Hospital De La Concepcion INC
Carr 2 Km 173 4 Bo Cain Alto, San German, PR 00683 · Non profit - Corporation · 30 certified beds · (787) 892-1860 Medicare only — no Medicaid
The public record raises real questions here. Weigh the concerns below carefully.
- 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
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0605) — 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, F0568, F0569, F0570)
- a high number of inspection citations overall (51) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | Not rated |
Location & what’s nearby
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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.
Met the expected recovery: 73.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 30 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 1.17 therapist hours per resident per day in 2026Q1 — more than 98% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 42% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 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 | 73.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 56.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 83.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 93.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this 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 number of residents or resident stays is too small to report. 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 | 13.3% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 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
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.24 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 3.24 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 0.00 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.66 hrs/resident/day on weekends vs 3.48 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 3.48 to 2.66 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
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
51 citations, most serious first. The 10 most serious are shown; the remaining 41 are one tap away and print in full.
- Potential for harm · F2026-03-05 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of the responsibilities assigned to the Charge Nurse position and staff interview , on 03/04/2026 at 1:22 PM, it was determined that the facility failed to ensure that the Charge Nurse performed all the responsibilities assigned during each shift. Findings include: On 03/04/2026 at 1:22 PM, during an interview with the Nursing Supervisor (employee #2), stated that the facility assigns a Nurse leader on each shift. The nursing staff are not formally designated as nurse leaders, and the facility have not ensured that these nurses perform all the responsibilities associated with the nurse leader position. Charge Nurse is a licensed nurse with specific responsibilities designated by the facility that may include staff supervision, emergency coordinator, physician liaison, as well as direct resident care.
- Potential for harm · F2026-03-05 · tag F0726 — failed to have competent, trained nursing staff — widespreadEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — the official record, unedited, may be distressing
Based on staff interview and review of staff competency practice, it was determined that the facility failed to ensure that the per diem nursing staff assigned to the skilled nursing facility completed annual competency evaluation.Findings include: On 03/05/2026 at 9:51 AM, during an interview with the Nursing Supervisor (employee #2), stated that per diem nursing is hired by the hospital. The supervisor further indicated that competency evaluations for per diem staff were conducted only at the time of initial hiring.The facility failed to ensure that all staff who provide direct care to residents must maintain current competencies that are evaluated on a periodic basis, including per diem staff.
- Potential for harm · E2026-03-05 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Base on the review of the of Skilled Nursing Facility (SNF) Beneficiary Notification of three (3) resident discharge, it was determined that the facility failed to ensure to inform each Medicare-eligible resident, in writing, at the time of admission and 48 hour previous to be discharge the Important Medicare Message in 3 out of 3 supplemental sample Resident (R) # 63, #64, and #65.Finding include: 1 . Resident #63 was a [AGE] years old female admitted on [DATE] with a diagnosis of Right (Rt) Total Knee Replacement (TKR) and was discharge to home on [DATE], during the record review performed on 03/05/2026 10:22 AM, no evidence was found related to the Important Medicare Message was provided in writing and informed at admission and at least 48 hours before discharge. 2. Resident #64 was a 78-years-old male admitted on [DATE] with a diagnosis of Rt TKR and was discharge to home on [DATE], during the record review performed on 03/05/2026 10:30 AM, no evidence was found related to the Important Medicare Message 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.
