Centro Medico Wilma N Vazquez SNF
Road 2 Km 39. 5 Bo Algarrobo, Vega Baja, PR 00693 · For profit - Corporation · 45 certified beds · (787) 858-1580 Medicare only — no Medicaid
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (27% vs 45% nationally) — better care continuity
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (35) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $29,997 in federal fines (most recent 2024-04-09)
- its payroll-based staffing score sits well above its independent inspection score
- 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) | 5 of 5 |
| Quality measuresSelf-reported by the facility | Not rated |
Worth a closer look. This home's staffing rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
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.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 0.3% | 1.4% | better than state‡ — see note marked double-dagger below the table |
| Short-stay residents given the seasonal flu vaccine | 90.4% | 97.9% | 79.4% | better |
‡ 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.
57.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 45 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 78.3% 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 23 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 1.74 therapist hours per resident per day in 2026Q1 — more than 99% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 38% 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 | 57.4%CMS range 49.5–63.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.9%CMS range 5.9–17.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 78.3% | 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 | 87.0% | 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 | 73.9% | 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 | 4.3% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 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 number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 45 beds and averages 21.6 residents a day — about 48% occupied, or roughly 23 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.04 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 3.72 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 3.95 hrs/resident/day on weekends vs 5.50 on weekdays — 28% thinner on weekends — a notable drop. RN hours go from 4.14 to 2.73 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 27% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. 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.
35 citations, most serious first. The 12 most serious are shown; the remaining 23 are one tap away and print in full.
- Immediate jeopardy · Lcited before2026-05-21 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, staff interview, and facility documentation review, the facility failed to ensure food was stored, handled, and maintained under sanitary conditions by failing to maintain the dietary department walk-in freezer in operational condition. The deficient practice resulted in unsafe food storage temperatures and unsanitary environmental conditions within the dietary department, creating a likelihood that residents would be exposed to contaminated or temperature-abused food products. This failure placed residents at risk for serious adverse outcomes, including foodborne illness, infection, hospitalization, or death. The deficient practice constituted Immediate Jeopardy and had the potential to affect all residents receiving food services from the facility.Findings include: The facility failed to ensure food was stored, handled, and maintained under sanitary conditions by failing to maintain the dietary department walk-in freezer in operational condition. The deficient practice resulted in unsafe food storage conditions and unsanitary environmental…
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.
- Actual harm · Icited before2026-05-21 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and document review performed on 5/20/2026 from 8:30 AM through 8:00 PM, it was determined that the facility failed to employ sufficient staff with appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 11 out of 11 residents. Findings include: The Facility policy and procedure, Section 6.1- Evaluación y seguimiento nutricional -Nutritional evaluation and follow up - February 2023 revision, was reviewed on 5/20/2026 at 7:02 PM. The policy states that the nutritional assessment must be performed by the clinical nutritionist during 24 hours after admission following nutritional risk criteria. 1. Resident #21 is a[AGE] years old female admitted to the facility on [DATE] with a diagnosis of Septic arthritis, Right knee cleanser. On 05/20/2025 at 8:30 am. Resident stated that she did not eat breakfast this morning because she does not like the scrambled eggs, the bread, many cream, the milk. The surveyor asks if she was evaluated 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 · Fcited before2026-05-21 · tag F0802 — failed to prepare enough nourishing food — widespreadProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations and interviews performed on 05/20/2026 from 8:00 AM thru 4:00 PM, it was determined that the facility failed to employ a qualified dietitian to provide sufficient support for personnel safely and effectively carry out the functions of the food and nutrition service.Findings include:During interview performed with the Director of Operations (employee # 3) on 5/20/2026 at 11:00 AM the following was identified:The clinical nutritionist submitted resignation letter on 04/13/2026 with an effective date of 4/24/26. The resigning the clinical nutritionist signed a professional services agreement and contract in which the clinical dietitian agreed to provide services as a clinical dietitian on Tuesdays, Thursdays, and Saturdays.
