedure with the facility Administrator (employee #3), 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 requested to the facility the resident right manual, and it was found the following: 1. The facility Elder/ Dependent Adult abuse #4015, State Operation Manual Guidance- Abuse and Neglect #4015.1, Abuse Reporting/posting #4015.3 and Abuse and Neglect -Definition #4015.4 and Unusual Occurrence Reporting #4021policie and procedure provided by the facility Administrator (employee #3) on 09/25/2024 at 10:55 AM. As part of the Resident Right structure facility present policies and procedures written in English base on the State operations Manual. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with resident rights and be provided to residents. The policies…
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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
No harm found · C2024-09-25 · tag F0685 — widespread
Assist a resident in gaining access to vision and hearing services.
What the surveyor found here — the official record, unedited, may be distressing
Based on an interview with the Compliance Office (employee #2) on 09/24/2024 at 1:50 PM, 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 Compliance Officer (employee #2) 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.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
No harm found · C2024-09-25 · tag F0687 — failed to care for feet properly — widespread
Provide appropriate foot care.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview with the Compliance Office (employee #2) on 09/24/2024 at 1:56 PM, it was determined that the facility failed to ensure that residents receive proper treatment and care to maintain mobility and good foot health in accordance with professional standards of practice. Findings include: 1. During the review of the procedure manual, the foot care policy and procedures was not found. The Compliance Officer (employee #2) 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 foot care and treatment, in accordance with professional standards of practice.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
No harm found · C2024-09-25 · tag F0691 — failed to provide colostomy / ostomy care — widespread
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of policies and procedures with the Compliance Officer (employee #2) on 09/24/2024 1:50 PM, 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 Compliance Officer (employee #2) 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.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
No harm found · C2024-09-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — widespread
Provide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of policies and procedures with the Compliance Officer (employee #2) on 09/24/2024 1:55 PM, it was determined that the facility failed to ensure have a policy and procedure so that residents receive care consistent with the respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences. Findings include: 1. During the review of the procedure's manual, the policy and procedure with professional standards of respiratory care practice. The Compliance Officer (employee #2) 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, and medical services when respiratory care is needed.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
No harm found · C2024-09-25 · tag F0696 — widespread
Provide appropriate care/assistance for a resident with a prosthesis.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of policies and procedures with the Compliance Officer (employee #2) on 09/24/2024 at 1:12 PM, 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 Compliance Officer (employee #2) 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.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
No harm found · C2024-09-25 · tag F0698 — failed to provide proper dialysis care — widespread
Provide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of policies and procedures with the Compliance Officer (employee #2) on 09/24/2024 at 1:17 PM, it was determined that the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Findings include: 1. During the review of the procedure's manual, the policy and procedure with professional standards of dialysis practice. The Compliance Officer (employee #2) 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 dialysis.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
No harm found · C2024-09-25 · tag F0699 — widespread
Provide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — the official record, unedited, may be distressing
Based on reviwe of policies and procedures with the Compliance Officer (employee #2) on 09/24/2024 at 1:21 PM, 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 Compliance Officer (employee #2) was 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.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
No harm found · C2024-09-25 · tag F0700 — widespread
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of policies and procedures with the Compliance Officer (employee #2) on 09/24/2024 at 1:28 PM, 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 Compliance Officer (employee #2) were 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.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
No harm found · Ccited before2024-09-25 · tag F0732 — widespread
Post nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on reviewed of policy and procedure (P&P) on 09/25/2024 at 1:49 PM, it was determined that the facility failed to establish retention of daily nurse staffing data for a minimum of 18 months. Findings include: 1. During the interview of the director of nursing (DON) (employee #6) about how long the daily nursing notes data would be kept and she stated that it would be kept for a few months. The surveyor requested the policies and procedure, and it was found the following: a. 09/25/2024 at 2:10 PM, the DON provided the P&P for the Daily Personnel Submission, and it was noted that she did not have how long the nursing station data would be retained. The facility failed to ensure the Maintenance of Daily Nursing Personnel Data posted for a minimum of 18 months within their policies and procedures.
Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
No harm found · C2024-09-25 · tag F0757 — failed to avoid unnecessary drugs — widespread
Ensure each resident’s drug regimen must be free from unnecessary drugs.
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, staff interview and review of policies and procedures performed during the survey process from 09/24/2024 through 09/25/2024 from 8:30 AM through 4:30 PM, it was determined that the facility failed to ensure that each resident's drug regimen is free from unnecessary drugs. This deficient practice is identified in 4 out of 8 residents (R) receiving services at the facility (R #51, # 52, #101, and #201). Findings include: 1. A mechanism to ensure that facility provide oversight of each resident medication regimen review to ensure resident's drug regimen is free from unnecessary drugs: a.Resident #101 is [AGE] years old female resident was admitted on [DATE] with a diagnosis of Right Ischemic Cerebrovascular Accident. Review of resident medical record on 09/24/2024 at 2:45 PM revealed that resident had order for Insulin Lantus subcutaneous 100 units at bedtime and Eliquis 5 mgs PO BID since 09/23/2024 when was admitted to the facility. A medication review performed by the pharmacist 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.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction
No harm found · C2024-09-25 · tag F0790 — failed to provide dental care — widespread
Provide routine and 24-hour emergency dental care for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews with administrator (employee #3) 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 #3) was interview on 09/25/2024 at 1:15 PM and it was requested information to him in relation of a dental services as an option to be provided by their facility. 2. The Facility administrator (employee #3) stated in an interview on 09/25/2024 at 1:20 PM that at the moment the facility have a contract with a dental service in order to make available dental services in according to the scope permitted to a SNF. 3. Facility did not provide evidence of a dental contract with a physician dentist. 4. The facility provides evidence of a letter send to the Dentist services and the facility policies and procedure on 09/25/2024 at 1:20 PM, related to this services and states that in an emergency 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.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
No harm found · C2024-09-25 · tag F0802 — failed to prepare enough nourishing food — widespread
Provide 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 observations, staff interview and review of policies and procedures performed during the survey process from 09/24/2024 through 09/25/2024 from 8:30 AM through 4:30 PM it was determined that the facility failed to provide evidence of a process to estimate staffing needs in the kitchen through a kitchen staffing pattern. This deficient practice had the potential to affect 8 out of 8 residents admitted receiving at the facility. Findings include: 1. The staffing pattern calculation was requested by the surveyor to the kitchen manager (employee #12) on 09/24/2024 at 11:20 AM. The kitchen staffing pattern calculation was not provided. 2. A staffing pattern who include the number of personnel of the food and nutrition department needed to safely carry out all the functions, was not provided, not evidence during the survey process from 09/24/2024 through thru 09/25/2024 from 8:30 AM through 4:30 PM. 3. Facility failed to evidence that had a mechanism established to determine the quantity of staff needed to prepare and serve meals in a timely manner and to maintain food safety…
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.
Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
No harm found · C2024-09-25 · tag F0838 — failed to assess facility resources and resident needs — widespread
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interview and review of policies and procedures performed during the survey process from 09/24/2024 through 09/25/2024 from 8:30 AM through 4:30 PM it was determined that the facility failed to a required Facility Assessment. This deficient practice had the potential to affect 8 of 8 residents in the facility. Findings include: 1. During the entrance conference performed on 09/24/2024 at 9:00 AM with the Administrator, the surveyors request the facility assessment, as one of the documents that they must provide within four hours of the entrance conference. 2. On 09/25/2024 at 2:30 PM during interview the Administrator (employee #3) stated that facility is in the process of development of the facility assessment. 3. The Administrator (employee #3) provides evidence of an attendance list on 09/25/2024 at 2:45 PM of a meeting performed on 09/15/2024 where facility personnel discuss the requirement of facility assessment. 3. The Administrator (employee #3) stated on 09/25/2024 at 2:35 PM that the facility is in the process of contracting personnel to collect…
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.
Administration Deficiencies · Deficient, Provider has date of correction
No harm found · Ccited before2024-09-25 · tag F0851 — widespread
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of the policy and procedures manual with the Nursing Supervisor (employee #6) on 09/25/2024, it was determined that the facility failed to have policies and procedures in place regarding the electronic reporting and submission of the Payroll Based Journal to CMS. Findings include: 1. During an interview with the nursing supervisor (employee #6) on 09/25/2024 at 1:08 PM, stated that she did not have a Payroll Based Journal policy available.
Administration Deficiencies · Deficient, Provider has date of correction
No harm found · Ccited before2024-09-25 · tag F0868 — widespread
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — the official record, unedited, may be distressing
Based on reviewed of the quality assessment performance improvement (QAPI) program conducted on 09/24/2024 through 09/25/2024 and interview with Compliance Officer (employee #2), it was determined that the facility did not demonstrate Nursing Director and Infection Control participation in its quality assurance committee. Findings include: b. on 09/24/2024 at 3:10 PM, it was observed the signature of the director of nursing (DON) (employee #6) was observed in the quality manual, but the appointment of the DON was not found in the file. c. On 09/25/2024 at 2:50 PM, it was noted in the quality improvement manual that the quality committee did not include the director of nursing and infection control in the activities and evaluations of the Multy Medical Skilled Nursing Facility.
Administration Deficiencies · Deficient, Provider has date of correction
No harm found · C2024-09-25 · tag F0895 — widespread
Have a Compliance and Ethics Program.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview with the compliance officer (employee #2) 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 compliance officer (employee #2) was interviewed on 09/25/2024 at 11:45 AM and information in relation to policies and procedures was requested and the implementation of the compliance and ethics program at the facility. 2. Facility compliance officer (employee #2) stated on interview on 09/10/2024 at 11:55 AM that facility provide the training's required to comply with the ethics program. 3. No policies and procedures who include the structure, purpose and details on how the facility will fulfill the compliance and ethics program components with respect to a facility was provided.
Administration Deficiencies · Deficient, Provider has date of correction
No harm found · C2024-09-25 · tag F0908 — failed to keep essential equipment working — widespread
Keep all essential equipment working safely.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations made at the nurse's station with Nursing Supervisor (employee #6) on 09/25/2024, it was determined that the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition. Findings include: 1. During the tour of the nursing station in the company of the nursing supervisor (employee #6), the following was found: a. On 09/25/2024 a las 2:26 PM, the Oxygen tank was observed in the crash cart with the pressure gauge indicating zero, when the tank was evaluated, the flow meter was not properly positioned. The Compliance Officer (employee #2) promptly replaced the Oxygen tank.
Environmental Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:

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.

Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.

It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / manager	Type	Role	Share	Since
CONDE STERLING, TANIA	Individual	5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF	100%	since 09/01/2016
SEPULVEDA-IRIZARRY, FERNANDO	Individual	CORPORATE DIRECTOR; ADP OF THE SNF	—	since 10/28/2018

CMS files one row per role, so the 6 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.

What families pay in PR

Paying with Medicaid

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.

Typical monthly cost in Puerto Rico

$9,581/mo

Nursing home (semi-private)*

$10,798/mo

Nursing home (private)*

$6,200/mo

Assisted living*

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 405034. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-26, 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.

What to do next

Understand itWhat this inspection record meansDeficiencies, scope & severity, and the fines — read them like an inspector does.→Afford itCan your family afford this?Model the care years, taxes, and what’s left in My Plan. Free, private, no login.→DecideIs this the right level of care?A two-minute check: skilled nursing, assisted living, memory care, or help at home.→