- Potential for harm · E2026-03-05 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on residents interview and environmental observation on 03/04/2026, it was determined that the facility failed to ensure a comfortable room temperature for residents 3 out of 29 residents (Residents #24, #36 and #39).Findings include:According to the facility policy monitoreo Temperaturas y Humedades - Monitoring of Temperature and Humidity in the Skilled Nursing Facility- SNF, dated May 2025, Section IV states that based on ASHRAE recommendations, the temperature in resident rooms must be maintained between 70 Fahrenheit (F) and 75 F. Page 2 of 3.Resident #24 is a 64 year- old female admitted on [DATE] with Left Knee Arthroplasty. During a resident interview on 03/04/2026 at 10:45 AM, she stated that the temperature in the room was excessively cold. At the time of the observation, there was no thermometer available in the room to indicate the temperature. Proceeded to measure the room temperature using a thermometer, which registered 67.8 F, below the temperature range established by the facility's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-05 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical records reviewed (RR) and staff interviews, it was determined that the facility failed to ensure that a resident's weight was monitored and documented after admission to assess the residents. This deficient practice was identified for 1 out of 29 RR (RR# 42).Findings include:During de medical record review conducted on 03/04/2026 at 11:10 AM, it was identified that the Resident Record #42 a [AGE] year-old male admitted on [DATE] with Prosthetic Joint Infection of Left Hip, had documentation of weight obtained only at the time of admission. Further review of the clinical record revealed no additional documentation of weight monitoring after admission.During an interview conducted on 03/04/2026 at 11:25 AM, Nursing Supervisor (employee # 2) stated that the facility did not have a policy regarding routine weight monitoring for residents. On 03/05/2026 at 11:10 AM, the facility provided a newly developed policy regarding weight monitoring. This policy was created after the surveyors request,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-09-12 · tag F0550 — failed to protect resident dignity and rights — widespreadHonor 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 institutional program director (employee #1), 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 right and Exercise facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided. The Resident Rights and Responsibilities sheet provided to the resident at the admission provide evidence that this was hospital based, containing information about how to contact regulatory agency as The Joint Commission. This sheet provides to the resident the form to perform a complaint however, the Department of Health Assistant Secretary for Public…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-09-12 · tag F0551 — widespreadGive the resident's representative the ability to exercise the resident's 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 review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with resident right to designate a representative in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by state law. Findings include: During the survey process it was 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 Exercised by representative facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided, the Notice of Privacy Practices sheet provided to the resident at the admission provides evidence that this was hospital based.
- Potential for harm · F2024-09-12 · tag F0552 — widespreadEnsure that residents are fully informed and understand their health status, care and treatments.
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 institutional program director (employee #1), 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 and Exercise facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided. The Resident Rights and Responsibilities sheet provided to the resident at the admission provide evidence that this was hospital based, containing information about how to contact regulatory agency as The Joint Commission. This sheet provides to the resident the form to perform a complaint however, 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.
- Potential for harm · F2024-09-12 · tag F0553 — failed to let residents help plan their care — widespreadAllow resident to participate in the development and implementation of his or her person-centered plan of care.
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 institutional program director (employee #1), 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, the Resident Rights and Responsibilities sheet provided to the resident at the admission provide evidence that this was hospital based, contain information about how to contact regulatory agency as The Joint Commission. This sheet provides to the resident the form to perform a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-09-12 · tag F0554 — widespreadAllow residents to self-administer drugs if determined clinically appropriate.
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 institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the 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 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 self-administer medications facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided, the Resident Rights and Responsibilities sheet provided to the resident at the admission provide evidence that this was hospital based, contain information about how to contact regulatory agency as The Joint Commission. This…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 41 citations
- Potential for harm · F2024-09-12 · tag F0555 — widespreadHonor the resident's right to choose his or her attending physician.
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 insititutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to choose his/her attending physician. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right to choose his/her attending physician facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
- Potential for harm · F2024-09-12 · tag F0557 — widespreadHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
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 institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to be treated with respect and dignity. 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 be treated with respect and dignity facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
- Potential for harm · F2024-09-12 · tag F0558 — failed to accommodate residents' needs and preferences — widespreadReasonably 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 institutional program director (employee #1), 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 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 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 10:00 AM and no evidence was provided.
- Potential for harm · F2024-09-12 · tag F0559 — widespreadHonor 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 institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with 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 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 10:00 AM and no evidence was provided.
