RYDER MEMORIAL HOSPITAL INC
Non profit - Corporation
62 Beds
Independent
Data: November 2025
Trust Grade
75/100
#4 of 6 in PR
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Ryder Memorial Hospital Inc has a Trust Grade of B, indicating it is a good choice for nursing care, though it is not among the top facilities in Puerto Rico, ranking #4 out of 6. In Humacao County, it holds the top position, meaning it is the best option in the area. The facility is on an improving trend, with issues decreasing from 17 in 2024 to 13 in 2025. Staffing is a strong point, receiving a perfect score of 5/5, with only 8% turnover, which is significantly lower than the state average, suggesting a stable workforce that knows the residents well. However, there are concerns, including specific incidents where food was not served at the right temperature, the kitchen sanitation processes were not followed, and staff failed to consistently practice proper hand hygiene during medication administration. While there are strengths, these issues indicate areas that need attention.
- Trust Score
- B
- In Puerto Rico
- #4/6
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ✓ Good
- 8% annual turnover. Excellent stability, 40 points below Puerto Rico's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Puerto Rico facilities.
- Skilled Nurses ✓ Good
- Each resident gets 177 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
- 41 deficiencies on record. Higher than average. Multiple issues found across inspections.
75/100
Bottom 34%
No red flags
17 → 13 violations
★★★★☆
4.0
Overall Rating
★★★★★
5.0
Staff Levels
☆☆☆☆☆
0.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 17 issues
2025: 13 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
Low Staff Turnover (8%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (8%)
40 points below Puerto Rico average of 48%
Facility shows strength in staffing levels, staff retention, fire safety.
The Bad
No Significant Concerns Identified
This facility shows no red flags. Among Puerto Rico's 100 nursing homes, only 1% achieve this.
The Ugly 41 deficiencies on record
Mar 2025
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations made through the initial pool process and the request for policies and procedures to the administrativ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations made through the initial pool process and the request for policies and procedures to the administrative staff conducted on 03/24/2025 through 03/26/2025 from 8:00 AM to 3:30 PM, it was determined that the facility failed to provide a respectable service where the residents' dignity was maintained. This deficiency was identified in 1 out of 24 cases reviewed during the initial pool process (Resident #265).
1. Resident #265 is an [AGE] year-old female admitted on [DATE] with a diagnosis of decondition. The resident was observed on 03/24/2025 at 10:11 AM leaving the scale with no pants or sheets covering her legs so she was exposed to view.
On 03/25/2025 at 9:15 AM a policy was requested from the facility regarding the procedure for female wheelchair use and was not provided.
The facility failed to treat each resident with respect and dignity and provide care and services in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of 12 medical records reviewed (RR) and interviews performed on 03/24/2025 through 03/26/2025 from 8:00 AM throu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of 12 medical records reviewed (RR) and interviews performed on 03/24/2025 through 03/26/2025 from 8:00 AM through 3:30 PM, it was determined that the facility failed to promote mechanisms to identify the psychotropic drugs are not given unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. This deficient practice was identified in 2 out of 12 active records reviewed. (R.R. #265 and #268).
Findings include:
1. Resident #265 is an [AGE] year-old female admitted on [DATE] with a diagnosis of decondition. Record review conducted on 03/24/2025 at 2:25 PM, it was noted that the resident has high risk medications orders: Eliquis 2.5 milligrams (mg) 1 tab orally (PO) two times per day (BID), Lasix 40mg PO Daily and Seroquel 25mg tab PO hour of sleep (HS).
No evidence was found that the License Pharmacist performed a Medication Regimen requirement to identify the psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record.
2. Resident #268 is a [AGE] year-old male admitted on [DATE] with a diagnosis of lumbar discitis osteomyelitis. Record review conducted on 03/24/2025 at 1:44 PM it was noted that the resident has high risk medication orders: Lovenox 40mg subcutaneous (SQ) Daily, Zoloft 50mg tab PO Daily, Xanax 1mg tab PO HS x 5 days, Tylenol #3 with codeine 2 tabs PO every 6 hours as needed (PRN) for pain.
No evidence was found that the License Pharmacist performed a Medication Regimen requirement to identify the psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record.
3. During the interview with pharmacy licensee employee # 7 conducted on 03/25/2025 at 11:09 AM she indicated that medication reconciliations are initial only and are not provided follow-up unless there is a specific order for it. She also indicated that there was no documentation other than the signature on the stipulated document for medication reconciliation.
The facility failed to provide or promote a mechanism to ensure that the review of each resident's medication regimen is monitored to improve their condition, reduce risks or deterioration of their condition.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on dining observations, review of policies procedures and facility staff interview performed on 03/24/2025 through 03/26/2...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on dining observations, review of policies procedures and facility staff interview performed on 03/24/2025 through 03/26/2025 from 8:00 AM through 3:30 PM, it was determined that the facility failed to ensure that each resident receives food that accommodates resident allergies, intolerances, and preferences. This deficiency was identified in 1 out of 12 residents of the sample selection (Resident #268).
1. Resident interview #268 is a [AGE] year-old male admitted on [DATE] with a diagnosis of lumbar discitis osteomyelitis.
-During the initial pool process on 03/24/2025 at 8:21 AM resident #268 indicated that when food is brought in sometimes there are foods that are not to his liking, when this happens the staff does not offer him some substitute food to ensure he has adequate food intake.
-Record reviewed conducted on 03/24/2025 at 1:44 PM noted that the dietician made an estimate of the resident's tastes and needs, and these went to the kitchen for preparation.
The facility failed to ensure that resident preference was granted, and recommendation of the nutritionist was granted.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and eighteen records reviewed (RR) on 03/24/2025 through 03/26/2025 from 9:00 AM to 3:00 PM, it was determi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and eighteen records reviewed (RR) on 03/24/2025 through 03/26/2025 from 9:00 AM to 3:00 PM, it was determined that the facility did not ensure providing in making decisions regarding medical care and treatment with the resident or representative in advance directives 2 out of 18 records reviewed. (R.R #106 and #108).
Findings include:
1. During the evaluation of the records review on 03/25/2025, the following was found:
a. R.R #215 is a [AGE] year-old male admitted [DATE] with Infected Sacral Ulcer. Noted in the record review on 03/26/2025 at 10:13 AM, the advance directive was observed without the signature of the resident or representative.
b. R.R #217 is a [AGE] year-old male admitted on [DATE] with Amputation of the First Toe of the Right Foot. Noted in the record review on 03/25/2025 at 2:10 PM, that the resident was on Family Department Service and that the advance directive was not signed by a proxy.
It was verified that the resident had signed an X on the advance directive document. A request was made on 03/25/2025 at 8:43 AM to employee administrator #1 for a policy indicating when the resident was unable to sign and was unavailable.
Social Work employee #8 was interviewed on 3/25/2025 at 11:44 AM and stated that when a resident is in the Family Services Department, staff is responsible for signing all the resident's paperwork.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews with residents, facility administrator and physical environment personnel during the survey...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews with residents, facility administrator and physical environment personnel during the survey for the physical environment, it was determined that the facility failed to ensure that resident's sleeping rooms have comfortable and safe temperature levels and room environment is not homelike. This deficient practice was identified in 5 out of 20 residents' rooms.
Findings include:
1. During the tour of physical environment with a nurse, performed on 03/25/2025 at 10:30 AM all residents' sleeping rooms were visited. Residents located in room [ROOM NUMBER], 106 and 114 referred that room temperature was very cold. Those residents were observed covered with blankets and complained about low temperatures.
2. Resident located in rooms # 105,# 106 and # 114 stated during individual interviews on 03/25/2025 from 10:30 AM through 11:00 AM they would prefer warmer temperatures. It was identified that those rooms did not have a thermostat to be used to regulate the temperature of the room.
3. Physical environment personnel (employee #3) stated during interview on 03/25/2025 at 11:40 AM that resident rooms #105,# 106 and # 114 did not have a thermostat to be used to regulate the temperature of the room. He explains that room air condition temperature is set between 71 degrees and 81 degrees. That every resident room air condition system had a thermostat that continuously monitors the temperature in the room and sends signals to the control board to adjust the cooling output of the air conditioner as needed , however it is impossible to read or identify what the room temperature is.
4.The facility administrator (employee #1) was asked on 03/25/2025 at 1:20 PM if facility had a system or mechanism to monitor resident rooms temperature in order to adjust this temperature based on each resident preference. She stated that the facility did not have a mechanism or procedure to monitor resident rooms temperature in order to adjust this temperature based on each resident preference.5. During the tour for physical environment with an LPN Nurse ( employee #17) on 03/24/2025 from 8:45 AM till 10:45 AM on patients' rooms 116 A, 116C and 117C the following was observed:
a. On resident room [ROOM NUMBER] the bathtub curtain has one of the holes on the right side broken and lacks one of the hooks which makes the curtain touch the floor.
b. On resident room [ROOM NUMBER]C wall behind the patient's bed, paint detachment was observed. The arm of the TV, wheelchair and the air conditioning grill were observed with mold.
6. Based on observations of the physical environment, review of policies procedures on 03/24/2024 from 8:30 AM through 4:00 PM, it was determined that the facility failed to promote the resident right to receive services in a safe, clean, comfortable and homelike environment. This deficient practice could affect 24 out of 24 residents admitted receiving care at the facility.
1.
Black mold spots were observed on ceiling tile of cubicle #5 on the Physical Treatment area.
2.
Lifted paint was observed on back wall of cubicle #3 on the Physical Treatment area.
3.
Black mold spots were observed on ceiling tile of open area on the Physical Treatment area.
4.
Excessive dust was observed on filter grills of two AC units on the Physical Treatment area.
5.
Excessive vegetative material was found on the bottom part of the emergency exit door next to station #4.
6.
Exterior wall of treatment station #5 (orange wall) was observed with broken gypsum board on the bottom part of the wall.
7.
Several residents were interviewed, and they reported that the rooms were very cold. Room temperatures were taken, and the following was found:
a.
room [ROOM NUMBER]- 71 degrees
b.
room [ROOM NUMBER] -73 degrees
c.
room [ROOM NUMBER] - 68 degrees
d.
room [ROOM NUMBER] - 69 degrees
e.
room [ROOM NUMBER] - 67 degrees
f.
room [ROOM NUMBER] - 68 degrees
g.
room [ROOM NUMBER] - 69 degrees
h.
room [ROOM NUMBER] - 72 degrees
i.
room [ROOM NUMBER] - 73 degrees
The facility does not have a specific policy for room temperature, but they adjust to the temperature policy for the medication room Toma de Temperatura de Cuarto de Medicamento which states parameters between 71- and 81-degrees Fahrenheit.
8.Extractor grill on room [ROOM NUMBER] on wall of rooms were observed with rust and excessive dust.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #6 is an 83-year male admitted on [DATE] at 10:20 PM with diagnosis of Left hip fracture status post-op. admitted fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #6 is an 83-year male admitted on [DATE] at 10:20 PM with diagnosis of Left hip fracture status post-op. admitted for rehabilitation with Physical Therapy and Occupational therapy.
a. During the record review performed on 03/24/2025 at 1:18 PM, it was found that the MDS was performed and signed for MD on 1/18/2025, LDN signed on 1/20/2025, PT on 1/22/2025, OT on 1/23/2025, Pharmacy on 1/25/2025 and Social Worker on 1/20/2025. However, LND and Phycology signed on 3/20/2025 sixty-two days later than the admission. The MDS lacks the intervention of the Recreative therapist since admission to 66 days later.
b. The consultation report to Speech Pathology performed on 3/20/2025 at 9:30 AM lacks reason to request the Speech Pathology evaluation, no date, time and signature of Attending Physician signature.
c. The PMR consultation report lacks who notified the consultant, date, time and to whom.
4. Resident #7 is a 73 -year female admitted on [DATE] at 2:57 PM with diagnosis of Right Total Hip Replacement status post-op. admitted for rehabilitation with Physical Therapy daily.
a. During the record review performed on 03/24/2025 at 2:03 PM the standardized admission orders miss the signature of the register nurse, title, license number, date and time.
b. The physician admission evaluation was maintained in blank.
c. The physician's orders performed on 3/24/2025 at 2:03 PM lack the physician signature.
d. On 3/24/2025 at 2:03 PM no evidence of the physical therapy evaluation in patient record.
e. The discharge planning performed on 3/22/2025 per Interdisciplinary Equipment did not have the physician and the physical therapist participation.
5. Resident #10 is a 61-year male admitted on [DATE] with primary diagnosis of Amputation of right finger of left toe, Osteomyelitis and Acute Renal Failure, Metabolic Acidosis, HBP, CVD, HTN Decondition, Peripheral Vascular Disease, Hyperlipidemia. On 01/03/2025 at 6:40 PM the resident was transferred to [NAME] Hospital at Telemetry because the laboratory results were altered.
The record was reviewed on 03/25/2025 at 9:54 AM and the following was identified:
a. The Interdisciplinary Discharge Planning was performed on 12/17/2024 and there is no evidence of the Physical Therapy participation.
b. The infection history, allergy history and vaccination history it's in blank.
6. Resident #13 is a 45-year male admitted on [DATE] and discharge on [DATE] with diagnosis of Stroke, Debility, Gota, Dermatitis, Hight Blood Pressure and Raynaud's Syndrome. The record was reviewed on 03/25/2025 at 11:12 AM and the following was identified:
a. The physician progress note did not have the hour and date when the physician documented.
b. The PMR, Physical Therapy and Occupational Therapy consult lacks information. Physician signature and license number.
c. Discharge orders did not have the date when the physician wrote the order.
d. The Interdisciplinary Discharge plan lacks disposition of case.
e. The protocol for Pulmonary prevention was maintained in blank, only have the physician signature, lacks the nurse's signature, date and time.
f. Vaccination history was maintained in blank.
g. Photography consent form lacks resident name
7. R.R #108 is a [AGE] year-old male admitted on [DATE] with Amputation of the First Toe of the Right Foot. Noted in the record review on 03/25/2025 at 2:10 PM, lack of signatures of the resident or representative in the following documents:
a. Permission to take photo.
b. Consent to Admission.
c. Commitment to pay.
d. Certification of patient and/or family orientation.
e. Interdisciplinary Care Plan.
f. Advance directives.
g. Baseline Care Planning.
h. Guidance received on care plans.
i. Use of bedside rails.
j. Estimated administration of Influenza, Pneumococcal and Covid -19 vaccines.
k. Validation of education offered to patient or family members.
l. Guidance on Minimum Data Set (MDS).
Social Work Employee #8 was interviewed on 03/25/2025 at 11:44 AM regarding the documents with an X signed by the resident, she stated that the X is valid as a signature, she was asked for a policy that she would have to verify if the administrator had the policy which she did not have created.
The social worker also stated that the resident is in a mental state of disorientation period and is in the service of the Family Department at the Yabucoa location, they are responsible for signing those documents that are pending in the medical record.
Based on review of twelve medical records, resident interview and interview with the Administrator (employee #1) performed from 03/24/2025 thru 03/26/2025, from 8:00 AM thru 3:30 PM, it was determined that the facility failed to develop and implement baseline care plan within 48 hours of a resident's admission in order to promote the continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services. This deficient practice was identified in 2 out of 12 cases reviewed. (RR #265, #266) and fail to update information based on the comprehensive care plan identified on 5 out of 6 records reviews. (Residents #6, # 7, #10, #13 and #108 ).
Findings include:
1.Record Review #265 is an [AGE] year-old female admitted on [DATE] with a diagnosis of decondition.
-The resident was admitted for rehabilitation and therapy services. Record review conducted on 03/24/2025 at 2:25 PM, it was identified that the resident's plan of care was identified with another patient's label.
-The facility removed the label with the other patient's name and proceeded to place the correct label without signing or evaluating other options.
-A policy stating the process to follow when this occurs was requested and the facility did not provide one.
2. File review #266 is an [AGE] year-old female admitted on [DATE] with a diagnosis of L+ femur fracture.
-The resident was interviewed during the initial pool on 03/24/2025 at 8:55 AM and stated that she suffers from urinary incontinence. She also stated that she is kept in a diaper in the SNF and when she calls the nurse call system, she is diapered after approximately 30 minutes.
-During the care plan review conducted on 03/24/2025 at 1:18 PM it was noted that the incontinent care plan was not opened by nursing.
The facility failed to implement a care plan that provided follow-up to the residents' current problems.
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** 2. Resident #4 is a [AGE] year-old female admitted [DATE] with osteomyelitis sacral ulcer stage 4, according to the information ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #4 is a [AGE] year-old female admitted [DATE] with osteomyelitis sacral ulcer stage 4, according to the information collected in the medical record.
a. On 3/24/2025 at 1:20 PM, it was noted in the medical record that the interdisciplinary care plan was not completed by recreational therapy, nutrition and pharmacy staff. The interdisciplinary care plan in the expected outcomes on the evaluation date there was no continuity or outcomes according to the care plan.
On 03/25/2025 at 9:03 AM, medication pass nurse #11, referred that they discuss the interdisciplinary care plan every Tuesday with the nursing staff.
On 03/25/2025 at 10:05 AM, employee #12, MDS coordinator, was interviewed and stated that cases are evaluated individually in the first seven days when they are completing the MDS, but officially the interdisciplinary group has not met since the pandemic.
3. Resident #217 is a [AGE] year-old male admitted with amputation of the first toe of the right foot according to the information collected in the medical record.
a. Minimum Data Set (MDS) resident Assessment and Car Screening noted incomplete participation in the assessment and setting (identify all active participants in the assessment process) the part of another legally authorized representative and Cognitive Skill for Daily Decision Making (decision making related to daily living tasks) blank.
b. During the evaluation of the medical record on 03/26/2025 at 2:40 PM, it was noted that the resident was not oriented to his care plan or given the opportunity to participate in the care .
Based on observations on 03/24/25 through 03/26/25 from 8:30 AM till 4:00 PM and interview with Nursing personnel (employee #16), it was identified that facility failed to evidence the participation of Interdisciplinary Team (IDT) professionals in the development, implementation and review of the comprehensive person-centered care plan for a resident who is identified with non- compliance with the drug regimen. This deficient practice affects 3 out of 12 residents included in the sample selection. (Resident, #4, #67, #217).
Findings include:
1. The following information was identified while reviewing the medical record of resident #67 with the Nursing personnel (employee #16), on 03/26/2025 at 9:00 AM:
a. RR #67 is a 45 male resident admitted on [DATE] with a diagnosis of Right Knee Replacement. According with information documented in the medical record this resident had history of Anxiety Disorder and Depression (other than bipolar ).
b. When the resident was admitted to the facility on [DATE] nursing personnel perform medication reconciliation. During medication reconciliation resident notifies that he refuses to take Zoloft Elavil and Klonopin since he was receiving services at the hospital before being admitted to the SNF.
c. Zoloft PO is a prescription medication that can help treat depression and other mental health conditions, Elavil PO, that is a tricyclic antidepressant used to treat depression and mood disorders and Klonopin PO is used to prevent and treat anxiety disorders.
d. Comprehensive plan of care for this resident was prepared by the interdisciplinary team on 03/20/2025. Pharmacy and medications areas of this plan include the medications that the resident is refusing and not using. No information was documented as notified to the physician or pharmacist in relation to resident refusal of those prescribed medications used to treat depression and other mental health conditions. So, using this type of medications can create a chemical imbalance and result side effects.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations performed on 03/24/25 through 03/26/25 from 8:30 AM till 4:00 PM and interview with Nursing personnel (emp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations performed on 03/24/25 through 03/26/25 from 8:30 AM till 4:00 PM and interview with Nursing personnel (employee #16), and Administrator (employee #1) it was identified that facility failed to develop and implement comprehensive person-centered care plan for a resident who is identified with social service's needs and failed to guarantee participation of the interdisciplinary group in the comprehensive care plan meetings This deficient practice affects 1 out of 12 residents included in the sample selection. (Resident #3).
Findings include:
1. The following information was identified while reviewing the medical record of resident #3 with the Nursing personnel (employee #16), on 03/25/2025 at 9:15 AM:
a.RR #3 is an 80 male resident admitted on [DATE] with a diagnosis of Right Femur Fracture. Accordingly with information documented on the medical record Social Worker Initial Assessment resident lives alone in an independent elderly apartments complex. Apparently, the resident begins to experience disorientation episodes, felt down and fractured right hip. After surgery the resident was admitted receiving rehabilitation in the SNF and the social worker of the SNF communicate with resident daughter on 01/20/2025.
Accordingly with information documented by the social worker in the medical record, resident daughter notifies the social worker that she and her sister were in charge to provide care to their mother who had Alzheimer, they notify that cannot take care of their father or have the economic resources to pay for housing and care for their father.
On 01/31/2025 the case was referred to Puerto Rico State Social Family Department in order to request help to locate the resident when was discharged home from the SNF.
b. The Social worker follow-up with the social services department of Puerto Rico state social family department on 02/03/2025, 02/04/2025, 02/05/2025,02/06/2025,02/10/2025,02/11/2025 and 02/18/2025.
There is no evidence of any other social worker intervention for this case, after 02/18/2025.
c. On 03/25/2025 facility administrator document that communicated with social services department of Puerto Rico state social family department in order to request information of status of resident location. The Social services department of Puerto Rico state social family department requests a certification of resident medical conditions.
d. The comprehensive care plan of this resident was reviewed by IDT
on 03/17/2025. Social services areas were not triggered or included in this comprehensive care plan.
e. Facility administrator stated on interview on 03/25/2025 at 10:00 AM that facility social worker resigns from her position on 02/19/2025. She informs that this social worker who resign from her position was recruited by contract as part-time position on 03/27/2025 while facility recruit another social worker. She also informs that another part-time social worker was recruited on 03/21/2025 while the facility recruit a full time social worker.
f. The surveyor asked the facility administrator (employee #1) on 03/25/2025 at 10:30 AM if there is the possibility that those part-time social worker employees failed to participate and document the development and implementation of case #3 social services comprehensive plan. The administrator (employee #1) stated that there is the possibility that they did not document interventions carried out to follow-up with the State social services department of Puerto Rico Social family department the status of resident location. 2. The MDS coordinator employee #12 was interviewed on 03/25/2025 at 10:05 AM about the meetings held by the interdisciplinary group. She said that they used to meet once a week, but since the pandemic they no longer meet.
The meetings that are held individually with part of the interdisciplinary group are the first seven days when staff come in to fill out the MDS and then they take the opportunity to discuss the relevance of a resident. Virtual meetings were not considered according to employee #12 MDS coordinator.
The only interdisciplinary group meetings that were held were the weekly nursing staff meetings every Tuesday according to nursing employee #14.
Administrator employee #1 was interviewed on 3/25/2025 at 10:25 AM, she stated that they had not met due to Covid-19, but now she knew she was going to meet with staff to start interdisciplinary group meetings.
The facility did not ensure participation of the interdisciplinary group to work together to provide the greatest benefit to the residents.
The facility did not develop an alternative method, i.e., face-to-face or virtual meetings, for the interdisciplinary group members to provide input into the development and review of the resident's plan of care.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations performed on 03/24/25 through 03/26/25 from 8:30 AM till 4:00 PM and interview with Nursing personnel (emp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations performed on 03/24/25 through 03/26/25 from 8:30 AM till 4:00 PM and interview with Nursing personnel (employee #16), it was identified that facility failed to evidence that identify irregularities in the medication review were documented, reported and if necessary to the attending physician and pharmacist. This deficient practice affects 3 out of 12 residents included in the sample selection. (Resident #67, #265 and #268).
Findings include:
1.The following information was identified while reviewing the medical record of resident #67 with the Nursing personnel (employee #16), on 03/26/2025 at 9:00 AM:
a.RR #67 is a 45 male resident admitted on [DATE] with a diagnosis of Right Knee Replacement. According to the information documented in the medical record this resident had history of Anxiety Disorder and Depression (other than bipolar ).
b. When the resident was admitted to the facility on [DATE] nursing personnel perform medication reconciliation. During medication reconciliation resident notified that he refused to take Zoloft Elavil and Klonopin since he was receiving services at the hospital before being admitted to the SNF.
c. Zoloft PO is a prescription medication that can help treat depression and other mental health conditions, Elavil PO, that is a tricyclic antidepressant used to treat depression and mood disorders and Klonopin PO is used to prevent and treat anxiety disorders.
No evidence was found documented on the medical record or drug regimen review of the oversight by pharmacy or physician when was identified that this resident is refusing previously ordered for depression and other mental health conditions. This resident had history of anxiety disorder and Depression (other than bipolar ) accordingly with information documented in the medical record.
d. The reason why residents refuse to take those medications was not found documented as part of the documentation of the drug regimen review.
e. No evidence was found documented related to information provided to resident #67 in relation of the possible effects that he could experience when stopping antidepressants and other mental health medications or withdrawal symptoms.
2. Record Review #265 is an [AGE] year-old female admitted on [DATE] with a diagnosis of decondition.
-Record review conducted on 03/24/2025 at 2:25 PM, it was noted that medication reconciliation by pharmacy was incomplete. Although she had a signed medication reconciliation within the stipulated time, it lacked documentation indicating the reaction or interaction of each medication and suggestions or consultation with the medical director if necessary.
3. Record review #268 is a [AGE] year-old male admitted on [DATE] with a diagnosis of lumbar discitis osteomyelitis.
-Record review conducted on 03/24/2025 at 1:44 PM noted that the medication reconciliation by pharmacy was incomplete. Although he had a signed medication reconciliation within the stipulated time frame, it lacked documentation indicating the reaction or interaction of each medication and suggestions or consultation with the medical director if necessary. In addition, the resident was prescribed opioids for pain after the initial medication reconciliation and there was no follow-up medication reconciliation.
During the interview with pharmacy licensee employee #7 conducted on 03/25/2025 at 11:09 AM she indicated that medication reconciliations are initial only and are not provided follow-up unless there is a specific order for it. She also indicated that there was no documentation other than the signature on the stipulated document for medication reconciliation.
4. The facility failed to provide or promote a mechanism to ensure that the review of each resident's medication regimen is monitored to improve their condition, reduce risks or deterioration of their condition.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on dining observations, review of policies procedures and facility staff interview performed on 03/24/2025 through 03/26/2...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on dining observations, review of policies procedures and facility staff interview performed on 03/24/2025 through 03/26/2025 from 8:00 AM through 3:30 PM, it was determined that the facility failed to ensure that each resident (R), receives and the facility provides food and drink that is palatable, attractive, and at a safe and appetizing temperature. This deficiency affects 1 out of 12 residents admitted receiving services (R #268).
Findings include:
1. Resident interview #268 is a [AGE] year-old male admitted on [DATE] with a diagnosis of lumbar discitis osteomyelitis.
-During the initial pool process on 03/24/2025 at 8:21 AM resident #268 indicated that when food is brought in sometimes there are foods that are not to his liking, when this happens the staff does not offer him some substitute food to ensure he has adequate food intake.
-Record reviewed conducted on 03/24/2025 at 1:44 PM noted that the dietician made an estimate of the resident's tastes and needs, and these went to the kitchen for preparation.
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 Kitchen, review of policies procedures and facility staff interview performed on 03/24/2025 from 8:00 AM through 3:30 PM, it was determined that the facility failed to com...
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Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 03/24/2025 from 8:00 AM through 3:30 PM, it was determined that the facility failed to comply with the required sink compartment sanitations. This deficient practice could affect 24 out of 24 residents admitted receiving care at the facility.
Findings include:
Review of facility's policy and procedure Lavado, Enjuage y Saneamiento, Cleaning and Disinfection of three compartment Sinks regarding the process of cleaning and sanitization of kitchen equipment was reviewed on 03/24/2025 at 11:30 AM and it says that compartment one (1) must have a temperature of 110º F, on compartment two (2) and on compartment three (3) utensils should be for 30 seconds with a sanitizing solution concentration of 200 ppm.Test strip container was verified and stated that concentration testing should be taken with a temperature of 75 degrees Fahrenheit.
1.During the visual inspection and staff interview it was noticed that 3 compartment sinks were not prepared as stated in the facility policies and procedures. It was observed that the staff working the sink did not have knowledge of the temperatures required in the sanitization compartments. It was requested that the concentration of sanitizer be taken on the third compartment, and the concentration measurement was found to be higher than the requirement of 200 ppm. Overuse of the sanitizing agent could be harmful.
2.During observation of the dry storage area, loose rice and beans were observed underneath the storage racks. A tuna can was observed left on the floor.
3.Lettuce was observed cut and wrapped in plastic wrapping with no date.
4.Prepared cereal (farina) was observed on container with no date of preparation.
5.Mandarin oranges were observed on container, apple juice wrapping, and plastic was inside container with oranges.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings include:
1. During the drug past performance on 03/25/2024 from 8:22 AM till 9:30 AM, it was observed two register nurs...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings include:
1. During the drug past performance on 03/25/2024 from 8:22 AM till 9:30 AM, it was observed two register nurses in the process medication administration, and it was found the following.
a. On 03/25/2025 at 8:55 AM RN #10 failed to follow appropriate hand washing process during the medication administration and failed to hand wash 1 out to 7 opportunities for hand wash 14.28%.
b. On 03/25/2025 at 8:22 AM RN #11 failed to follow appropriate hand washing process during the medication administration and failed to hand wash 9 out to 11 opportunities for hand wash 81.81%.
2. R.R #215 is a [AGE] year-old male admitted [DATE] with Infected Sacral Ulcer. During the bed bathing procedure by Licensed Practical Nurse (LPN) employee #15, she performed 3 water changes and did not perform 3 glove changes.
Based on observation during medication pass performance on 03/25/2025 from 8:22 AM till 9:30 AM, it was determined that the facility failed to ensure establish and maintain an infection prevention and control program relate to hand washing during the drug pass and failed to ensure establish and maintain an infection prevention and control program related to changing gloves in bed baths in 1 out of 1 resident observed (RR #215)
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
Based on observations performed on 03/24/2025 from 8:30 AM through 3:30 PM, it was determined that the facility failed to maintain all patient care equipment in safe operating condition. This deficien...
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Based on observations performed on 03/24/2025 from 8:30 AM through 3:30 PM, it was determined that the facility failed to maintain all patient care equipment in safe operating condition. This deficient practice affects 24 out of 24 residents admitted receiving treatment at the facility.
Findings include:
1. During a visual inspection of the equipment in the physical therapy area, it was observed that of 7 wheelchairs observed, 3 of these had peeling paint and signs of rust, and clinical tape on the arm rests.
2. It was also observed that of 15 walkers available, 5 of them showed signs of rust and wear and tear.
3. Two (2) out of two (2) of pedal floor exerciser were observed with signs of rust.
May 2024
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on thirteen records reviewed (R.R.), and interview with the nursing supervisor (employee #3), it was determined that the f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on thirteen records reviewed (R.R.), and interview with the nursing supervisor (employee #3), it was determined that the facility failed to ensure that treatment and care provided to residents' place priority on identifying health identified concerns. This deficiency affects 1 out of 13 records reviewed. (Resident #120).
Findings include:
Sample selection resident #120-A is a [AGE] year-old female resident admitted on [DATE] with a diagnosis of Left Knee Replacement. On 05 /10/22 at 8:25 AM during initial pool process resident was interview and stated that she had diabetes disease history and that since admission facility is monitoring her sugar levels with Dextrostix every 6 hours and if sugar levels are out of expected range personnel will administer to her regular insulin to control them.
Review of medical record on 05/13/24 evidence that physician order subcutaneous insulin protocol on 05/10/24 at 10:00 PM to monitor resident blood sugar levels however did not select on the standing order the type of insulin that personnel must administer if blood sugar levels are out of expected range.
Blood sugar monitoring and insulin protocol standing order include regular human insulin and human: Lispro human insulin which it is a rapid acting human analog insulin that works parenterally to lower blood glucose by regulating the metabolism of carbohydrates, proteins, and fats.
During interview on 05/13/24 at 10:30 AM nursing supervisor (employee #3) stated that physician did not select the type of insulin in the insulin protocol and that on 05/11/24 at 5:00 PM and 9:30 PM nursing personnel administer regular human insulin subcutaneous.
Nursing supervisor notified the physician and he ordered on 05/13/24 at 2:54 PM to use regular human insulin when levels are out of expected range.
The facility failed to notify physician immediately when they identify that physician did not select the type of insulin in the insulin protocol.
The facility failed to ensure that physician is timely consulted when is needed based on pertinent aspects that were identified related with resident treatment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on dining observations, review of policies procedures, thirteen records reviewed (RR) and facility staff interview perform...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on dining observations, review of policies procedures, thirteen records reviewed (RR) and facility staff interview performed on 05/13/2024 through 05/15/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to ensure that kitchen personnel follow therapeutic diet specifications consistent with the resident's comprehensive assessment. This deficiency affects 1 out of 13 records reviewed. (Resident #55).
Findings include:
Facility policy Title: Nutritional Needs was reviewed on 05/15/2024 at 3:05 PM with Dietitian. Policy clearly stated on the procedures that for every resident admitted to the facility and accordingly with a comprehensive assessment therapeutic diet specifications must be followed accordingly with resident's needs.
1. RR# 55 is a male [AGE] year-old resident admitted on [DATE] with a diagnosis of Fracture on Left Femur. This resident case was consulted with the Speech Language Pathology (SLP) on 05/13/24 at 9:00 PM because resident was presenting difficulty to swallow food. SLP evaluate the resident on 05/14/24 at 10:41 AM and recommend that due to resident difficulty to swallow liquid and solid food, diet consistency must be provided with blenderized food, no broths, no gelatin and to use thickening for the liquids which must reach a puree consistency.
2. On 05/14/24 at 3:21 PM the facility dietitian evaluates the SLP recommendations and a diet of 1,600 kilocalorie mash and ground low sugar diet with no liquid food was ordered.
3. On 05/15/24 at 8:15 AM it was observed that residents receive for breakfast coffee, hot cereal, apple juice and orange gelatin.
4. On 05/15/24 at 8:20 AM it was informed by the Dietitian that resident received gelatin on his breakfast tray.
Dietitian (employee #2) stated in an interview on 05/15/24 at 8:25 AM that kitchen personnel must comply with diet recommendations.
5. Review of department of kitchen card with diet specifications of resident #55 on 05/15/24 at 8:30 AM evidence that card clearly specify that no gelatin must be served on resident tray.
6. No explanation was provided by the facility dietitian (employee #2) of the reason why the kitchen personnel did not address the correct diet recommendations.
7. Facility failed to offer a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed (RR), residents' interview and registered nurse (RN) interview and policy and procedure review, it was...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed (RR), residents' interview and registered nurse (RN) interview and policy and procedure review, it was found that the facility failed to ensure that patient right to request and formulate advance directive auto determination for 3 out of 18 resident record review. (Resident #105, #111 and #124)
Findings include:
Facility policy and procedure number 4.9 update on 7/14/16 title: Advance Directive Auto determination evaluate on 05/14/24 at 01:56 PM refer in the item #1 and #2 that the physician during the initial evaluation must oriented the resident related to his right to auto determine his treatment and answer to the resident if have any advance directive formulated. The physician completes the sheet of the resident orientation about the auto determination indicating if have or not any advance directive.
1. Resident #105 is a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Diabetes Mellitus and Right Total Knee Replacement. During the record review performed on 5/13/2024 at 11: 41 AM it was found that resident was oriented related to the advance directive and sign the orientation on 05/04/2024, however no mark if have or not any advance directive the space for this was left in blank.
2. Resident #111 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Deconditioning. During record review performed on 05/13/24 at 03:05 PM, it was found that residents on 05/08/2024 sign the advance directive orientation, however no mark if have or not any advance directive.
During interview with the RN employee #5 related to why the resident orientation related if have or not advance directive was left in blank, she states that this was the responsibility of the physician when performed the initial evaluation
3. Resident #124 is a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Left Total Knee Replacement. During the record review performed on 5/13/2024 at 10:12 AM it was found that resident was oriented related to the advance directive and sign the orientation on 05/04/2024, however no mark if have or not any advance directive the space for this was left in blank.
During the interview the RN (employee # 3) stated that it is the responsibility of the physician when performing the initial evaluation to complete the area if resident to have or not any advance directive.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 05/13...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 05/13/2024 through 05/15/2024 from 8:00 AM through 5:00 PM, it was determined that the facility failed to promote the resident right to receive services in a safe, clean, comfortable, and homelike environment.
Findings include:
During observational tour the following was observed related with environment in the facility:
1. Room headlights are missing lightbulbs or one light not working on room [ROOM NUMBER], #103, #117
2. The room temperatures were not within the parameters established by the institution's Politica de Temperaturas en Habitaciones de Pacientes policy which states room tempertures must be between 68 and 72 degrees farenheit . Some residents reported feeling hot temperaures and even waking up at night sweaty. When taken, the temperature in room [ROOM NUMBER] was 83 degrees farenheit and room [ROOM NUMBER] was 82 degrees farenheit.
3. Wooden closets were observed with dust and spider webs.
4. Residents in room [ROOM NUMBER] and #119 stated that water temperature of showers did not reach a comfortable warm temperature.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on dining observations, review of policies procedures and facility staff interview performed on 05/13/2024 through 05/15/2...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on dining observations, review of policies procedures and facility staff interview performed on 05/13/2024 through 05/15/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to ensure that each resident receives food that accommodates resident allergies, intolerances, and preferences. This deficiency was identified in 1 out of 13 residents of the sample selection receiving services (Resident #108).
Findings include:
Facility policy Title: Nutritional Needs last updated in January 2024, was reviewed on 05/15/2024 at 3:05 PM with Dietitian. The policy clearly stated on the procedures that for every resident admitted to the facility food will be provided considering each resident preferences and food intolerances.
1. Resident #108 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Right Total knee Replacement. During the interview 05/13/2023 at 10:00 AM, she states that she likes some days with a sandwich for breakfast and Lactose Free milk, that she notified the nutritionist but continued with regular milk.
During the record review performed on 05/14/24 at 3:27 PM the nutritionist evaluation was performed on 5/7/2024 and recommended 1500 kilocalories diet low sodium, low sugar, 25 gram of fiber, 60 gram of protein, 1500 milliliter of liquid, Lactose free milk, no sauce food, option of sandwich for breakfast to vary, 8 ounces of Glucerna for snack.
The diet kitchen cart reviewed on 05/14/24 12:00 PM, revealed that resident preference was some days sandwich for breakfast, No Lactose, no sauce, 2 snack and include fresh fruits on 5/7/24.
During observation on 5/13/2024 at breakfast time the meals tray not observe Lactose free milk, during the lunch time the lunch was cold, and no fresh fruit was observed. On 5/14/2024 at 7:45 AM resident was asked about breakfast and stated that the milk she do not drink because she do not know if it is lactose free milk.
During an interview with the nutritionist employe #2 related to resident observation she states that supposed to be labeled the milk as Lactose free.
The facility failed to ensure that resident preference was granted, and recommendation of the nutritionist was granted, and the fruit was caned not palatable, attractive, and appetizing temperature.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During review of record review of case #105 it was identified that facility nursing personnel receive telephonic orders on 05...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During review of record review of case #105 it was identified that facility nursing personnel receive telephonic orders on 05/09/24 at 9:00 PM, and on 05/11/24 at 9:13 PM by the physician. No authentication, sign, or confirmation of those telephone orders by the physician was evidenced on 05/13/24.
3. During the record review of case #108 it was identified that facility nursing personnel receive telephonic orders on 05/10/24 at 9:00 PM, and on 05/12/24 at 9:00 PM by the physician. No authentication, sign, or confirmation of those telephone order by the physician was evidenced on 05/13/24.
Based on review of thirteen medical records on 05/13/24 through 05/15/24 from 8:00 AM till 4:30 PM and interview with facility nursing supervisor (employee #3), it was determined that facility failed to ensure that telephone orders taken by nursing personnel were signed and authenticated accordingly with facility policies and procedures. This deficient practice was identified in 3 out of 13 cases reviewed. (Case RR#105, #108 and #117).
Findings include:
Facility policy Title: Notificación al Médico por Vía Telefónica Sobre Cambios en la Condición [NAME] Paciente last update July 15, 2016, was reviewed on 05/13/2024 at 2:35 PM with Nursing Supervisor (employee #3). Policy clearly stated on the procedures that every order prescribed by physician by telephone must be authenticated in a period of 48 hours.
1. During review of record review of case #117 it was identified that facility nursing personnel receive telephonic orders on 05/10/24 at 10:00 PM, and on 05/11/24 at 12:00 PM by the physician. No authentication, sign, or confirmation of those telephone orders by the physician was evidenced on 05/13/24.
Nursing Supervisor (employee #3) stated in an interview on 05/13/2024 at 2:45 PM that every telephone order must be authenticated and signed by the physician in a period no later than 48 hours.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
Based on observations of the physical environment and facility staff interview performed on 05/13/2024 through 05/15/2024 from 8:00 AM through 5:00 PM, it was determined that the facility failed to ma...
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Based on observations of the physical environment and facility staff interview performed on 05/13/2024 through 05/15/2024 from 8:00 AM through 5:00 PM, it was determined that the facility failed to maintain adequately equipped rooms to allow residents to call for staff assistance . This deficient practice had the potential to affect 4 out of 21 residents.
Findings include:
Rooms #102 and #106 nurse call were found not working.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on observations and interview with the Dietitian (employee #2) performed from 05/13/2024 thru 05/15/2024, from 8:00 AM thru 5:00 PM, it was determined that the facility failed to provide suffici...
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Based on observations and interview with the Dietitian (employee #2) performed from 05/13/2024 thru 05/15/2024, from 8:00 AM thru 5:00 PM, it was determined that the facility failed to provide sufficient support for personnel safely and effectively carry out the functions of the food and nutrition service.
Findings include:
During an interview with the Dietitian performed on 05/14/2024 she stated that the facility did not have all the necessary personnel in the kitchen.
A kitchen personnel pattern was requested to the kitchen manager by the surveyor and it was noticed that the pattern revealed 5 more employees were needed for optimal operation.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** e. During an interview with the Dietitian performed on 05/14/2024 she stated that the facility did not have all the necessary pe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** e. During an interview with the Dietitian performed on 05/14/2024 she stated that the facility did not have all the necessary personnel in the kitchen.
A kitchen personnel staffing pattern was requested to the kitchen manager by the surveyor, and it was noticed that the pattern revealed 5 more employees were needed for optimal operation.
f. Facility dietitian (employee #2) stated in an interview on 05/13/24 at 11:10 AM that a new kitchen company began to offer services on March 1, 2024. She stated that since this company began to offer services; she met with kitchen manager on several occasions to explain to her the importance of adjust resident's food delivery in a way that adjust to their resident preferences and rehabilitation routine. She stated that kitchen manager agrees since the company began to offer services, that food delivery was going to be carried out in a way that adjusts to resident preferences and rehabilitation routine. She stated that those are the agreements that they made with the kitchen contractor manager, but she also explained that she had knowledge that the kitchen contracted company had experience staff turnover and this could affect services provided.
Based on dining observations, review of policies procedures and facility staff interview performed on 05/13/2024 through 05/15/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to ensure that residents needs and preferences related with food services are met. This deficiency was identified in 3 out 13 sample cases reviewed (Resident #116, #120 and #121).
Findings include:
Facility policy Title: Food Services to Residents was reviewed on 05/13/2024 at 11:35 AM with Dietitian (employee #2) Policy clearly stated on the procedures that every resident's breakfast must be delivered between 7:00 AM-8:15 AM.
1. During initial pool process residents located in room [ROOM NUMBER]-A, #116-A and #117-A stated that breakfast did not arrive at a time in the morning that best suits their needs.
a. Resident sample # 116 stated in the interview on 05/13/24 at 8:40 AM that breakfast has arrived for the past four days after 8:30 AM. She stated that she was admitted on [DATE] due to status post right hip surgery for rehabilitation. She stated that breakfast came at the same time physical therapy escort personnel comes for us to take us to physical therapy in the morning. Because breakfast came at the same time physical therapy escort personnel is coming for us to take us to physical therapy in the morning this does not permit us to eat calmly and to go to the bathroom before going to the physical therapy treatment. She also stated that she prefers to have breakfast between 7:30 AM and 8:00 AM.
b. Resident sample # 120 stated in an interview on 05/13/24 at 8:50 AM that breakfast has arrived for the past four days after 8:30 AM. She stated that she was admitted on [DATE] due to Left Knee Replacement for rehabilitation. She stated that breakfast came at the same time physical therapy escort personnel is coming for me to take me to physical therapy in the morning. Resident stated that she has diabetes, and she usually eats breakfast earlier in the morning. She also stated that she prefers to have breakfast between 7:30 AM and 8:00 AM.
c. Resident sample # 121 stated in an interview on 05/13/24 at 9:10 AM that breakfast has arrived for the past four days after 8:30 AM. He stated that he was admitted on [DATE] due to Left Knee Replacement for rehabilitation. He stated that breakfast came at the same time physical therapy escort personnel is coming for me to take me to physical therapy in the morning. Resident stated that he has diabetes, and he usually eats breakfast earlier in the morning. He also stated that she prefers to have breakfast between 7:30 AM and 8:00 AM.
d. Resident preferences related with time where breakfast came in the morning is discussed with facility administrator (employee #1) on 05/13/24 at 10:50 AM. Facility administrator stated on interview that she had knowledge of the situation and that referred the situation to the facility dietitian for her to meet with kitchen contracted manager to solve the situation. Facility administrator also stated in an interview that agreements had been reached with the kitchen contracted company to adjust food delivery in a way that adjusts to resident preferences and rehabilitation routine.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. Resident #108 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Right Total knee Replacement....
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. Resident #108 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Right Total knee Replacement. During the interview 05/13/2023 at 10:00 AM, she states that she likes some days with a sandwich for breakfast and Lactose Free milk, that she notified the nutritionist but continued with regular milk.
During the record review performed on 05/14/24 at 3:27 PM the nutritionist evaluation was performed on 5/7/2024 and recommended 1500 kilocalories diet low sodium, low sugar, 25 gram of fiber, 60 gram of protein, 1500 milliliter of liquid, Lactose free milk, no sauce food, option of sandwich for breakfast to vary, 8 ounces of Glucerna for snack.
The department of kitchen card with diet specifications of resident #108 reviewed on 05/14/24 12:00 PM, revealed that resident preference was some days sandwich for breakfast, No Lactose, no sauce, 2 snack and include fresh fruits on 5/7/24.
During observation on 5/13/2024 at breakfast time the meals tray not observe Lactose free milk, during the lunch time the lunch was cold, and no fresh fruit was observed.
On 5/14/2024 at 7:45 AM resident was asked about breakfast and stated that she does not drink milk because she do not know if it is lactose free milk.
During an interview with the nutritionist related to resident observation she states that supposed to be labeled the milk as Lactose free.
The facility failed to ensure that resident preference was granted, and recommendation of the nutritionist was granted, and the fruit was caned not palatable, attractive, and appetizing temperature.
No explanation was provided by the facility dietitian (employee #2) of the reason why the kitchen personnel did not address the correct diet recommendations.
Based on dining observations, review of policies procedures and facility staff interview performed on 05/13/2024 through 05/15/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to ensure that input received from residents and preferences related with food services are met. This deficiency affects 4 out of 13 cases reviewed during initial pool process (Resident #108, #116, #120 and #121).
Findings include:
The facility policy Title: Nutritional Needs last updated in January 2024, was reviewed on 05/15/2024 at 3:05 PM with Dietitian. Policy clearly stated the procedures that for every resident admitted to the facility food will be provided considering each resident preference.
1. During initial pool process residents located in room [ROOM NUMBER]-A, #116-A and #117-A stated that food brought by the kitchen personnel had items that they do not like in their breakfast, lunch, and dinner.
a.Resident sample #116 stated in an interview on 05/13/24 at 8:40 AM that she receives in her breakfast eggs and coffee with milk and that she does not like those. She stated that she receives milk with lunch and dinner, and she does not drink milk. She also stated that she wants and request fresh fruit and receives canned fruits.
Review of department of kitchen card with diet specifications of resident #116 on 05/15/24 at 11:00 AM evidence that card clearly specifies that resident prefer black coffee, that she does not want milk with foods, and that she prefers fresh fruits.
Resident preferences of resident #116 was discussed with facility dietitian (employee #2) on 05/13/24 at 10:55 AM.
Facility dietitian (employee #2) stated on interview on 05/13/24 at 11:00 AM that she performs the nutritional initial assessment to resident #116 on 05/04/24 when she was admitted and she specify in the diet order that no eggs or milk were liked by the resident, she also specifies that resident want to receive fresh fruits.
On 05/14/24 at 8:00 AM it was observed that residents receive for breakfast scrambled eggs and coffee with milk. On 05/14/24 at 12:10 PM it was observed that residents receive canned mandarin orange.
b. Resident sample #120 stated in an interview on 05/13/24 at 8:50 AM that she does not like to eat rice every day during lunch and dinner. She said that she prefers salad or potatoes, cassava or other starchy tuberous. She stated that she does not like carrots. She stated that she receives rice with lunch and dinner, and she does not want to eat rice on daily basis.
Review of department of kitchen card with diet specifications of resident #120 on 05/15/24 at 11:30 AM evidence that card clearly specify that resident prefer starchy tuberous instead of rice.
Resident #120 preferences were discussed with facility dietitian (employee #2) on 05/13/24 at 11:15 AM.
Facility dietitian (employee #2) stated on interview on 05/13/24 at 11:25 AM that she performs the nutritional initial assessment to resident #120 on 05/10/24 when she was admitted , and she specify in the diet order that resident prefer starchy tuberous instead of rice.
On 05/13/24 at 12:15 PM it was observed that residents received for lunch pasta and steamed carrots.
c. Resident sample #121 stated in an interview on 05/13/24 at 9:10 AM that he does not eat hot cereal for breakfast. He stated that he prefers a sandwich in the morning. He also stated that if he receives eggs or hot cereal for breakfast, he does not like it and he does not eat those items.
Review of department of kitchen card with diet specifications of resident #120 on 05/15/24 at 11:55 AM evidence that card clearly specify that resident prefer sandwich for breakfast and does not like hot cereal.
Resident #121 preferences were discussed with facility dietitian (employee #2) on 05/13/24 at 11:35 AM.
Facility dietitian (employee #2) stated on interview on 05/13/24 at 11:30 AM that she performs the nutritional initial assessment to resident #121 on 05/10/24 when he was admitted , and she specify in the diet order that resident prefer sandwich for breakfast.
On 05/14/24 at 12:22 PM it was observed that residents receive scrambled eggs for breakfast.
No explanation were provided by the facility dietitian (employee #2) of the reason why the kitchen personnel did not address the correct diet recommendations.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. Resident #108 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Right Total knee Replacement....
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. Resident #108 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Right Total knee Replacement. During the interview 05/13/2023 at 10:00 AM, she states that she likes some days a sandwich for breakfast and Lactose Free milk, that she notified the nutritionist but continued with regular milk.
During the record review performed on 05/14/24 at 3:27 PM the nutritionist evaluation was performed on 5/7/2024 and recommended 1500 kilocalories diet low sodium, low sugar, 25 gram of fiber, 60 gram of protein, 1500 milliliter of liquid, Lactose free milk, no sauce food, option of sandwich for breakfast to vary, 8 ounces of Glucerna for snack.
The diet kitchen cart reviewed on 05/14/24 12:00 PM, revealed that resident preference was some days sandwich for breakfast, No Lactose, no sauce, 2 snack and include fresh fruits on 5/7/24.
During observation on 5/13/2024 at breakfast time the meals tray no Lactose free milk observed, during the lunch time the lunch was cold, and no fresh fruit was observed. On 5/14/2024 at 7:45 AM resident was asked about breakfast and stated that she do not drink milk because she do not know if it is lactose free milk.
During an interview with the nutritionist related to resident observation she states that supposed to be labeled as Lactose free milk.
The facility failed to ensure that resident preference was granted, and recommendation of the nutritionist was granted, and the fruit was caned not palatable, attractive, and appetizing temperature.
e. Resident #111 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Deconditioning. During the interview the resident stated that the food was cold.
During observation on 5/13/2024 at 8:15 AM at breakfast time and at 12:00 PM lunch time the resident says that food was cold, and she likes it hot.
The facility failed to ensure that resident preference was granted for appetizing temperature.
Based on dining observations, review of policies procedures and facility staff interview performed on 05/13/2024 through 05/15/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to ensure that each resident receives, and the facility provides food and drink that is palatable, attractive, and at a safe and appetizing temperature. This deficiency affects 5 out of 13 cases admitted receiving services (Resident #108, #111, #116, #120 and #121).
Findings include:
Facility policy Title: Nutritional Needs last updated in January 2024, was reviewed on 05/15/2024 at 3:05 PM with Dietitian. Policy clearly stated the procedures that for every resident admitted to the facility food will be provided considering each resident preference.
1. During initial pool process residents located in room [ROOM NUMBER]-A, #116-A and #117-A, stated that food brought by the kitchen personnel is not palatable, appetizing and at appetizing temperature.
a. Resident sample # 116 stated in an interview on 05/13/24 at 8:40 AM that food that she receives for breakfast, lunch and dinner lack of flavor and is not agreeable to the palate or taste.
She also stated that food brought by kitchen personnel does not have an appetizing temperature during breakfast, lunch, or dinner. She stated that cold food items are warm and hot food is brought cold.
b. Resident sample # 120 stated in an interview on 05/13/24 at 8:50 AM that food items brought by the kitchen personnel for breakfast, lunch and dinner are not pleasant to taste. She also stated that food at the facility is not appetizing, savory, tasty or tempting. She stated that the fact that cold food is brought by kitchen personnel warm and hot food is brought by kitchen personnel cold it has its effect on the desire to eat those food items.
c. Resident sample # 121 stated in an interview on 05/13/24 at 9:10 AM that food items brought by kitchen personnel for breakfast, lunch and dinner are not palatable or agreeable to the palate. He also stated that cold food items are brought by kitchen personnel warm and that hot food items are brought by kitchen personnel cold. He stated that he does not opt for asking personnel to heat hot food items because he thinks that it may make its taste worse, and he eats a little, but he remains hungry sometimes.
Facility dietitian (employee #2) stated in an interview on 05/13/24 at 11:10 AM that a new kitchen company begin to offer services on March 1, 2024. She stated that since this company began to offer services, she met with kitchen manager on several occasions to explain to her the importance of adjusting residents' food preferences. She stated that kitchen manager agreed since the company began to offer services, that food delivery was going to be carried out in a way that adjusts to resident preferences. She stated that those are the agreements that they did with the kitchen contractor manager, but she also explained that she had knowledge that the kitchen contracted company had experience staff turnover and this could affect services provided.
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 Kitchen, review of policies procedures and facility staff interview performed on 05/13/2024 from 8:00 AM through 4:00 PM, it was determined that the facility failed to com...
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Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 05/13/2024 from 8:00 AM through 4:00 PM, it was determined that the facility failed to comply with the required sink compartment sanitations.
Findings include:
Review of facility's policy and procedure Lavado, Enjuage y Saneamiento, Cleaning and Disinfection of three compartment Sinks regarding the process of cleaning and sanitization of kitchen equipment was reviewed on 05/13/2024 at 11:30 AM and it says that compartment one (1) must have a temperature of 110º F, on compartment two (2) and on compartment three (3) utensils should be for 30 seconds with a sanitizing solution concentration of 200 ppm.
1. During the visual inspection and staff interview it was noticed that 3 compartment sink was not prepared as stated in the facility policies and procedures. It was observed that the staff working the sink did not have knowledge of the temperatures required in the different sinks' compartments. It was requested that the concentration of sanitizer be taken on the third compartment and the concentration measurement higher than 600 ppm and the requirement is 200 ppm. Overuse of the sanitizing agent could be harmful.
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 review of Quality Assessment Performance Improvement ( QAPI) activities and interview with facility administrator (employee #1) performed on 05/13/24 through 05/15/24 from 8:00 AM till 4:30 P...
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Based on review of Quality Assessment Performance Improvement ( QAPI) activities and interview with facility administrator (employee #1) performed on 05/13/24 through 05/15/24 from 8:00 AM till 4:30 PM it was determined that facility failed to ensure the participation of all required members on the Quality Assessment Performance Improvement (QAPI) committee meetings.
Findings include:
1. During review of facility committee meetings of QAPI during year 2023 and the months of January 2024 and April 2024 the following was identified:
Upon review of facility rules and procedures related with QAPI program committee meeting activities last reviewed on July 15, 2016, it was identified that rule did not establish that the Infection Preventionist must participate in every QAPI committee meeting.
a. There is no evidence of participation of facility Infection Preventionist on QAPI committee meetings performed on April 19, 2023, July 20, 2023, October 25, 2023, January 30, 2024, and April 17, 2024.
b. During interview on 05/15/24 at 1:00 PM facility administrator (employee #1) stated that infection control officer gives her the infection control report and discuss with her relevant areas and is her as administrator who present the findings on the QAPI committee meetings.
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
Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 05/13/2024 through 05/15/2024 from 8:00 AM through 5:00 PM, it was determined...
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Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 05/13/2024 through 05/15/2024 from 8:00 AM through 5:00 PM, it was determined that the facility failed to maintain all patient care equipment in safe operating condition. This deficient practice had the potential to affect 21 out of 21 residents.
Findings include:
During observational tour the following was observed related with equipment in the facility:
1. 10 out of 15 wheelchairs in the Physical Therapy area were observed with rust.
2. 1 out of 2 walking canes in the Physical Therapy area were observed with rust.
3. 5 out of 10 walkers in the Physical Therapy area were observed with rust.
4. The parallel bars and steps showed rust in some of their parts.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
Based on observations of the physical environment and facility staff interview performed on 05/13/2024 through 05/15/2024 from 8:00 AM through 5:00 PM, it was determined that the facility failed to pr...
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Based on observations of the physical environment and facility staff interview performed on 05/13/2024 through 05/15/2024 from 8:00 AM through 5:00 PM, it was determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. This deficient practice had the potential to affect 21 out of 21 residents.
Findings include:
During observation tour with Safety Officer (employee #6) the following was observed:
1. