CENTRO DE CUIDADO PROLONGADO SAN LUCAS

CARR 844 KM 0 5 CUPEY, RIO PIEDRAS, PR 00928 (787) 761-8383
Non profit - Church related 25 Beds Independent Data: November 2025 4 Immediate Jeopardy citations
Trust Grade
0/100
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Last Inspection: October 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Centro de Cuidado Prolongado San Lucas has received a Trust Grade of F, indicating significant concerns about the quality of care and management at this facility. It ranks at the bottom of all facilities in Puerto Rico and San Juan County, with no other facilities listed for comparison. The trend is concerning as this is the first inspection, revealing a total of 73 issues found, including 4 critical deficiencies that pose immediate risks to residents’ health and safety. Staffing is reported to have a 0% turnover rate, which is good, but there are no registered nurses on staff, and the facility lacks a full-time Director of Nursing, raising serious questions about oversight and care quality. Specific incidents include failures to establish resident rights compliance, lack of appropriate nursing management, and ineffective resource use, all of which could jeopardize resident safety. While there are no fines recorded, the overall lack of structure and support is a significant red flag for families considering this home.

Trust Score
F
0/100
In Puerto Rico
#112/223
Top 50%
Safety Record
High Risk
Review needed
Inspections
Too New
0 → 73 violations
Staff Stability
○ Average
Turnover data not reported for this facility.
Penalties
✓ Good
No fines on record. Clean compliance history, better than most Puerto Rico facilities.
Skilled Nurses
○ Average
RN staffing data not reported for this facility.
Violations
⚠ Watch
73 deficiencies on record. Higher than average. Multiple issues found across inspections.
☆☆☆☆☆
0.0
Overall Rating
☆☆☆☆☆
0.0
Staff Levels
☆☆☆☆☆
0.0
Care Quality
☆☆☆☆☆
0.0
Inspection Score
↔
Stable
: 0 issues
2024: 73 issues

The Good

  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record

Facility shows strength in fire safety.

The Bad

No Significant Concerns Identified

This facility shows no red flags. Among Puerto Rico's 100 nursing homes, only 0% achieve this.

The Ugly 73 deficiencies on record

4 life-threatening
Oct 2024 73 deficiencies 4 IJ (4 facility-wide)
CRITICAL (L)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Resident Rights (Tag F0550)

Someone could have died · This affected most or all residents

⚠️ Facility-wide issue

Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with resident right and exerc...

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Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with resident right and exercise of right which can affect all admitted residents. This Constituted and Immediate Jeopardy to the health and safety for residents. 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 facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the institutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanisms to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13-page policy were including all 483.10 resident right statement in one policy.
CRITICAL (L)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0727 (Tag F0727)

Someone could have died · This affected most or all residents

⚠️ Facility-wide issue

Based on review of policies and procedures with the Nursing Supervisor (employee #15), Acting Manager (employee # 18) was interviewed on 09/09/2024 at 9:00 AM through 9:45 AM, it was determined that t...

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Based on review of policies and procedures with the Nursing Supervisor (employee #15), Acting Manager (employee # 18) was interviewed on 09/09/2024 at 9:00 AM through 9:45 AM, it was determined that the facility failed to secure itself by failing to appoint the services of a full-time Director of Nursing. The deficient practice can affect all residents admitted at the facility. This Constituted and Immediate Jeopardy to the health and safety for residents. Findings include: 1. During the interview with the Nursing Supervisor (employee # 15) at 9:30 AM, he stated that they did not have a nursing director, but they did have an acting manager. The Acting Manager (employee # 18) is also interviewed and states that there is no director of nursing. The facility failed to hire a full-time director of nursing.
CRITICAL (L)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Administration (Tag F0835)

Someone could have died · This affected most or all residents

⚠️ Facility-wide issue

Based on interview with the facility human resources personnel (employee #11), it was determined that facility failed to demonstrate is being managed in a manner that enables it to use resources effec...

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Based on interview with the facility human resources personnel (employee #11), it was determined that facility failed to demonstrate is being managed in a manner that enables it to use resources effectively and efficiently. This Constituted and Immediate Jeopardy to the health and safety for residents. Findings include: 1. Credential file of the administrator was reviewed on 09/10/2024 at 11:00 AM. It was identified on this credential file that he was appointed as administrator of the hospital on June 21, 2024. This facility requests initial survey to become a Medicare provider as is a facility located in a hospital. 2. No information was found in the credential file of the administrator that indicated that he is going to be responsible for planning, organizing, and supervising the delivery of care to the residents of the facility. No information was found on this credential file that indicates that he is going to oversee and work with the facility to ensure that the facility adheres to the latest healthcare regulations pertaining to a Skilled Nursing Facility (SNF).
CRITICAL (L)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0837 (Tag F0837)

Someone could have died · This affected most or all residents

⚠️ Facility-wide issue

Based on review of governing body rules and regulations and committee meetings, it was determined that facility failed to demonstrate that had a governing body, or designated persons functioning as a ...