- Potential for harm · F2024-09-12 · tag F0560 — widespreadProtect 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 the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right 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. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right to refuse to transfer to another room facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
- Potential for harm · F2024-09-12 · tag F0561 — failed to honor residents' choices — widespreadHonor 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 the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to Self-determination to make choices. 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 Self-determination to make choices facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
- Potential for harm · F2024-09-12 · tag F0562 — widespreadProvide immediate access to any 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 institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to have provide immediate access to any representative of the State, to resident's individual physician, to any representative of the protection and advocacy systems. Findings include: During the survey process it was 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 have immediate access to any representative of the State, to resident's individual physician, to any representative of the protection and advocacy systems facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
- Potential for harm · F2024-09-12 · tag F0563 — failed to protect the right to visitors — widespreadHonor 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 — 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 institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable. 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 receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
- Potential for harm · F2024-09-12 · tag F0564 — widespreadInform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.
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 institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to inform visitation rights and equal visitation privileges. 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 visitation rights and equal visitation privileges facility policy and procedure were requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
- Potential for harm · F2024-09-12 · tag F0565 — failed to support the resident council — widespreadHonor the resident's right to organize and participate in resident/family groups 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 the review of policy and procedure with the institutional program director (employee #1), it was determined that the facility failed to establish the structure to comply with the resident has the 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 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 to organize and participate in resident groups facility policy and procedure were requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
- Potential for harm · F2024-09-12 · tag F0566 — widespread1) 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 institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to choose or refuse to perform services for the facility. Findings include: During the survey process it was 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 to choose or refuse to perform services for the facility policy and procedure were requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
- Potential for harm · F2024-09-12 · tag F0567 — failed to protect residents' money held by the home — widespreadHonor 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 institutional program director (employee #1), it was determined that the facility failed to establish the structure to comply with the resident right to manage his or her financial affairs. Findings include: During the survey process it was 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 to manage his or her financial affairs policy and procedure were requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
- Potential for harm · F2024-09-12 · tag F0568 — widespreadProperly hold, secure, and manage each resident's personal money which is deposited with 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 institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to Accounting and Records of personal funds. Findings include: During the survey process it was 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 residents' rights to Accounting and Records of personal funds policy and procedure were requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
- Potential for harm · F2024-09-12 · tag F0569 — widespreadNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
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 institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to notice of certain balances. Findings include: During the survey process it was 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 to notice of certain balances policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
- Potential for harm · F2024-09-12 · tag F0570 — widespreadAssure the security of all personal funds of residents deposited with 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 the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to Assurance of financial security. Findings include: During the survey process it was 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 to Assurance of financial security policy and procedure were requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
- Potential for harm · F2024-09-12 · tag F0571 — widespreadLimit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.
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 institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to not impose a charge against the personal funds of a resident for any item or service for which payment is made under Medicare. Findings include: During the survey process it was 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 to not impose a charge against the personal funds of a resident for any item or service for which payment is made under Medicare policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
- Potential for harm · F2024-09-12 · tag F0572 — widespreadGive residents a notice of rights, rules, services and charges.
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 institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to be informed of his or her rights and of all rules and regulations governing resident conduct and responsibilities during his or her stay. Findings include: During the survey process it was 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's rights to be informed of his or her rights and of all rules and regulations governing resident conduct and responsibilities during his or her stay policy and procedure were requested at the facility on 09/12/2024 at 10:00 AM and no evidence was provided. The Resident Rights and Responsibilities sheet provided to the resident at the admission provides evidence…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-09-12 · tag F0573 — widespreadLet 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 institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to access personal and medical records pertaining to him or herself. Findings include: During the survey process it was 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 to access personal and medical records pertaining to him or herself policy and procedure were requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
- Potential for harm · F2024-09-12 · tag F0574 — widespreadThe resident has the right to receive notices in a format and a language he or she understands.
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 institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident's right to receive notices orally and in writing in a format and a language he or she understands. Findings include: During the survey process it was 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 to receive notices orally and in writing in a format and a language he or she understands policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided. The Resident Rights and Responsibilities sheet provided to the resident at the admission provides evidence that this was hospital based, contain information about how to contact regulatory agency as The Joint…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-09-12 · tag F0575 — widespreadPost 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 institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to post, in a form and manner accessible and understandable to residents, a 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 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 to receive notices orally and in writing in a format and a language he or she understands policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided. The Resident Rights and Responsibilities sheet provided to the resident at the admission provides evidence…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-09-12 · tag F0576 — widespreadEnsure residents have reasonable access to and privacy in their use of communication methods.
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 institutional program director (employee #1), it was determined that the facility failed to establish the structure to comply with the resident right to have reasonable access to the use of a telephone, including TTY and TDD services, and a place in the facility where calls can be made without being overheard. Findings include: During the survey process it was 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 to have reasonable access to the use of a telephone, including TTY and TDD services, and a place in the facility where calls can be made without being overheard policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
- Potential for harm · F2024-09-12 · tag F0577 — widespreadAllow 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 institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. Findings include: During the survey process it was 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 residents have the rights 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 10:00 AM and no evidence was provided.
- Potential for harm · F2024-09-12 · tag F0578 — failed to honor advance directives / code status — widespreadHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Findings include: During the survey process it was 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 to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advanced directive policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided. The Information Brochure Advance Directives (Previous Will Declaration)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-09-12 · tag F0579 — widespreadProvide information about how to apply for and use Medicare and Medicaid benefits.
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 institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to display in the facility written information, and provide to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. Findings include: During the survey process it was 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. Policy and procedure for displaying 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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-09-12 · tag F0580 — failed to tell family and doctor about changes — widespreadImmediately 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 institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to Notification of Changes. Findings include: During the survey process it was 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 to Notification of Changes facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
- Potential for harm · F2024-09-12 · tag F0583 — failed to protect personal privacy — widespreadKeep residents' personal and medical records private and confidential.
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 institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to Privacy and Confidentiality. 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 residents' rights to Privacy and Confidentiality facility policy and procedure were requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
- Potential for harm · F2024-09-12 · tag F0585 — failed to handle grievances — widespreadHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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 institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to Grievances. Findings include: During the survey process it was 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 to Grievances facility policy and procedure were requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
- Potential for harm · F2024-09-12 · tag F0586 — widespreadNot 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 institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to Contact with External Entities. Findings include: During the survey process it was 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 to Contact with External Entities facility policy and procedure were requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
- Potential for harm · F2024-09-12 · tag F0604 — failed to not use physical restraints improperly — widespreadEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
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 institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to be free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Findings include: During the survey process it was 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 residents' rights to be free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the residents' medical symptoms facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
- Potential for harm · F2024-09-12 · tag F0605 — failed to not use drugs as a restraint — widespreadPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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 institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident's right to be free from chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Findings include: During the survey process it was 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 residents' rights to be free from chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the residents' medical symptoms facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
- Potential for harm · F2024-09-12 · tag F0655 — widespreadCreate 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 records reviewed (RR) and interview with register nurse (employee #7) and medical record personnel (employee # 6) performed on 09/11/2024 through 09/12/2024 from, 8:30 AM through 3:00 PM, it was determined that the facility failed to provide a written copy of the Baseline Care Plan developed that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission to the facility. This deficient practice was identified in 8 out of 8 cases receiving services at the facility (RR #51, #52, #57, R#104, R#201, #202, #203, and #204). 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 09/11/2024 from 8:45 AM through 10:00 AM on the first day of the survey, screening residents, to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-09-12 · tag F0790 — failed to provide dental care — widespreadProvide routine and 24-hour emergency dental care for each resident.
What the surveyor found here — the official record, unedited, may be distressing
Based on interviews with the institutional program director (employee #1), and review of facility policies and procedures, it was determined that facility failed to determine if they were 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 institutional program director (employee #1) was interviewed on 09/12/2024 at 2:15 PM and surveyor requested information to her in relation to a dental service as an option to be provided by their facility. 2. Facility institutional program director (employee #1), stated in interview on 09/12/2024 at 2:15 PM at the moment the facility did not have any contract with a dental service in order to make dental services available in accordance to the scope permitted to a SNF, if needed the hospital has dentist. 3. Facility failed to have a contract or agreement that meets with CMS regulation 483.55 Dental services to assist residents in obtaining routine and 24-hour emergency dental care.