- Potential for harm · Fcited before2026-05-21 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct 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 — the official record, unedited, may be distressing
Based on interviews and document review performed on 5/20/2026 at 3:30 PM, it was determined that the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents during operations and emergencies.Findings include:During entrance conference and interview with the Director of Operations (employee # 3), the facility assessment document was requested to be submitted within 4 hours after the entrance conference took place (05/20/2026 at 8:00 AM). The document was provided on 05/21/2026 at 3:30 PM.
- Potential for harm · Fcited before2026-05-21 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility failed to implement and maintain an effective infection prevention and control program that develop and implement written policies and procedures for appropriate transmission-based precautions. These deficient practices had the potential to increase the risk of cross-contamination and transmission of infectious organisms among residents. Findings include: 1. Resident #21 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Septic arthritis Right knee cleanser, resident was evaluated by the infection control preventionist employee #2 on 05/07/2026 and resident refuse influenza and pneumococcus vaccine and indicate that has 3 Covid 19 vaccine. The residents had wound cultured on 05/05/2026 and the result on 05/07/2026 was negative. The resident was observed with Right subclavian Central Line. On 05/20/2026 at 1:10 pm, it was observed nurse personnel employee #4, performing Central line Care only with glove,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-05-21 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews performed on 05/20/2026 from 8:00 AM thru 4:00 PM, it was determined that the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition. Findings include:During the survey of resident's rooms, the following electrical hazards were observed:In room [ROOM NUMBER], Bed A, a modified power plug was observed with no strain relief at the cable-to-plug connection. The cord was pinched at the connection point, creating stress on the electrical wiring.In room [ROOM NUMBER], Bed A, a modified power plug was observed with no strain relief at the cable-to-plug connection, and the cord was similarly pinched at the connection point.In room [ROOM NUMBER], Bed B, a modified power plug was observed with no strain relief at the cable-to-plug connection.In room [ROOM NUMBER], Bed A, a modified power plug was observed with no strain relief at the cable-to-plug connection.In room [ROOM NUMBER], Bed B, a modified power plug was observed with no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-05-21 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interviews, records reviewed (RR), and review of facility policy, it was determined that the facility failed to maintain resident rooms within acceptable temperature ( 69.8 grade ( ) Fahrenheit (F) and 75.2 F) and humidity parameters between 30 percent (%) and 60 % to provide a comfortable environment for 9 out of 11 residents interviewed (R.R #21, # 28, #29, #30, #31, #32, #34, #35 and #36).Findings include: During resident interviews and environmental observations conducted on 05/20/2026 between 9:00 AM to 12:00 PM, it was identified concerns related to the facility's ability to provide a comfortable environment. The following was observed: Review of the policy Temperature and Relative Humidity of Skilled Nursing Facility Rooms on 05/20/2026 at 3:10 PM, section 5.3.3 revealed that the environmental parameters established for resident rooms were temperatures between 69.8 degrees F and 75.2 degrees F and humidity between 30 % and 60 %. 1.R.R #29 is a [AGE] year-old female admitted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-05-21 · tag F0803 — failed to meet residents' dietary needs — patternEnsure 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 records reviewed (RR) and interview, it was determined that the facility failed to ensure that menu was adequacy, meet the nutritional needs of residents and be updated periodically for 3 out of 11 residents (R. R.# 21, #35 and #36.)Findings include: The Facility policy and procedure, Section 6.1- Evaluacion y seguimiento nutricional -Nutritional evaluation and follow up - February 2023 revision, was reviewed on 5/20/2026 at 7:02 PM. The policy states that the nutritional assessment must be performed by the clinical nutritionist during 24 hours after admission following nutritional risk criteria. 1. Resident #21 is a[AGE] years old female admitted to the facility on [DATE] with a diagnosis of Septic arthritis, Right knee cleanser. On 05/20/2025 at 8:30 am Resident stated that she did not eat breakfast this morning because she does not like the scrambled eggs, the bread, many cream, the milk. The surveyor asks if she was evaluated by the nutritionist and if she notified nurse personnel about her tastes…
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 · D2026-05-21 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 — the official record, unedited, may be distressing
Based on observation and staff interview, it was determined that the facility failed to ensure medications were stored and secured to prevent unauthorized access when a medication cart was left unattended and in locked in a resident care area.Findings include: On 05/21/2026 at 8:54 AM, during medication administration observations, a Registered Nurse (employee #7) was observed leaving the medication cart unattended in the hallway without securing or locking it while going to the medication storage room. The medication cart remained accessible to residents, visitors and other unauthorized individuals during the nurse's absence. This practice had the potential to allow unauthorized access to medications and failed to ensure the safe storage and security of drugs and biologicals in accordance with facility policy and accepted standard of practice.