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Based on review of governing body rules and regulations and committee meetings, it was determined that facility failed to demonstrate that had a governing body, or designated persons functioning as a governing body, legally responsible for establishing and implementing policies regarding the management and operation of the facility. This Constituted and Immediate Jeopardy to the health and safety for residents. Findings include: 1. Governing body rules and regulations and committee meetings administrator was reviewed on 09/10/2024 at 11:30 AM. It was identified on that hospital governing body had meetings on November 29, 2023, September 06, 2023, June 21, 2024, and March 06, 2024. 2. Those meetings are directed in a way that reflects that the Skilled Nursing Facility is another unit of the hospital and not a separate unit with an active (engaged and involved) governing body that is responsible for establishing and implementing policies regarding the management of the facility, that had specific requirements to be followed. 3. A process who evidence how the administrator is held accountable and reports specific information about the Skilled Nursing Facility (SNF) services to the hospital was not evidenced. 4. No identification of members who are going to be assigned to the SNF governing body information was provided.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0551 (Tag F0551)

Could have caused harm · This affected most or all residents

Based on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with resident right to desig...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident has t...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0553 (Tag F0553)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policies and procedures and interview with nursing supervisor (employee #15), it was determined that facility...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policies and procedures and interview with nursing supervisor (employee #15), it was determined that facility failed to promote the right of each resident to sign the forms stating they understand their condition and the proposed treatment, and that they agree to the treatment. This deficient practice was identified in 2 out of 2 closed records (CR) of residents that receive services at the facility. (CR #3 and CR #4). Findings include: 1.CR#3 reviewed is a [AGE] year-old male resident admitted on [DATE] with a diagnosis of Left Knee Replacement. Resident was admitted receiving services for short term rehabilitation after surgery. During review of the medical record on 09/09/2024 at 2:00 PM it was identified that this resident was alert and oriented when admitted to the facility, however, inform consent authorizing disclosure of information, Health Insurance Portability and Accountability Act (HIPAA) notification and treatment consent did not have the signature of the resident. 2.CR#4 reviewed is a [AGE] year-old male resident admitted on [DATE] with a diagnosis of Right Total Hip Replacement. Resident was admitted receiving services for short term rehabilitation after surgery. During review of the medical record on 09/09/2024 at 9:15 AM it was identified that this resident was alert and oriented when admitted to the facility, however, inform consent authorizing disclosure of information, and treatment inform consent did not have the signature of the resident.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the residents' right...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0555 (Tag F0555)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right ...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0557 (Tag F0557)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right ...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right ...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0559 (Tag F0559)

Could have caused harm · This affected most or all residents

Based on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to s...

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Based on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to share a room with his or her spouse, with his or her roommate of choice when practicable when residents live in the same facility and receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the insititutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13 page policy were include all 483.10 resident right statement in one policy.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0560 (Tag F0560)

Could have caused harm · This affected most or all residents

Based on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right refu...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected most or all residents

Based on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right prom...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0562 (Tag F0562)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right ...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0563 (Tag F0563)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right ...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0564 (Tag F0564)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right ...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0565 (Tag F0565)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right ...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0566 (Tag F0566)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right ...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0567 (Tag F0567)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right ...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0568 (Tag F0568)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right ...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0569 (Tag F0569)

Could have caused harm · This affected most or all residents

Based on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to n...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0570 (Tag F0570)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right ...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0571 (Tag F0571)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right ...

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Based on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to not impose a charge against the personal funds of a resident for any item or service for which payment is made under Medicare. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the insititutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13 page policy were include all 483.10 resident right statement in one policy.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0572 (Tag F0572)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right ...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0573 (Tag F0573)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right ...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0574 (Tag F0574)

Could have caused harm · This affected most or all residents

Based on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to r...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0575 (Tag F0575)

Could have caused harm · This affected most or all residents

Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to po...

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Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to post, in a form and manner accessible and understandable to residents, at list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the institutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13-page policy were include all 483.10 resident right statement in one policy. 5. The signpost with the list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups the letter was to small for residents' to read.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0576 (Tag F0576)

Could have caused harm · This affected most or all residents

Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to ha...

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Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to have reasonable access to the use of a telephone, including TTY and TDD services, and a place in the facility where calls can be made without being overheard. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the institutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13-page policy were including all 483.10 resident right statement in one policy.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0577 (Tag F0577)

Could have caused harm · This affected most or all residents

Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to ex...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected most or all residents

Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to re...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0579 (Tag F0579)

Could have caused harm · This affected most or all residents

Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to di...

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Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to display in the facility written information, and provide to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the institutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13-page policy were including all 483.10 resident right statement in one policy.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected most or all residents

Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to no...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed (RR), it was found that the facility failed to ensure that resident understand the right to be oriente...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected most or all residents

Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to pe...

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

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected most or all residents

Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to sa...

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

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected most or all residents

Based on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to g...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0586 (Tag F0586)

Could have caused harm · This affected most or all residents

Based on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to c...

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

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right t...

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Based on the review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to be free from Abuse, Neglect, and Exploitation. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the institutional program director (employee #6) and provide three policy that was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. a. Identifying and Reporting Victims of Abuse/Neglect/Domestic Violence/Rape and Exploitation. b. Victims of abuse/neglect/domestic violence/sexual violence/exploitation/abuse. c. Preventing abuse and neglect. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure for freedom from abuse and neglect and exploitation 483.12, was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro or addressed to the Episcopal Hospital San [NAME] Metro.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0602 (Tag F0602)

Could have caused harm · This affected most or all residents

Based on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to b...

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Based on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to be free from Abuse, Neglect, misappropriation of resident property, and exploitation. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the insititutional program director (employee #6), and provide three policy that was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. a. Identifying and Reporting Victims of Abuse/Neglect/Domestic Violence/Rape and Exploitation. b. Victims of abuse/neglect/domestic violence/sexual violence/exploitation/abuse. c. Preventing abuse and neglect. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure for freedom from abuse and neglect and explotation 483.12, was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro or addressed to the Episcopal Hospital San [NAME] Metro.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0603 (Tag F0603)

Could have caused harm · This affected most or all residents

Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to be...

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Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to be free from Abuse, Neglect, and Exploitation or involuntary seclusion. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the institutional program director (employee #6) and provide three policy that was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. a. Identifying and Reporting Victims of Abuse/Neglect/Domestic Violence/Rape and Exploitation. b. Victims of abuse/neglect/domestic violence/sexual violence/exploitation/abuse. c. Preventing abuse and neglect. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure for freedom from abuse and neglect and exploitation 483.12, was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro or addressed to the Episcopal Hospital San [NAME] Metro.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0604 (Tag F0604)

Could have caused harm · This affected most or all residents

Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to be...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0605 (Tag F0605)

Could have caused harm · This affected most or all residents

Based on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to b...

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

Potential for Harm - no one hurt, but risky conditions existed

Employment Screening (Tag F0606)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility f...

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

Potential for Harm - no one hurt, but risky conditions existed

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected most or all residents

Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to develop and implement written policies and procedures that proh...

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

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected most or all residents

Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to ensure that alleged violations involving abuse, neglect, exploi...

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Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to ensure that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The policy and procedure title Abuse and Neglect Prevention, Identification and Reporting of Victims of Abuse/Neglect/Domestic Violence/Rape/Exploitation and Victims of Abuse/Neglect/Domestic Violence/Rape/Exploitation/Abuse, reviewed on 09/10/2024 at 1:00 PM with the institutional program director (employee #6), provide by the facility was hospital based and was addressed to the Episcopal Hospital San [NAME] Metro not directed to the skilled nursing facility, and not include reported immediately, not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected most or all residents

Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to ensure that all alleged violations are thoroughly investigated,...

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Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to ensure that all alleged violations are thoroughly investigated, and prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The policy and procedure title Abuse and Neglect Prevention, Identification and Reporting of Victims of Abuse/Neglect/Domestic Violence/Rape/Exploitation and Victims of Abuse/Neglect/Domestic Violence/Rape/Exploitation/Abuse, reviewed on 09/10/2024 at 1:00 PM with the institutional program director (employee #6), provide by the facility was hospital based and was addressed to the Episcopal Hospital San [NAME] Metro not directed to the skill, and not include reported the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

MDS Data Transmission (Tag F0640)

Could have caused harm · This affected most or all residents

Based on interview with the facility appointed Minimum Data Set (MDS) Coordinator (employee #5), it was determined that facility failed to demonstrate that is capable of transmit to the CMS System inf...

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Based on interview with the facility appointed Minimum Data Set (MDS) Coordinator (employee #5), it was determined that facility failed to demonstrate that is capable of transmit to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State. Findings include: 1.On 09/10/2024 at 9:30 AM it was request to the MDS Coordinator (employee #5) an initial connectivity test who evidence facility is capable of transmit data to the CMS System. 2. During interview the MDS Coordinator (employee #5) stated on 09/10/2024 at 9:40 AM that facility had not perform this test. She stated that facility is collecting data on paper based MDS-RAI assessment instrument and they plan to begin with transmission once they had a Medicare provider number. 3. Information related the contact person on the Puerto Rico state agency MDS-RAI automation coordinator was provided on 09/10/2024 at 10:00 AM to promote facility request information of how to perform the test if they needed. 4.No validation report who include information of the initial test file was provided. 5. Facility did not evidence any efforts to upload the test file or inform if had any technical issues or questions to upload the test file.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on two records reviewed R.R.' it was found that the facility failed to ensure that to newly admitted resident was develope...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected most or all residents

Based on interview with Nursing Supervisor (employee #15) on 09/09/2024 at 9:45 AM, It was determined that the facility failed to ensure it had a policy and procedure that the residents received appro...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0691 (Tag F0691)

Could have caused harm · This affected most or all residents

Based on review of policies and procedures with the Nursing Supervisor (employee #15) on 09/09/2024 at 10:00 AM, it was determined that the facility failed to ensure have a policy and procedure so tha...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0696 (Tag F0696)

Could have caused harm · This affected most or all residents

Based on review of policies and procedures with the Nursing Supervisor (employee #15) on 09/09/2024 at 10:20 AM, it was determined that the facility failed to ensure that residents who have a prosthet...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0699 (Tag F0699)

Could have caused harm · This affected most or all residents

Based on review of policies and procedures with the Nursing Supervisor (employee #15) on 09/09/2024 at 10:30 AM, it was determined that the facility failed to ensure that trauma-survivor residents rec...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected most or all residents

Based on review of policies and procedures with the Nursing Supervisor (employee #15) on 09/09/2024 at 10:42 AM, it was determined that the facility failed to ensure the risks and benefits of bedrails...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0740 (Tag F0740)

Could have caused harm · This affected most or all residents

Based on review of policies and procedures, records reviewed, and interview, with Administrator (employee #10), it was determined that the facility failed to have an organized behavioral health care a...

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Based on review of policies and procedures, records reviewed, and interview, with Administrator (employee #10), it was determined that the facility failed to have an organized behavioral health care and services program, to promote the maintenance of highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care to residents with mental and substance use disorders. Findings include: On survey procedures behavioral health care and services program policies and procedures were requested to the facility Administrator. As part of the behavioral health care and services program structure facility present a contract with information who defines who facility is expected to do to comply with this requirement. This contract address provisions to be taken when behavior and mental health conditions were presented by residents receiving services at the facility. The contract stipule that if necessary and based on the assessment performed by health care personnel in charge of the residents, those cases were transferred to a psychiatric facility that provides specialized inpatient care for mental health conditions. During interview on 09/10/2024 at 10:00 AM Administrator (employee #10), stated that facility had establish their structure to comply with this requirement sending residents to a psychiatric facility that provides specialized inpatient care for mental health conditions. Facility Administrator (employee #10) was asked during interview on 09/10/2024 at 10:10 AM how facility plan to provide health care and services as an integral part of the person-centered environment at the facility with an interdisciplinary approach to care. He was asked also how facility plan to have available qualified staff to provide those services as part of a supportive physical, mental, and psychosocial environment, and are directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities, to the resident at the facility. During interview Facility Administrator (employee #10), stated on 09/10/2024 at 10:30 AM understand after the interview with surveyors during initial survey performed on 09/09/2024 through 09/10/2024 from 8:00 AM till 5:00 PM that facility need to re-structure this program in order to comply with the requirement. He also stated during interview that he understands that facility need to adopt and implement a different approach to comply with the requirement. Administrator (employee #10) stated that if a resident needs a Behavioral health services program due to a mental and substance use disorders, they could consult the case with a psychiatrist. He stated that at this moment facility did not have contract with a psychiatrist, psychology or counselors to came to the facility to offer those services, because facility initially understand that they comply with the requirement if they transfer those cases to a psychiatric facility that provides specialized inpatient care for mental health conditions.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0741 (Tag F0741)

Could have caused harm · This affected most or all residents

Based on review of policies and procedures, record review, and interview, with Administrator (employee #10), it was determined that the facility failed to have staff who provide direct services to res...