- Potential for harm · F2024-09-12 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — the official record, unedited, may be distressing
Based on infection control observation during the Drug pass performed on 09/12/2024 from 8:33 AM through 9:45 AM, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Findings include: During the medication Pass performed on 09/12/2024 from 8:33 AM through 9:45 AM, it was the following: 1. During the medication pass with the registered nurse employee #16 it was observed that nurse failed to wash his hand in 10 out of 19 opportunity for washing his hand during the drug pass.
- Potential for harm · F2024-09-12 · tag F0949 — failed to train staff on dementia and abuse — widespreadProvide behavior health training consistent with the requirements and as determined by a facility assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the initial recertification survey, and interview with the facility institutional program director (employee #1) and director of nursing (employee #8), it was determined that facility failed to offer behavioral health training to their personnel that provide services at the facility. Findings include: 1. The surveyor requested to the facility institutional program director (employee #1) and to the director of nursing (employee #8) on 09/12/2024 at 11:30 AM evidence of the behavioral health training that must be offered to the personnel providing services at the facility. 2. During interview on 09/12/2024 at 1:35 PM the director of nursing (employee #8) stated that training related with care specific to the individual needs of residents that are diagnosed with dementia were not offered to personnel providing services at the facility. 3. Institutional program director (employee #1) was asked by the surveyor on 09/12/2024 at 11:45 AM if facility include in their in-service training plan the CMS (CMS Hand in Hand: A Training Series for Nursing Homes that is an example of a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-09-12 · tag F0636 — patternAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed (RR) performed on 09/11/2024 through 09/12/2024 from 8:30 AM through 3:00 PM and interview with register nurse (employee #7) and medical record personnel (employee # 6), it was determined that the facility failed to perform a complete and accurate comprehensive assessment of each resident admitted to the facility. This deficient practice was identified in 2 out of 8 cases receiving services at the facility (RR #51 and #57). Findings include: 1.RR#51 is [AGE] year-old female resident admitted on [DATE] with a diagnosis of General Weakness, Hyperlipidemia, Coronary Artery Disease and Chronic Kidney Disease Stage 4. When admitted to the facility the resident was admitted coming from hospital with a nasal cannula Oxygen at 3 liters/minute. The resident was observed in her room sitting on a wheelchair in company of her daughter on 09/11/2024 at 9:35 AM using a nasal cannula Oxygen at 3 liters/minute. Review of resident nursing admission assessment on the medical record on 09/11/2024 at 10:30…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-09-12 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based records reviewed (RR)and interviews performed on 09/11/2024 through 09/12/2024 from, 8:30 AM through 3:00 PM with register nurse (employee #7) and medical record personnel (employee # 6), it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for each resident based on the information collected in the comprehensive assessment when admitted to the facility. This deficient practice was identified in 3 out of 8 cases receiving services at the facility. (RR #51, #57 and RR#104). Findings include: 1.RR#51 is [AGE] year-old female resident admitted on [DATE] with a diagnosis of General Weakness, Hyperlipidemia, Coronary Artery Disease and Chronic Kidney Disease Stage 4. When admitted to the facility resident was admitted coming from hospital with a nasal cannula Oxygen at 3 liters/minute. Resident was observed on her room sitting on a wheelchair in company of her daughter on 09/11/2024 at 9:35 AM using a nasal cannula Oxygen at 3 liters/minute. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-12 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on initial certification survey, interview with Resident and Dietitian (employee # 12) conducted from 09/11/2024 to 09/12/2024 from 9:00 AM to 1:00 PM, it was determined that the facility failed to ensure the tastes and preferences related with food to residents 1 out of 17 (Resident# 170). Findings include: 1. During the initial process the resident located in room [ROOM NUMBER]-B stated that the kitchen staff brought her the same protein most of the time, during lunch and dinner. a. Resident #170-B stated in the interview conducted on 09/11/2024 at 10:45 AM that most of the time they always brought her chicken for lunch and dinner, she stated that she does not like to eat chicken every day. The dietitian (employee #12) was interviewed on 09/12/2024 at 12:46 PM, she indicated that when the resident arrives, she fills out likes and preferences form and it is signed by the dietitian and the resident. It was noted that resident #170-B likes and preferences form was signed by the resident, but not by 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.
- Potential for harm · D2024-09-12 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on an initial certification survey, interview with Resident and Nursing Supervisor (employee #9) conducted from 09/11/2024 to 09/12/2024 from 9:00 AM to 1:00 PM, it was determined that the facility failed to ensure the temperature of the food served to residents for 1 out of 17 (Resident# 204). Findings include: 1. During the initial process, the resident located in room [ROOM NUMBER] stated that the kitchen staff brought him lunch and food at inadequate temperatures. a.Resident #204 stated in the interview conducted on 09/11/2024 at 9:11 AM that at times lunch and dinner arrived cold. The Nursing Supervisor (employee #9) was interviewed, who stated that the residents' meals arrive on meal delivery carts.
- No harm found · C2024-09-12 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on the initial certification survey, interview with de nursing supervisor (employee #9) on 09/11/2024 through 09/12/2024 at 8:30 AM to 4:00 AM, it was determined that the facility failed to comply with nursing assignments and post nursing staff who are directly responsible for the care. Findings include: The Facility policy #018 Daily Distribution Notification, last revised February 2024, was provided on 09/12/2024 by Nursing Supervisor (employee #9). 1. During the interview with the nursing supervisor (employee #9) on 09/11/2024 at 11:43 AM, she mentioned that she had work assignments. When she provided the assignment to the surveyor, it was placed in a binder and in a wooden paper organizer on the nursing counter. The facility did not have nursing staffing information or posting requirements with facility name, current date, nursing staff, hours performed and resident census. On 09/12/2024 at 2:25 PM the Nursing Supervisor (employee #9) provided policy and procedures (P&P) and corrected work assignments.
- No harm found · C2024-09-12 · tag F0806 — failed to honor food preferences — widespreadEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on initial certification survey, interview and observation with Resident and Nursing Supervisor (employee #9) conducted from 09/11/2024 to 09/12/2024 from 9:00 AM to 1:00 PM, it was determined that the facility failed to each residents receives food that accommodate residents' allergies, intolerances, and preference 1 out of 17 (Resident #204). Findings include: 1. During the initial process, the resident located in room [ROOM NUMBER] stated that since her admission on [DATE] she has been receiving dairy products. The resident was brought milk on several occasions, when she is lactose intolerant. a.Resident #204 is a [AGE] year-old female who was admitted on [DATE] with a diagnosis of right total knee arthroplasty. During the interview with the resident on 09/11/2024 at 9:11AM, the resident stated that she had been brought dairy products for several days. The electronic record was observed that the dietitian performed her assessment on 03/09/2024 which indicated 1500 kal, high iron, no dairy, 1 snack and 1…
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.
- No harm found · C2024-09-12 · tag F0851 — widespreadElectronically 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 interview with the director of nursing (employee #8) and review of Payroll Based Journal reporting system policies and procedures, it was determined that facility failed to evidence the development of a complete structure who include information on how facility is going to support PBJ electronic data transmissions and submissions as required by Center for Medicare and Medicaid (CMS). Findings include: Facility's policy #075 Informe Mandatorio de Nómina Payroll-Based Journal (PBJ) last reviewed in February 2024. On 09/12/2024 at 3:45 PM was reviewed, the Policy stated that facility is going to collect auditable staffing data to be transmitted accordingly with Center for Medicaid & Medicare Services (CMS). 1.The facility did not provide evidence on the policy or procedures about arrangements related with software to be used to work PBJ system, persons in charge or responsible for the data entry and transmission,(payroll vendors) and who is going to have Payroll Based Journal system access.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| HOSPITAL DE LA CONCEPCION INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 01/17/2025 |
| CALDERON, LIZMARI | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/17/2025 |
| CARDONA RODRIGUEZ, VANESSA | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/17/2025 |
| FERRER, MARIE | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/17/2025 |
| QUINONES BODEGA, CARLOS | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/17/2025 |
CMS files one row per role, so the 18 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
What families pay in PR
CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Puerto Rico Medicaid page for homes that do.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner. The starred figure is the national median (no state figure published).
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 405032. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-05, 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.