- Potential for harm · F2024-12-06 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on initial tour observation, resident interview, observations done during the assembly of the food trays, staff interviews and policies reviewed (Line assembly and delivery of meals or special foods), it was determined that the facility failed to ensure that food and drink is palatable, attractive, and at a safe and appetizing temperature. This deficient practice was identified in 1 out of 8 residents receiving services (sample resident #106). Findings include: 1. Resident #106 is an [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Right Hip Fracture, on 12/04/2024 at 8:30 AM during resident interview he state that the food came on disposable Styrofoam every time and that when he eats was cold. 2. During the test trays performed on 12/04/2024 at 11:46 AM was observed that all the food came in a Styrofoam tray inside came a match sweat potatoes with chicken thigh that was an open tray, over them came a plastic glass with carrot, a plastic bowl with Stew with rice, plastic cup 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 · Fcited before2024-12-06 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 12/04/2024 through 12/06/2024 from 8:00 AM through 3:30 PM, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Findings include: 1. During the visual inspection of the kitchen area it was observed that the High Temperature Sanitizing Door-type Dishwasher was inoperable at the time of the survey. This was confirmed by the Nutritional Services Manager (employee #1) who stated Sanitizing Dishwasher has been broken since September 2024. 2. During the visual inspection of the kitchen area it was observed that the Dish washing detergent and Arrex dispenser were inoperable at the time of the survey. This was confirmed by the Nutritional Services Manager (employee #1) who stated that the automatic dispenser has been broken since October 2024. 3. Food remains were observed on the floor below the food line.
- Potential for harm · Fcited before2024-12-06 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation during the drug pass, it was determined that the facility failed to ensure establish and maintain an infection prevention to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections and hand hygiene procedures be followed by staff involved in direct resident contact for 6 out of 6 observations Findings include: 1. During the drug pass performed on 12/05/2024 from 08:25 AM till 8:39 AM, it was observed that the registered nurse Registered Nurse (RN) #2 initiate with the drug pass without washing her hand and disinfecting the medication cart. 2. During the medication preparation for resident #106 the nurse put her glove without washing her hand, the resident request to RN #2 to provide a jar of gum in the floor, the RN procced to take the gum jar of the floor placed it over the dinner table, and do not remove her glove and continue administrating the resident medication without removing her gloves and washing her hand. 3.…
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 23 citations
- Potential for harm · Fcited before2024-12-06 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working safely.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of the physical environment, on 12/04/2024 through 12/06/2024 to from 8:00 AM through 3:30 PM, it was determined that the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition. This deficient practice had the potential to affect 8 out of 8 residents receiving services at areas where the deficient environment and items (equipment) is located. Findings include: 1. Commodes on bathrooms of rooms [ROOM NUMBERS] were observed with rust in component parts. 2. 3 out of 3 four contact points walkers were observed with rust in the base. 3. 1 out of 4 crutches was observed with medical tape on the grab cushion.
- Potential for harm · Ecited before2024-12-06 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 12/04/2024 through 12/06/2024 to from 8:00 AM through 3:30 PM, it was determined that the facility failed to promote the residents right to receive services in a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect 8 out of 8 residents receiving services at areas where the deficient environment and items (equipment) is located. Findings include: 1. Residents on rooms [ROOM NUMBERS] complained about room temperatures being too cold, when the surveyor took temperature measurement it was noted that room temperatures exceeded the temperature stated in the facility's temperature policy Temperatura y Humedad relativa de las Habitaciones [NAME] Skilled Nursing Facility Temperature and Relative Humidity of the rooms of the Skilled Nursing Facility, which states that room temperature should be between 71- and 80-degrees (º) Fahrenheit (F). a. 101 -…
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 · D2024-12-06 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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 made during the initial pool process and facility staff interview performed on 12/04/2024 through 12/06/2024 to from 8:00 AM through 3:30 PM, it was determined that the facility failed to promote the right of each resident to have personal privacy. This deficient practice had the potential to affect 8 out of 8 residents receiving services. Findings include: 1. During the initial pool process on 12/04/2024 at 8:55 AM it was observed that the resident located in room [ROOM NUMBER]-B (resident #58) participating in Occupational Therapy treatment. 2. The resident was observed sitting on the edge of the bed. 3. The resident was observed with only clothing from the waist down than the disposable diaper. 4. The curtain was drawn, however personnel failed to provide visual personal privacy before beginning the treatment. The Nursing supervisor (employee #6) was asked by the surveyor on 12/04/2024 at 9:00 AM if residents had available pajama pants. The Nursing supervisor stated in an interview on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-06 · tag F0636 — isolatedAssess 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 observations made during the initial pool process, records reviwed (RR) and facility staff interview performed on 12/04/2024 through 12/06/2024 to from 8:00 AM through 3:30 PM, it was determined that the facility failed to ensure that there is documentation of resident capacity and plan of care to have medications at bedside self-administer these medications. This deficient practice was identified in 1 out of 8 residents receiving services (RR#3). Findings include: The facility's Policy & Procedures, WNV-FARM-028 Self Administration of Medications last updated March 2023 is reviewed with pharmacist on 12/06/2024 at 9:00 AM. 1.RR # 3 is an [AGE] year-old female resident with Dx of Pneumonia, Muscle Decondition, S/P hip arthroplasty, depression and anxiety disorder, was admitted on [DATE], due to status post left hip fracture, resident is chronically bedridden. The resident was visited on 12/04/2024 at 8:53 AM and observed several albuterol pumps (Brand name Proventil - is a bronchodilator that relaxes…
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 · D2024-12-06 · tag F0813 — isolatedHave a policy regarding use and storage of foods brought to residents by family and other visitors.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of policies, procedures and facility staff interview performed on 12/06/24 to from 8:00 AM through 4:30 PM, it was determined that the facility failed to comply with the policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Findings include: Review on 12/06/2024 at 10:00 AM of facility's policy and procedure Almacenaje, Limpieza y Mantenimiento de Neveras Departamentales, Storage, Cleaning and Maintenance of Departmental Refrigerators stated that all food in the refrigerator must be identified with the resident's initials, room number and date. Approximately at 9:30 AM some snacks (birthday cake and snacks) were observed with no date or labeled in the residents' refrigerator.
- Potential for harm · F2024-04-09 · 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 — an excerpt from the official record, may be distressing
Based interview with the Director of nursing on 04/07/2024 through 04/09/2024 from 8:00 AM to 4:00 PM, it was determined that the facility failed to provide evidence of resident's categorization of dependence needs to be used to determine numbers each type of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans for 21 out of 21 residents. Findings include: 1.Director of Nursing (DON) (employee #2) was interviewed on 04/07/2024 at 8:00 AM and was asked for the categorization of residents admitted to the facility. DON stated that they did not have it available. DON explained that the person in charge of patient categorization is the facility supervisor, and this person has been suspended from duty since 04/05/2024. DON is trying to perform resident categorization; however, she was unsure whether to categorize residents daily or weekly and also does not know the exact procedure performed by nursing supervisor to perform the categorization. On 04/07/2024 at 10:00 AM during the interview with the DON referred when there is no staff…
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 · F2024-04-09 · tag F0800 — widespreadProvide 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 — the official record, unedited, may be distressing
Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 04/08/2024 through 04/09/2024 to from 8:00 AM through 5:30 PM, it was determined that the facility failed to provide each resident with a nourishing, palatable,special dietary needs. Findings include: During observation of the food service it was noted that food was served in Styro foam containers, these containers do not assure that food will get to residents in correct temperatures.
- Potential for harm · Fcited before2024-04-09 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 04/08/2024 through 04/09/2024 to from 8:00 AM through 5:30 PM, it was determined that the facility failed to ensure there is sufficient and qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services for 24 out of 24 residents admitted . Findings include: After review of the personnel roster with Kitchen Supervisor ( employee #17), it was determined that facility does not have an Administrative Dietitian or to that effect a Kitchen Manager.
- Potential for harm · Fcited before2024-04-09 · tag F0802 — failed to prepare enough nourishing food — widespreadProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 04/08/2024 through 04/09/2024 to from 8:00 AM through 5:30 PM, it was determined that the facility failed to ensure there is sufficient and qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services. Findings include: 1. The surveyor requested the kitchen staffing pattern to Kitchen Supervisor (employee #17) on 04/07/2024 at 11:00 AM , after 3 days of survey it was not provided.
- Potential for harm · Fcited before2024-04-09 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 04/08/2024 through 04/09/2024 to from 8:00 AM through 5:30 PM, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Findings include: 1. During the visual inspection, the defrosting sink was observed that the hoses were covered by cloths. This accumulates water and promotes the generation of bacteria. The facility's policy Lavabo a [NAME] en Fregadero de 3 Compartimientos was provided by Kitchen Supervisor(employee #17) and reviewed on 04/08/2024. During observation of the preparation of the 3 compartment lavatory it was observed that the first compartment was prepared with VEL dish soap,and was not prepared as stated in the policy with a temperature of 110 degrees. The preparation of the third compartment (sanitation compartment) was observed and tested for Arrex consentration and did not reach the 200…
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 · F2024-04-09 · 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 — an excerpt from the official record, may be distressing
Based on interview with the Administrator (employee#1) on 04/07/2024 at 12:13 PM, it was determined that the facility failed to ensure complete and accurate information related with Payroll Based Journal (PBJ) was submitted accordingly with CMS requirements in addition to other verifiable and auditable data in according with specifications established. Findings include: 1. On 04/07/2024 at 12:13 PM the Administrator stated on interview that facility was not reviewing and auditing correctly information related with the PBJ and other verifiable data before transmitting to CMS in order to identify errors that could be corrected before transmission. He stated that he has been involved in the system of data collection and data entry to the computerized system and had identified errors that must be corrected before the final transmission of the information. He also stated that last quarter (2023) data was transmitted with errors, and he communicate with CMS to identify if data could be corrected, but it was impossible. He stated that the facility identified that quantity reported the last…
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 · F2024-04-09 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespreadHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, review of policies procedures, review of facility documents and facility staff interview performed on 04/7/2024 through 04/09/2024 to from 8:00 AM through 5:30 PM, it was determined that the facility failed to maintain a Quality Assurance and Performance Improvement Program (QAPI). Each LTC facility, including a facility that is part of a multiunit chain, must develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality. Findings include: On 04/07/2024 2:00 PM during interview with the Skilled Nursing Facility-( SNF) Administrator (employee #1) on 04/08/2024 at 9:30 AM related to the Quality Committee meetings of Skilled Nursing Facility he stated that the last meeting of the QAPI of the Skilled Nursing Facility was done on July 20 of 2022. He refers to the fact that the SNF did not have a Quality Committee for one year. 1.There is no evidence of later meetings until present. It is important to point out that the person in charge of these functions resigned from her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-04-09 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, review of policies procedures and facility staff interview performed on 04/7/2024 through 04/09/2024 to from 8:00 AM through 5:30 PM, it was determined that the facility failed to maintain a Quality Assurance and Performance Improvement Program (QAPI). The facility failed to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Findings include: 1.The SNF failed to collect and maintain data, develop indicators to monitor and improve quality of life, quality of care and safety through an effective QAPI program and was unable tpo provide documentation and evidence of quality indicators the committee had identified, monitored, and evaluated for improvement. In addition, they were unable to provide evidence that key facility staff from each department was in attendance and actively participating in SNF QAPI meeting. The facility did not provide evidence of Annual Monitoring Plan, quality indicators, meetings and other information related to the Skilled Nursing…
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 · F2024-04-09 · tag F0868 — widespreadHave 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 review of policies procedures, facility documents and facility staff interview performed on 04/7/2024 through 04/09/2024 to from 8:00 AM through 5:30 PM, it was determined that the facility failed to maintain a Quality Assurance and Performance Improvement Program (QAPI),Committee failed to conduct Quarterly meetings exclusively for the Skilled Nursing Facility (SNF), and when they did, not all required committee members were in attendance as required by Federal Regulations. Findings include: On 04/07/2024 2:00 PM During interview with the Hospital Administrator and Skill Nursing Facility Administrator (employee #1) on 04/08/2024 at 9:30 AM related to the Quality Committee of meetings of Skilled Nursing Facility he stated that the Skill Nursing Facility did not have a Quality Committe for more than one year. The last meeting of the Quality Improvement Committee of the Skilled Nursing Facility was done on July 20 of 2022.
- Potential for harm · F2024-04-09 · tag F0924 — widespreadPut firmly secured handrails on each side of hallways.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 04/08/2024 to from 8:00 AM through 5:30 PM, it was determined that the facility failed to equip corridors with firmly secured handrails on each side. Findings include: Two hand rails on the main corridor between room [ROOM NUMBER] and 110 were observed loose and with plastic cover stiking out of base.
- Potential for harm · F2024-04-09 · tag F0925 — failed to control pests — widespreadMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 04/08/2024 to from 8:00 AM through 5:30 PM, it was determined that the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents. Findings include: Seven mouse traps were observed on the dry storage, during interview with the Kitchen supervisor (employee #17) stated that some time ago a [NAME] was found and that they requested more mouse traps.
- Potential for harm · E2024-04-09 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of fifteen records reviewed (R.R.) records, and interview with social worker (employee #11), it was determined that the facility failed to comply with the requirements with Advance Directives. This deficient practice was identified in 2 out of 15 records reviewed of selected for the initial pool (RR#1, RR#59). Findings include: Review of policy WNV-SNF-Title: Directrices Anticipadas, Advance Directives last update in December 2023, was reviewed on 04/08/2024 at 1:35 PM with Social Worker (employee #11). The policy clearly stated on the procedures that every resident admitted to the facility is oriented by admission personnel in relation to advance directives. In section 6.5 procedures policy establish that in cases where is necessary based on alteration on cognitive status in the resident, that the resident representative accept or refuse medical or surgical treatment facility must notify a physician who will be the professional in charge to take the advance directive. 1. During 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 · Ecited before2024-04-09 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 04/08/2024 through 04/09/2024 to from 8:00 AM through 5:30 PM, it was determined that the facility failed to promote the resident right to receive services in a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect 19 out of 21 residents receiving services at areas where the deficient environment and items (equipment) is located. Findings include: During initial observational tour the following was observed related with environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, and bathrooms: 1. Night tables located on resident rooms 107-A,107-B, and 110, were observed with the front door out of square. 2. The bed, located in room [ROOM NUMBER]-B, was observed with rust on the metal areas of the base. 3. Bedside rest chairs located in rooms 104-B and 110-A were observed with rust on 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 · E2024-04-09 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide 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 3. R.R #208 is an [AGE] year-old female admitted on [DATE] to the facility with a diagnosis of Right Total Hip Replacement due to fracture. This resident stated in an interview on 04/07/2024 at 11:00 AM that her weight was not taken when she was admitted to the facility. She stated that the facility food is very good, and she has a good appetite. She stated that she is eating very well, and she is sure that she has not lost weight since admission. She also stated that nursing personnel informed her that they are going to weigh her next Tuesday. Policy and procedure review on 04/08/2024 at 1:45 PM related to resident weight referred that resident are weight on admission and every Tuesday. 4. R.R.#155 A is a [AGE] year-old female admitted on [DATE] to the facility with a diagnosis of Right Knee Replacement, reviewed on 04/09/24 1:15 PM, during interview with the resident on 04/07/2024 at 9:00 AM she states that she was not weight when arrived. No evidence was found that the resident was weight on 04/04/2024 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.