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Based on review of policies and procedures, record review, and interview, with Administrator (employee #10), it was determined that the facility failed to have staff who provide direct services to residents with the appropriate competencies and skills through an organized behavioral health care and services program, to promote the maintenance of highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care to residents with mental and substance use disorders. Findings include: On survey procedures behavioral health care and services program personnel roster with schedule were requested to the facility Administrator (employee #10). Facility Administrator (employee #10) was asked by the surveyor during interview on 09/10/2024 at 10:10 AM how facility plan to provide health care and services as an integral part of the person-centered environment at the facility with an interdisciplinary approach to care. He was asked also how facility plan to have available qualified staff to provide those services as part of a supportive physical, mental, and psychosocial environment, and are directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities, to the resident at the facility. During interview Facility Administrator (employee #10),stated on 09/10/2024 at 10:30 AM that he understands after the explanation and interview with surveyors during initial survey performed on 09/09/2024 through 09/10/2024 from 8:00 AM till 5:00 PM that facility need to re-structure the process because they establish their structure to comply with this requirement sending residents to a psychiatric facility that provides specialized inpatient care for mental health conditions, with which they have contract. No behavioral health care and services program personnel schedule with psychiatrist, psychology or counselors to came to the facility to offer those services, were provided or evidenced.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Laboratory Services (Tag F0770)

Could have caused harm · This affected most or all residents

Based on interview with administrator (employee #10) and review of facility policies and procedures, it was determined that facility failed to determine if they are going to have a relationship with a...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0771 (Tag F0771)

Could have caused harm · This affected most or all residents

Based on interview with administrator (employee #10) and review of facility policies and procedures, it was determined that facility failed to determine if they are going to have a relationship with a...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0776 (Tag F0776)

Could have caused harm · This affected most or all residents

Based on interview with administrator (employee #10) and review of facility policies and procedures, it was determined that facility failed to determine if they are going to have a relationship with a...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0790 (Tag F0790)

Could have caused harm · This affected most or all residents

Based on interview with administrator (employee #10) and review of facility policies and procedures, it was determined that facility failed to determine if they are going to have a relationship with a...

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

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observations of the physical environment, with Engineering Director(employee #13) and Safety Officer (employee #2) performed on 09/09/2024 through 09/10/2024 from 8:00 AM through 4:00 PM, it ...

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Based on observations of the physical environment, with Engineering Director(employee #13) and Safety Officer (employee #2) performed on 09/09/2024 through 09/10/2024 from 8:00 AM through 4:00 PM, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This deficiency can affect all residents. Findings include: During visual inspection of the Diet Department it was observed that the walls of the dry warehouse almacen seco showed signs of humidity and water marks. This can affect the integrity of the food within this warehouse.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0813 (Tag F0813)

Could have caused harm · This affected most or all residents

Based on observations and interview with administrative dietitian (employee #3), it was determined that the facility failed to have in place a policy regarding use and storage food brought to resident...

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Based on observations and interview with administrative dietitian (employee #3), it was determined that the facility failed to have in place a policy regarding use and storage food brought to residents by family and other visitors. Findings include: 1. A mechanism to ensure that facility establish their responsibility to store food brought by resident family members or visitors to assure safe and sanitary storage and handling before consumption was not performed accordingly with the following findings identified during survey procedures on 09/09/2024 at 3:20 PM. 2. Administrative dietitian (employee #3), stated on interview on 09/09/2024 at 3:30 PM that facility had a refrigerator located at the back area of the nursing station, where if a resident, resident relative or visitor brings food or drink items personnel nursing were instructed to put the item in a plastic zip lock bag with residents' name and room number. 3. Administrative dietitian (employee #3), stated on interview on 09/09/2024 that once the food or drink item is stored on daily basis nursing personnel advice the resident in regarding to the food or drink item availability. Food and drink items are reviewed on an ongoing basis to ensure consistency and expiration date. If food or drink item expire or consistency is compromised nursing personnel inform the resident before discard the item. 4. Administrative dietitian (employee #3), was asked on 09/09/2024 at 3:35 PM if facility had a policy related with the storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption and she stated that facility did not develop and implement this policy and procedure.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0825 (Tag F0825)

Could have caused harm · This affected most or all residents

Based on interview with the Physical Therapy Supervisor (employee #16) on 09/10/2024 at 11:00 AM through 12:00 PM, it was determined that the facility failed to secure that speech-language pathology s...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected most or all residents

Based on interview with administrator (employee #10) and review of facility policies and procedures, it was determined that facility failed to determine if they are going to have a relationship with a...

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

Potential for Harm - no one hurt, but risky conditions existed

Staffing Data (Tag F0851)

Could have caused harm · This affected most or all residents

3. During the interviews with Nursing Supervisor (employee #15), Acting Manager (employee #18) and Human Resources (employee #14) on 09/09/2024 through 09/10/2024 at 8:00 to 11:00 AM, the following wa...

