HOSPITAL DE LA CONCEPCION INC

CARR 2 KM 173 4 BO CAIN ALTO, SAN GERMAN, PR 00683 (787) 892-1860
For profit - Corporation 30 Beds Independent Data: November 2025
Trust Grade
40/100
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Last Inspection: September 2024

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

Overview

Families researching Hospital de la Concepción Inc should be aware that it has received a Trust Grade of F, indicating significant concerns about the quality of care and operations. It ranks as #None of None in Puerto Rico and #None of None in San German County, suggesting there are no comparable facilities in the area, which is concerning. The facility is new, with its first inspection revealing 46 issues, of which 43 were classified as potential harm, indicating serious compliance problems. Staffing is a strength, with a 0% turnover rate, which is well below the Puerto Rico average, and it has more RN coverage than all other facilities in the region, ensuring better oversight of patient care. However, there have been specific incidents where the facility failed to establish proper monitoring of resident rights, meaning that residents may not be adequately informed or supported in their treatment decisions, raising additional red flags for families considering this nursing home.

Trust Score
D
40/100
In Puerto Rico
#112/223
Top 50%
Safety Record
Low Risk
No red flags
Inspections
Too New
0 → 46 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
✓ Good
Each resident gets 146 minutes of Registered Nurse (RN) attention daily — more than 97% of Puerto Rico nursing homes. RNs are the most trained staff who catch health problems before they become serious.
Violations
⚠ Watch
46 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: 46 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 46 deficiencies on record

Sept 2024 46 deficiencies
CONCERN (D)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on initial certification survey, interview with Resident and Dietitian (employee # 12) conducted from 09/11/2024 to 09/12/...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on initial certification survey, interview with Resident and Dietitian (employee # 12) conducted from 09/11/2024 to 09/12/2024 from 9:00 AM to 1:00 PM, it was determined that the facility failed to ensure the tastes and preferences related with food to residents 1 out of 17 (Resident# 170). Findings include: 1. During the initial process the resident located in room [ROOM NUMBER]-B stated that the kitchen staff brought her the same protein most of the time, during lunch and dinner. a. Resident #170-B stated in the interview conducted on 09/11/2024 at 10:45 AM that most of the time they always brought her chicken for lunch and dinner, she stated that she does not like to eat chicken every day. The dietitian (employee #12) was interviewed on 09/12/2024 at 12:46 PM, she indicated that when the resident arrives, she fills out likes and preferences form and it is signed by the dietitian and the resident. It was noted that resident #170-B likes and preferences form was signed by the resident, but not by the dietitian.
CONCERN (D)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an initial certification survey, interview with Resident and Nursing Supervisor (employee #9) conducted from 09/11/2024...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an initial certification survey, interview with Resident and Nursing Supervisor (employee #9) conducted from 09/11/2024 to 09/12/2024 from 9:00 AM to 1:00 PM, it was determined that the facility failed to ensure the temperature of the food served to residents for 1 out of 17 (Resident# 204). Findings include: 1. During the initial process, the resident located in room [ROOM NUMBER] stated that the kitchen staff brought him lunch and food at inadequate temperatures. a.Resident #204 stated in the interview conducted on 09/11/2024 at 9:11 AM that at times lunch and dinner arrived cold. The Nursing Supervisor (employee #9) was interviewed, who stated that the residents' meals arrive on meal delivery carts.
CONCERN (E)