- Potential for harm · Ecited before2024-04-09 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 04/07/2024 through 04/09/2024 to from 8:30 AM through 4:00 PM, it was determined that the facility failed to promote a safe, and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This deficient practice had the potential to affect 21 out of 21 residents receiving services at the facility. The facility failed to ensure promote the cleaning and maintenance, guaranteeing a safe and infection free environment. Findings include: 1. On 04/07/2024 at 8:50 AM a ceiling of resident room [ROOM NUMBER] was observed with yellow spots directly over the resident bed. Bed superior rails were observed with peeling paint. 2. The Occupational Room was visited on 04/08/2024 at 10:35 AM and was observed with dirty floor, dust, and stains. 3. Unlabeled refrigerator, no daily temperature registry, with plastic containers on the interior without lids…
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 · C2024-04-09 · 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
Based on observations, it was determined that the facility failed to ensure to have results of the survey conducted by Federal or State surveyors and any plan of correction made respecting the facility during the past preceding years, available for any individual to review upon request; and Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. Findings include: During the initial tours it was observed that the facility's result of the last survey conducted by Federal or State surveyors in 2023 when request was not available and posted for the residents and public. The facility last survey result that they had available was performed in April 2022.
- No harm found · C2024-04-09 · tag F0679 — failed to provide activities — widespreadProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, and interview with recreative therapist (employee # 10), it was determined that the facility failed to maintain an activity program that contains varied activities to promote and improve resident's physical, mental, and psychosocial well-being for 24 out of 24 admitted residents. Findings include: 1. During the initial observational tour at the facility performed on 04/07/2024 at 8:30 AM it was observed that the monthly activity calendar located in facility main hallway wall was empty and did not contain any activity for the month of April 2024. 2. It was asked to the recreative therapist (employee #10) on 04/08/2024 at 10:00 AM the reason why the monthly activity calendar located in facility main hallway wall was empty and did not contain any activity for the month of April 2024. She stated in an interview that she did not prepare the monthly activity calendar for the month of April 2024 because there are not available materials to coordinate activities that involve arts and crafts. She stated that she sent a requisition to the finances department to buy…
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 · Ccited before2024-04-09 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct 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 — the official record, unedited, may be distressing
Based on interview with facility administrator (employee#1), the facility failed to develop a required Facility Assessment. This deficient practice had the potential to affect 21 ot of 21 residents in the facility. Findings include: During the entrance conference performed on 04/07/2024 at 10:00 AM with the Administrator, the surveyors request the facility assessment, at 2:00 PM the Administrator state that he is the administrator of the facility since 1.5 years and he do not find the facility assessment. He is going to initiate and developed the facility assessment.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$29,997 in federal fines across 1 penalty.
- $29,997 — penalty dated 2024-04-09
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
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 405025. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-21, 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 →
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