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3. During the interviews with Nursing Supervisor (employee #15), Acting Manager (employee #18) and Human Resources (employee #14) on 09/09/2024 through 09/10/2024 at 8:00 to 11:00 AM, the following was found: Policy and procedures: Informe mandatorio de nomina (Payroll Based Journal) reviewed on 09/10/2024 at 11:20 AM indicate that the facility collect payroll information and other auditable data from direct care staff daily and continue to submit it quarterly to the Centers for Medicare and Medicaid Services. Responsibility: Post-acute care director, administrative supervisor and administrator. a. On 09/09/2024 at 9:38AM, the Nursing Supervisor (employee#15) and Acting Manager (employee #18) were interviewed, who reported not having a PBJ structure. Policies and procedures were requested from the payroll journal, which was not provided due to not being available. The supervisor was asked who would oversee the PBG and said the human resources staff. b. On 09/10/2024 at 10:09 AM, Human Resources (employee #14) was interviewed who did not know what the PBJ was ; stated that they would be communicating with payroll to begin creating a Payroll Based Journal structure. Based on interview with administrator (employee #10) and review of Payroll Based Journal reporting system policies, procedures it was determined that facility failed to establish the structure to comply with the mandated electronically submission of data required by Center for Medicare and Medicaid Services (CMS). Findings include: 1. Facility had not shown evidence the development of structure to comply with the mandatory submission of staffing information based on payroll data in a uniform format as required by CMS. 2. Facility administrator (employee #10) was interview on 09/10/2024 at 10:55 AM and it was requested information in relation of the process that facility is going to implement to comply with the Payroll Based Journal reporting system. The administrator stated that facility plan to assign this process to a department named Point click care who is a private company who will oversee all facility software and computer transmission requirements. However, no information related with the process that facility is going to use to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS was provided during this interview.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected most or all residents

Based on reviewed of the quality assessment performance improvement (QAPI) program conducted on 09/10/2024 from 8:00 AM to 4:00 PM and interview with Quality and Service Coordinator to Client (employe...

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Based on reviewed of the quality assessment performance improvement (QAPI) program conducted on 09/10/2024 from 8:00 AM to 4:00 PM and interview with Quality and Service Coordinator to Client (employee #17), it was determined that the facility did not demonstrate Nursing Director participation in its quality assurance committee. Findings include: 1. During the interview and observation on 09/10/2024 at 2:00 PM to 4:00 PM, the following was found: a. On 09/10/2024 at 2:35 PM, the Quality and Service Coordinator to Client (employee #17) was interviewed and said that the quality council is made up of the executive director, medical director, nursing manager, directors, managers and supervisors of departments and services, quality coordinator, infection control coordinator or members whose presence is necessary. During the interview with the coordinator, the nursing director was not mentioned as part of the quality council. b. On 09/10/2024 at 2:45 PM, it was observed in the quality improvement manual that the quality council was not made up of the nursing director and that the activities, evaluations and improvements were carried out with the hospital Episcopal San [NAME] Metro, which should be separate from the Centro de Cuidado Prolongado San [NAME] Skilled Nursing Facility.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected most or all residents

Based on review of policies and procedures and interview with infection control officer (employee # 1), it was determined that facility failed to develop and implement policies, procedures and structu...

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Based on review of policies and procedures and interview with infection control officer (employee # 1), it was determined that facility failed to develop and implement policies, procedures and structure to comply with COVID-19 immunizations and other requirements related with COVID-19 immunizations. Findings include: During interview on 09/09/2024 at 3:35 PM the infection control officer (employee #1) stated the following in relation with the compliance of the facility with COVID-19 vaccination: 1. Facility did not have available COVID-19 vaccines. 2. Facility had not had any contract or agreement with another entity to make available COVID-19 vaccines if a resident want to receive the vaccine. 3. No mechanism had been implemented since January of natural year 2024 when facility begun to offer services at the Skilled Nursing Facility (SNF) to residents for screening COVID-19 vaccination status. The medical record did not include documentation that indicates that the resident or resident representative was provided education with COVID-19 virus and vaccination. 4. No mechanism had been implemented since January of natural year 2024 when facility begun to offer services at the SNF to ensure every staff member is offered the COVID-19 vaccine unless the immunization is medically contraindicated, or staff member has already been immunized. 5. No mechanism had been implemented since January of natural year 2024 when facility begun to offer services at the SNF to ensure the COVID-19 vaccine status of staff and related information indicated by National Healthcare Safety Network (NSHN) reporting for nursing homes is collected. Facility did not demonstrate that is collecting data to comply with reporting requirements established that every CMS-certified SNF facility must comply.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0895 (Tag F0895)

Could have caused harm · This affected most or all residents

Based on interview with administrator (employee #10) and review of facility policies and procedures, it was determined that facility failed to develop and implement a compliance and ethics program, wi...

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

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 23. Receptacles under air conditioning units were observed with broken covers and faulty plugs. Based on observations of the phy...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 23. Receptacles under air conditioning units were observed with broken covers and faulty plugs. Based on observations of the physical environment, with Infection control officer (employee #1) performed on 09/09/2024 from 9:50 AM through 11:00 AM, it was determined that the facility failed to ensure resident care equipment is in safe operating condition. This deficient practice had the potential to affect 2 out of 2 residents receiving services. Findings include: 1. On rooms #212, #204, #200 the area where the air condition unit is built-in is observed detached from the base. This could promote that the system structural integrity over time be compromised. 2. Bathroom windows curtains located on rooms # 101, # 102, # 103, #105, #106 and # 108 lacks the balance or weight area, this does not permit to close the window in an easy way. 3. This facility had 13 rooms located on the second floor and 12 rooms on the first floor. Every room had two glass windows, one of the windows is located on the bathroom and the other is located at the side of bed located near the wall. All glass windows and other glass divisions are covered with green slimy texture dirt, in need of cleaning. 4. At the entrance of room [ROOM NUMBER] it was observed a floor tile broken and sunken and dropped. 5. Floor tiles located on bathroom (toilet and shower area) of rooms # 109, # 200, # 201 , # 202 # 203, # 204, # 205, #206 were observed with peeling paint. 6. Floor tiles located under the air condition unit, under the hand washing sink and under the bed on rooms # 101, # 111, # 106 and # 212 were observed with discoloration due to the accumulation of reddish colored rust and iron oxide deposits. 7. Floor tiles located on room [ROOM NUMBER], and # 204 were observed dull and worn-out. 8. Shower head of bathroom located on room # 205 is observed detached from the base. 9. A metal floor door channel located at the entrance door on room # 204 is observed uneven and stands out. This poses a tripping hazard for residents when try to enter to the area, using walkers, wheelchairs or walking to the area. 10. Soap dishes located on shower area of rooms # 100, # 201, # 202 and #203 were observed with peeling paint. 11. A metal device where the base used to locate the toothbrush base, located at the hand washing sink area of rooms # 111 and # 104 is observed broken with missing pieces. 12. A blue reclining chair located in room # 111 is observed with the recliner mechanism broken. 13. Dead flying insects were observed accumulated inside closed light fixtures on room # 206, near the toilet area, and on room # 109 on the ceiling light. 14. Ceiling tiles metal cross T devices located on rooms toilet, shower and closet areas of rooms # 102, 103, # 108, and # 110 # were observed with discoloration due to the accumulation of reddish colored rust and iron oxide deposits. 15. A floor tile located under the shower area of room # 202 is observed broken, broken tiles are very sharp, and someone could be hurt. 16. Humidity and moisture are observed in closet area of room # 102. 17. Broken tiles were observed in the hand washing sink area of room # 201 broken tiles are very sharp and someone could be hurt. 18. Floor tiles of toilet area of rooms # 106 and # 111 were observed with many white stains. 19. On room # 111 the entrance door of the shower area is observed with peeling paint. 20. Floor tiles of room # 109 had white and gray stains. 21. Shower head of bathroom located on room # 205 is observed detached from the base. 22. The entrance area of the multipurpose room located on the first floor had a small ramp with a metal channel who is observed with broken and unpainted raw cement. This floor concrete area was left unsealed. This poses a tripping hazard for residents when try to enter to the area, using walkers, wheelchairs or walking to the area.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0924 (Tag F0924)

Could have caused harm · This affected most or all residents

Based on observations of the physical environment, with Engineering Director (employee #13) and Safety Officer (employee #2) performed on 09/09/2024 through 09/10/2024 from 8:00 AM through 4:00 PM, it...

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Based on observations of the physical environment, with Engineering Director (employee #13) and Safety Officer (employee #2) performed on 09/09/2024 through 09/10/2024 from 8:00 AM through 4:00 PM, it was determined that the facility failed to equip corridors with firmly secured handrails on each side. This deficient practice had the potential to affect 2 out of 2 residents receiving services. Findings include: 1. Hand rail next to smoke barrier double door on main entrance on first floor was found loose and with loose endcaps. 2. Several hand rails on residents room corridor were found loose.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected most or all residents

Based on observations of the physical environment, with Engineering Director(employee #13) and Safety Officer (employee #2) performed on 09/09/2024 through 09/10/2024 from 8:00 AM through 4:00 PM, it ...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0946 (Tag F0946)

Could have caused harm · This affected most or all residents

Based on interview with administrator (employee #10) and review of facility policies and procedures, it was determined that facility failed to develop and implement a compliance and ethics program, wi...

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

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0949 (Tag F0949)

Could have caused harm · This affected most or all residents

Based on interview with the facility human resources personnel (employee #11), it was determined that facility failed to offer behavioral health training to their personnel that provide services at th...

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Based on interview with the facility human resources personnel (employee #11), it was determined that facility failed to offer behavioral health training to their personnel that provide services at the facility. Findings include: 1. Facility human resources personnel (employee #11) was requested on 09/10/2024 at 1:30 PM with evidence of the behavioral health training that must be offered to the personnel providing services at the facility. 2. During interview on 09/10/2024 at 1:35 PM the Facility human resources personnel (employee #11) stated that training related with care specific to the individual needs of residents that are diagnosed with dementia were not offered to personnel providing services at the facility. 3. Facility human resources personnel (employee #11) was asked on 09/10/2024 at 1:45 PM if facility include in their in service training plan the CMS (CMS Hand in Hand: A Training Series for Nursing Homes that is an example of a training that addresses behavioral health area). Facility human resources personnel (employee #11) stated on 09/10/2024 at 1:47 PM that facility did not provide this type of training to their facility staff, (direct and indirect care functions), contracted staff, and volunteers.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "What changes have you made since the serious inspection findings?"
  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • No fines on record. Clean compliance history, better than most Puerto Rico facilities.
Concerns
  • • Multiple safety concerns identified: 4 life-threatening violation(s). Review inspection reports carefully.
  • • 73 deficiencies on record, including 4 critical (life-threatening) violations. These warrant careful review before choosing this facility.
  • • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has 4 Immediate Jeopardy findings. Serious concerns require careful evaluation.

About This Facility

What is Centro De Cuidado Prolongado San Lucas's CMS Rating?

CENTRO DE CUIDADO PROLONGADO SAN LUCAS does not currently have a CMS star rating on record.

How is Centro De Cuidado Prolongado San Lucas Staffed?

Detailed staffing data for CENTRO DE CUIDADO PROLONGADO SAN LUCAS is not available in the current CMS dataset.

What Have Inspectors Found at Centro De Cuidado Prolongado San Lucas?

State health inspectors documented 73 deficiencies at CENTRO DE CUIDADO PROLONGADO SAN LUCAS during 2024. These included: 4 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 69 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Centro De Cuidado Prolongado San Lucas?

CENTRO DE CUIDADO PROLONGADO SAN LUCAS is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 25 certified beds and approximately 1 residents (about 4% occupancy), it is a smaller facility located in RIO PIEDRAS, Puerto Rico.

How Does Centro De Cuidado Prolongado San Lucas Compare to Other Puerto Rico Nursing Homes?

Comparison data for CENTRO DE CUIDADO PROLONGADO SAN LUCAS relative to other Puerto Rico facilities is limited in the current dataset.

What Should Families Ask When Visiting Centro De Cuidado Prolongado San Lucas?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.

Is Centro De Cuidado Prolongado San Lucas Safe?

Based on CMS inspection data, CENTRO DE CUIDADO PROLONGADO SAN LUCAS has documented safety concerns. Inspectors have issued 4 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 0-star overall rating and ranks #100 of 100 nursing homes in Puerto Rico. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Centro De Cuidado Prolongado San Lucas Stick Around?

CENTRO DE CUIDADO PROLONGADO SAN LUCAS has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.

Was Centro De Cuidado Prolongado San Lucas Ever Fined?

CENTRO DE CUIDADO PROLONGADO SAN LUCAS has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Centro De Cuidado Prolongado San Lucas on Any Federal Watch List?

CENTRO DE CUIDADO PROLONGADO SAN LUCAS is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

CENTRO DE CUIDADO PROLONGADO SAN LUCAS

CARR 844 KM 0 5 CUPEY, RIO PIEDRAS, PR 00928 | (787) 761-8383

F
Trust Grade (0/100)
3.0
CMS Rating
73
Deficiencies

Strengths

  • Licensed facility

Concerns

  • 4 Immediate Jeopardy citations
  • 73 deficiencies

Ask about: Inspection Response, Rn Coverage

nursinghomedata.org | Data: CMS November 2025