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

Comprehensive Assessments (Tag F0636)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed (RR) performed on 09/11/2024 through 09/12/2024 from 8:30 AM through 3:00 PM and interview with regist...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed (RR) performed on 09/11/2024 through 09/12/2024 from 8:30 AM through 3:00 PM and interview with register nurse (employee #7) and medical record personnel (employee # 6), it was determined that the facility failed to perform a complete and accurate comprehensive assessment of each resident admitted to the facility. This deficient practice was identified in 2 out of 8 cases receiving services at the facility (RR #51 and #57). Findings include: 1.RR#51 is [AGE] year-old female resident admitted on [DATE] with a diagnosis of General Weakness, Hyperlipidemia, Coronary Artery Disease and Chronic Kidney Disease Stage 4. When admitted to the facility the resident was admitted coming from hospital with a nasal cannula Oxygen at 3 liters/minute. The resident was observed in her room sitting on a wheelchair in company of her daughter on 09/11/2024 at 9:35 AM using a nasal cannula Oxygen at 3 liters/minute. Review of resident nursing admission assessment on the medical record on 09/11/2024 at 10:30 AM with nursing personnel (employee #7) evidence that resident is dependent on Oxygen and had history of Asthma. The Minimum Data Set (MDS) Resident Assessment and Care Screening performed to this resident dated 09/05/2024, was reviewed with medical record personnel (employee #6) on 09/12/2024 at 9:00 AM. It was identified in section O Special treatments, Procedures and Programs item C1, Oxygen therapy was not coded, or selected as one of the treatments that this resident is receiving. No comprehensive plan of care for the use of Oxygen was found developed and implemented as part of this resident plan of treatment. The facility failed to maintain a complete and accurate comprehensive assessment of each resident admitted to the facility to prepare a comprehensive plan of care to address resident safety and well-being. 2. RR#57 is [AGE] years old female resident admitted on [DATE] with a diagnosis of Pneumonia, and had history of Pleural effusion and Hypoxemia. When admitted to the facility the resident was admitted coming from hospital with a nasal cannula for Oxygen at 2 liters/minute. The resident was observed on 09/11/2024 at 10:55 AM in her room lying on bed using a nasal cannula for Oxygen at 2 liters/minute. Review of resident nursing admission assessment on the medical record on 09/12/2024 at 10:30 AM with nursing personnel (employee #7) evidence that resident is dependent on Oxygen and had history of Asthma. The Minimum Data Set (MDS) Resident Assessment and Care Screening performed to this resident dated 08/25/2024, was reviewed with medical record personnel (employee #6) on 09/12/2024 at 11:00 AM. It was identified in section O Special treatments, Procedures and Programs item C1, Oxygen therapy was not coded, or selected as one of the treatments that this resident is receiving. No comprehensive plan of care for the use of Oxygen was found developed and implemented as part of this resident plan of treatment. The facility failed to maintain a complete and accurate comprehensive assessment of each resident admitted to the facility in order to prepare a comprehensive plan of care to address resident safety and well-being.
CONCERN (E)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. Resident # 104 is [AGE] years old female resident admitted on [DATE] with a diagnosis of Post operate of Fracture Right Hip. ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. Resident # 104 is [AGE] years old female resident admitted on [DATE] with a diagnosis of Post operate of Fracture Right Hip. During the initial pool performed on 09/11/2024 at 9:10 AM, it was observed that residents have the 4-bed rail up, and using oxygen by canula nasal, resident daughter states that she signs the consent for authorization for resident bed rail up at admission for security so do not get out. During the record review performed on 09/12/24 at 10:38 AM, the consent was found sign by the daughter and authorized bed rail superior and inferior left and right. The nurses' note provides evidence of the vigilance security precaution taken of bed rail up. Physician ordered on 9/11/2024 at 8:57AM Nasal Canula at 2 litter per minutes. No evidence was found in the medical record of a Plan of Care for Oxygen in use. Based records reviewed (RR)and interviews performed on 09/11/2024 through 09/12/2024 from, 8:30 AM through 3:00 PM with register nurse (employee #7) and medical record personnel (employee # 6), it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for each resident based on the information collected in the comprehensive assessment when admitted to the facility. This deficient practice was identified in 3 out of 8 cases receiving services at the facility. (RR #51, #57 and RR#104). Findings include: 1.RR#51 is [AGE] year-old female resident admitted on [DATE] with a diagnosis of General Weakness, Hyperlipidemia, Coronary Artery Disease and Chronic Kidney Disease Stage 4. When admitted to the facility resident was admitted coming from hospital with a nasal cannula Oxygen at 3 liters/minute. Resident was observed on her room sitting on a wheelchair in company of her daughter on 09/11/2024 at 9:35 AM using a nasal cannula Oxygen at 3 liters/minute. Review of resident nursing admission assessment on the medical record on 09/11/2024 at 10:30 AM with nursing personnel (employee #7) evidence that resident is dependent of Oxygen and had history of Asthma. The Minimum Data Set (MDS) Resident Assessment and Care Screening performed to this resident dated 09/05/2024, was reviewed with medical record personnel (employee #6) on 09/12/2024 at 9:00 AM. It was identified in section O Special treatments, Procedures and Programs item C1, Oxygen therapy was not coded, or selected as one of the treatments that this resident is receiving. No comprehensive plan of care of care for the use of Oxygen was found developed and implemented as part of this resident plan of treatment. The facility failed to maintain a complete and accurate comprehensive assessment of each resident admitted to the facility to prepare a comprehensive plan of care to address resident safety and well-being. 2. RR#57, is [AGE] years old female resident admitted on [DATE] with a diagnosis of Pneumonia, and had history of Pleural effusion and hypoxemia. When admitted to the facility resident was admitted coming from hospital with a nasal cannula Oxygen at 2 liters/minute. Resident was observed on 09/11/2024 at 10:55 AM in her room lying on bed using a nasal cannula of Oxygen at 2 liters/minute. Review of resident nursing admission assessment on the medical record on 09/12/2024 at 10:30 AM with nursing personnel (employee #7) evidence that resident is dependent of Oxygen and had history of Asthma. The Minimum Data Set (MDS) Resident Assessment and Care Screening performed to this resident dated 08/25/2024, was review with medical record personnel (employee #6) on 09/12/2024 at 11:00 AM. It was identified in section O Special treatments, Procedures and Programs item C1, Oxygen therapy was not coded, or selected as one of the treatments that this resident is receiving. No comprehensive plan of care of care for the use of Oxygen was found developed and implemented as part of this resident plan of treatment. The facility failed to maintain a complete and accurate comprehensive assessment of each resident admitted to the facility in order to prepare a comprehensive plan of care to address resident safety and well-being.
CONCERN (F)

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

Resident Rights (Tag F0550)

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 #1), 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 #1), it was determined that facility failed to establish the structure to comply with resident right and Exercise of right. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right and Exercise facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided. The Resident Rights and Responsibilities sheet provided to the resident at the admission provide evidence that this was hospital based, containing information about how to contact regulatory agency as The Joint Commission. This sheet provides to the resident the form to perform a complaint however, the Department of Health Assistant Secretary for Public Health Regulation Secretaria Auxiliar para la Regulación de la [NAME] Pública (SARP) the address and telephone was not updated.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure with the institutional program director (employee #1), it was determined that facility 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 #1), it was determined that facility failed to establish the structure to comply with resident right to designate a representative in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by state law. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right Exercised by representative facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided, the Notice of Privacy Practices sheet provided to the resident at the admission provides evidence that this was hospital based.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to be informed of and participate in his or her treatment. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right and Exercise facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided. The Resident Rights and Responsibilities sheet provided to the resident at the admission provide evidence that this was hospital based, containing information about how to contact regulatory agency as The Joint Commission. This sheet provides to the resident the form to perform a complaint however, the Department of Health Assistant Secretary for Public Health Regulation Secretaria Auxiliar para la Regulación de la [NAME] Pública (SARP) the address and telephone was not updated.
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 the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to be informed of and participate in his or her treatment. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right to participate in the planning care facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided, the Resident Rights and Responsibilities sheet provided to the resident at the admission provide evidence that this was hospital based, contain information about how to contact regulatory agency as The Joint Commission. This sheet provides to the resident the form to perform a complaint however, the Department of Health Assistant Secretary for Public Health Regulation Secretaria Auxiliar para la Regulación de la [NAME] Pública (SARP) the address and telephone was not updated.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to self-administer medications if the interdisciplinary team has determined that this practice is clinically appropriate. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right to self-administer medications facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided, the Resident Rights and Responsibilities sheet provided to the resident at the admission provide evidence that this was hospital based, contain information about how to contact regulatory agency as The Joint Commission. This sheet provides to the resident the form to perform a complaint however, the Department of Health Assistant Secretary for Public Health Regulation Secretaria Auxiliar para la Regulación de la [NAME] Pública (SARP) the address and telephone was not updated.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the insititutional program director (employee #1), it was determined that facil...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the insititutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to choose his/her attending physician. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right to choose his/her attending physician facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to be treated with respect and dignity. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right to be treated with respect and dignity facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to share a room with his or her spouse, share a room with his or her roommate of choice when practicable and receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident has the right to share a room with his or her spouse, share a room with his or her roommate of choice when practicable facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to refuse to transfer to another room in the facility Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right to refuse to transfer to another room facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to Self-determination to make choices. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right to Self-determination to make choices facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to have provide immediate access to any representative of the State, to resident's individual physician, to any representative of the protection and advocacy systems. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right to have immediate access to any representative of the State, to resident's individual physician, to any representative of the protection and advocacy systems facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to inform visitation rights and equal visitation privileges. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident visitation rights and equal visitation privileges facility policy and procedure were requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that the fa...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that the facility failed to establish the structure to comply with the resident has the right to organize and participate in resident groups in the facility. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident rights to organize and participate in resident groups facility policy and procedure were requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to choose or refuse to perform services for the facility. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident rights to choose or refuse to perform services for the facility policy and procedure were requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that the fa...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that the facility failed to establish the structure to comply with the resident right to manage his or her financial affairs. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident rights to manage his or her financial affairs policy and procedure were requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to Accounting and Records of personal funds. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The residents' rights to Accounting and Records of personal funds policy and procedure were requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to notice of certain balances. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident rights to notice of certain balances policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to Assurance of financial security. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident rights to Assurance of financial security policy and procedure were requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to not impose a charge against the personal funds of a resident for any item or service for which payment is made under Medicare. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident rights to not impose a charge against the personal funds of a resident for any item or service for which payment is made under Medicare policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to be informed of his or her rights and of all rules and regulations governing resident conduct and responsibilities during his or her stay. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident's rights to be informed of his or her rights and of all rules and regulations governing resident conduct and responsibilities during his or her stay policy and procedure were requested at the facility on 09/12/2024 at 10:00 AM and no evidence was provided. The Resident Rights and Responsibilities sheet provided to the resident at the admission provides evidence that this was hospital based, contains information about how to contact regulatory agency as The Joint Commission. This sheet provides to the resident the form to perform a complaint however, the Department of Health Assistant Secretary for Public Health Regulation Secretaria Auxiliar para la Regulación de la [NAME] Pública (SARP) the address and telephone was not updated.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to access personal and medical records pertaining to him or herself. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident rights to access personal and medical records pertaining to him or herself policy and procedure were requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident's right to receive notices orally and in writing in a format and a language he or she understands. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident rights to receive notices orally and in writing in a format and a language he or she understands policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided. The Resident Rights and Responsibilities sheet provided to the resident at the admission provides evidence that this was hospital based, contain information about how to contact regulatory agency as The Joint Commission. This sheet provides to the resident the form to perform a complaint however, the Department of Health Assistant Secretary for Public Health Regulation Secretaria Auxiliar para la Regulación de la [NAME] Pública (SARP) the address and telephone was not updated.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to post, in a form and manner accessible and understandable to residents, a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident rights to receive notices orally and in writing in a format and a language he or she understands policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided. The Resident Rights and Responsibilities sheet provided to the resident at the admission provides evidence that this was hospital based, contains information about how to contact regulatory agency as The Joint Commission. This sheet provides to the resident the form to perform a complaint however, the Department of Health Assistant Secretary for Public Health Regulation Secretaria Auxiliar para la Regulación de la [NAME] Pública (SARP) the address and telephone was not updated. 3.The Resident Rights and Responsibilities sheet 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. 4. No signpost with the list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups the letter was observed in the bulletin board of the facility.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that the fa...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that the facility failed to establish the structure to comply with the resident right to have reasonable access to the use of a telephone, including TTY and TDD services, and a place in the facility where calls can be made without being overheard. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident rights to have reasonable access to the use of a telephone, including TTY and TDD services, and a place in the facility where calls can be made without being overheard policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The residents have the rights to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident rights to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advanced directive policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided. The Information Brochure Advance Directives (Previous Will Declaration) provided to the resident was from Hospital La [NAME] not directed to skilled nursing residents.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to display in the facility written information, and provide to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. Policy and procedure for displaying in the facility written information, and provide to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to Notification of Changes. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident rights to Notification of Changes facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to Privacy and Confidentiality. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The residents' rights to Privacy and Confidentiality facility policy and procedure were requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to Grievances. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident rights to Grievances facility policy and procedure were requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to Contact with External Entities. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident rights to Contact with External Entities facility policy and procedure were requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident right to be free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The residents' rights to be free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the residents' medical symptoms facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident's right to be free from chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The residents' rights to be free from chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the residents' medical symptoms facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
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** 3. Resident # 201 a [AGE] year-old female admitted on the facility 09/02/2024 with diagnosis of decrease mobility after a right ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident # 201 a [AGE] year-old female admitted on the facility 09/02/2024 with diagnosis of decrease mobility after a right Takotsubo syndrome (TKA). On 09/11/2024 at 9:42 AM, during the interview with the physical therapy supervisor (employee #4) and the evaluation of the clinical record, it was determined that the baseline care plan was not given to the residents and there was no record of it in the clinical record. 4. Resident #202 a [AGE] year-old male admitted on the facility 09/06/2024 with diagnosis of decrease mobility after a lumbar surgery. On 09/11/2024 at 9:53 AM, during the interview with the physical therapy supervisor (employee #4) and the evaluation of the clinical record, it was determined that the baseline care plan was not given to the residents and there was no record of it in the clinical record. 5. Resident #203 a [AGE] year-old male admitted on the facility 09/06/2024 with diagnosis of decrease mobility after a right Takotsubo syndrome (TKA). On 09/11/2024 at 10:23 AM, during the interview with the physical therapy supervisor (employee #4) and the evaluation of the clinical record, it was determined that the baseline care plan was not given to the residents and there was no record of it in the clinical record. 6. Resident # 204 a [AGE] year-old female admitted on the facility 08/30/2024 with right TKA revision. On 09/11/2024 at 10:02 AM, during the interview with the physical therapy supervisor (employee #4) and the evaluation of the clinical record, it was determined that the baseline care plan was not given to the residents and there was no record of it in the clinical record. On interview with the physical therapy supervisor (employee #4) on 09/11/2024 at 9:43 AM, the basic care plan was not found to be completed within 48 hours in the Meditech electronic record system and given to residents. 7. Resident # 52 is [AGE] years old male resident admitted on [DATE] with a diagnosis of Post operate of Cervical. During the record review performed on 09/12/24 10:16 AM with the medical record employee #, no evidence was found that the facility performed the baseline care plan within 48 hours of admission. 8. Resident # 104 is [AGE] years old female resident admitted on [DATE] with a diagnosis of Post operate of Fracture Right Hip. During the initial pool performed on 09/11/2024 at 9:10 AM, it was observed that residents have the 4-bed rail up, resident daughter states that she signs the consent for authorization for resident bed rail up at admission for security so do not get out. During the record review performed on 09/12/24 at 10:38 AM, the consent sign was found by the daughter and authorized bed rail superior and inferior left and right. The nurses Note provide evidence of the vigilance security precaution taken bed rail up. During the record review performed on 09/12/24 10:49 AM with the medical record employee #6, no evidence was found that the facility performed the baseline care plan within 48 hours of admission. Based on records reviewed (RR) and interview with register nurse (employee #7) and medical record personnel (employee # 6) performed on 09/11/2024 through 09/12/2024 from, 8:30 AM through 3:00 PM, it was determined that the facility failed to provide a written copy of the Baseline Care Plan developed that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission to the facility. This deficient practice was identified in 8 out of 8 cases receiving services at the facility (RR #51, #52, #57, R#104, R#201, #202, #203, and #204). Findings include: 1.RR# 51 is [AGE] year-old female resident admitted on [DATE] with a diagnosis of General Weakness after a Cerebro Vascular Accident, Hyperlipidemia, Coronary Artery Disease and Chronic Kidney Disease Stage 4. Initial pool process was performed on 09/11/2024 from 8:45 AM through 10:00 AM on the first day of the survey, screening residents, to identify the resident sample pool and seeking information related with choices residents have with regard to their daily life, any activities they partake in, and other issues revolving around dignity, abuse, resident-to-resident interaction, privacy, the accommodation of physical needs, and staffing levels. On this initial pool process the surveyor asked the resident if a written copy of the baseline care plan was provide to her after admission, RR #51 stated on interview that no copy of the baseline care plan was provide to her after admission, she stated that she receive verbal information related with the treatment and services that she is going to receive while was admitted to the facility, but no written copy of the baseline care plan was provide to her after admission. Review of the medical record on 09/11/2024 at 10:39 AM with nursing personnel (employee #7) evidence that verbal information related to the treatment and services that resident is going to receive while was admitted to the facility, was provided but no written copy of the baseline care plan was provided. 2. RR#57 is [AGE] years old female resident admitted on [DATE] with a diagnosis of Pneumonia and had history of Pleural effusion and hypoxemia. Initial pool process was performed on 09/11/2024 from 8:45 AM through 10:00 AM on the first day of the survey, screening residents, to identify the resident sample pool and seeking information related with choices residents have with regard to their daily life, any activities they partake in, and other issues revolving around dignity, abuse, resident-to-resident interaction, privacy, the accommodation of physical needs, and staffing levels. On this initial pool process it was identified that RR #57 has periods of disorientation and presents some difficulty in her cognitive skills and daily decision making. Resident #57could not inform or specify if she or her relatives and/or caregivers receive a written copy of the baseline care plan when she was admitted to the facility. Review of the medical record on 09/11/2024 at 11:49 AM with nursing personnel (employee #7) evidence that verbal information related with the treatment and services that resident is going to receive while was admitted to the facility, was provided but no written copy of the baseline care plan was provided. No copy of the baseline care plan developed and implemented was found filed as part of the medical record of this resident.
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 interviews with the institutional program director (employee #1), and review of facility policies and procedures, it was determined that facility failed to determine if they were going to hav...

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Based on interviews with the institutional program director (employee #1), and review of facility policies and procedures, it was determined that facility failed to determine if they were going to have a relationship with any dental services in obtaining routine and 24-hour emergency dental care (by contract) in order to provide those services at the facility. Findings include: 1. Facility institutional program director (employee #1) was interviewed on 09/12/2024 at 2:15 PM and surveyor requested information to her in relation to a dental service as an option to be provided by their facility. 2. Facility institutional program director (employee #1), stated in interview on 09/12/2024 at 2:15 PM at the moment the facility did not have any contract with a dental service in order to make dental services available in accordance to the scope permitted to a SNF, if needed the hospital has dentist. 3. Facility failed to have a contract or agreement that meets with CMS regulation 483.55 Dental services to assist residents in obtaining routine and 24-hour emergency dental care.
CONCERN (F)

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

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

Based on infection control observation during the Drug pass performed on 09/12/2024 from 8:33 AM through 9:45 AM, it was determined that the facility failed to maintain an infection prevention and con...

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Based on infection control observation during the Drug pass performed on 09/12/2024 from 8:33 AM through 9:45 AM, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Findings include: During the medication Pass performed on 09/12/2024 from 8:33 AM through 9:45 AM, it was the following: 1. During the medication pass with the registered nurse employee #16 it was observed that nurse failed to wash his hand in 10 out of 19 opportunity for washing his hand during the drug pass.
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 the initial recertification survey, and interview with the facility institutional program director (employee #1) and director of nursing (employee #8), it was determined that facility failed ...

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Based on the initial recertification survey, and interview with the facility institutional program director (employee #1) and director of nursing (employee #8), it was determined that facility failed to offer behavioral health training to their personnel that provide services at the facility. Findings include: 1. The surveyor requested to the facility institutional program director (employee #1) and to the director of nursing (employee #8) on 09/12/2024 at 11:30 AM evidence of the behavioral health training that must be offered to the personnel providing services at the facility. 2. During interview on 09/12/2024 at 1:35 PM the director of nursing (employee #8) stated that training related with care specific to the individual needs of residents that are diagnosed with dementia were not offered to personnel providing services at the facility. 3. Institutional program director (employee #1) was asked by the surveyor on 09/12/2024 at 11:45 AM if facility include in their in-service training plan the CMS (CMS Hand in Hand: A Training Series for Nursing Homes that is an example of a training that addresses behavioral health area). Institutional program director (employee #1) stated on 09/12/2024 at 11:47 AM that facility did not provide this type of training to their facility staff, (direct and indirect care functions), contracted staff, and volunteers.
MINOR (C)

Minor Issue - procedural, no safety impact

Staffing Information (Tag F0732)

Minor procedural issue · This affected most or all residents

Based on the initial certification survey, interview with de nursing supervisor (employee #9) on 09/11/2024 through 09/12/2024 at 8:30 AM to 4:00 AM, it was determined that the facility failed to comp...

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Based on the initial certification survey, interview with de nursing supervisor (employee #9) on 09/11/2024 through 09/12/2024 at 8:30 AM to 4:00 AM, it was determined that the facility failed to comply with nursing assignments and post nursing staff who are directly responsible for the care. Findings include: The Facility policy #018 Daily Distribution Notification, last revised February 2024, was provided on 09/12/2024 by Nursing Supervisor (employee #9). 1. During the interview with the nursing supervisor (employee #9) on 09/11/2024 at 11:43 AM, she mentioned that she had work assignments. When she provided the assignment to the surveyor, it was placed in a binder and in a wooden paper organizer on the nursing counter. The facility did not have nursing staffing information or posting requirements with facility name, current date, nursing staff, hours performed and resident census. On 09/12/2024 at 2:25 PM the Nursing Supervisor (employee #9) provided policy and procedures (P&P) and corrected work assignments.
MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0806 (Tag F0806)

Minor procedural issue · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on initial certification survey, interview and observation with Resident and Nursing Supervisor (employee #9) conducted fr...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on initial certification survey, interview and observation with Resident and Nursing Supervisor (employee #9) conducted from 09/11/2024 to 09/12/2024 from 9:00 AM to 1:00 PM, it was determined that the facility failed to each residents receives food that accommodate residents' allergies, intolerances, and preference 1 out of 17 (Resident #204). Findings include: 1. During the initial process, the resident located in room [ROOM NUMBER] stated that since her admission on [DATE] she has been receiving dairy products. The resident was brought milk on several occasions, when she is lactose intolerant. a.Resident #204 is a [AGE] year-old female who was admitted on [DATE] with a diagnosis of right total knee arthroplasty. During the interview with the resident on 09/11/2024 at 9:11AM, the resident stated that she had been brought dairy products for several days. The electronic record was observed that the dietitian performed her assessment on 03/09/2024 which indicated 1500 kal, high iron, no dairy, 1 snack and 1 protein. The dietitian was interviewed and indicated that the resident arrived on Friday at 7:59 PM and at that time the dietitian was no longer in the facility. The nursing staff oversees conducting the interview and filling out the residents' tastes, preferences and intolerances forms.
MINOR (C)

Minor Issue - procedural, no safety impact

Staffing Data (Tag F0851)

Minor procedural issue · This affected most or all residents

Based on interview with the director of nursing (employee #8) and review of Payroll Based Journal reporting system policies and procedures, it was determined that facility failed to evidence the devel...

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Based on interview with the director of nursing (employee #8) and review of Payroll Based Journal reporting system policies and procedures, it was determined that facility failed to evidence the development of a complete structure who include information on how facility is going to support PBJ electronic data transmissions and submissions as required by Center for Medicare and Medicaid (CMS). Findings include: Facility's policy #075 Informe Mandatorio de Nómina Payroll-Based Journal (PBJ) last reviewed in February 2024. On 09/12/2024 at 3:45 PM was reviewed, the Policy stated that facility is going to collect auditable staffing data to be transmitted accordingly with Center for Medicaid & Medicare Services (CMS). 1.The facility did not provide evidence on the policy or procedures about arrangements related with software to be used to work PBJ system, persons in charge or responsible for the data entry and transmission,(payroll vendors) and who is going to have Payroll Based Journal system access.
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

  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
  • • No fines on record. Clean compliance history, better than most Puerto Rico facilities.
Concerns
  • • 46 deficiencies on record. Higher than average. Multiple issues found across inspections.
  • • Grade D (40/100). Below average facility with significant concerns.
Bottom line: Trust Score of 40/100 indicates significant concerns. Thoroughly evaluate alternatives.

About This Facility

What is Hospital De La Concepcion Inc's CMS Rating?

HOSPITAL DE LA CONCEPCION INC does not currently have a CMS star rating on record.

How is Hospital De La Concepcion Inc Staffed?

Detailed staffing data for HOSPITAL DE LA CONCEPCION INC is not available in the current CMS dataset.

What Have Inspectors Found at Hospital De La Concepcion Inc?

State health inspectors documented 46 deficiencies at HOSPITAL DE LA CONCEPCION INC during 2024. These included: 43 with potential for harm and 3 minor or isolated issues.

Who Owns and Operates Hospital De La Concepcion Inc?

HOSPITAL DE LA CONCEPCION INC is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 30 certified beds and approximately 56 residents (about 187% occupancy), it is a smaller facility located in SAN GERMAN, Puerto Rico.

How Does Hospital De La Concepcion Inc Compare to Other Puerto Rico Nursing Homes?

Comparison data for HOSPITAL DE LA CONCEPCION INC relative to other Puerto Rico facilities is limited in the current dataset.

What Should Families Ask When Visiting Hospital De La Concepcion Inc?

Based on this facility's data, families visiting should ask: "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?"

Is Hospital De La Concepcion Inc Safe?

Based on CMS inspection data, HOSPITAL DE LA CONCEPCION INC has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 0-star overall rating and ranks #100 of 100 nursing homes in Puerto Rico. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Hospital De La Concepcion Inc Stick Around?

HOSPITAL DE LA CONCEPCION INC 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 Hospital De La Concepcion Inc Ever Fined?

HOSPITAL DE LA CONCEPCION INC 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 Hospital De La Concepcion Inc on Any Federal Watch List?

HOSPITAL DE LA CONCEPCION INC 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.

HOSPITAL DE LA CONCEPCION INC

CARR 2 KM 173 4 BO CAIN ALTO, SAN GERMAN, PR 00683 | (787) 892-1860

D
Trust Grade (40/100)
3.0
CMS Rating
46
Deficiencies

Strengths

  • Licensed facility

Concerns

  • 46 deficiencies

Ask about: Rn Coverage

nursinghomedata.org | Data: CMS November 2025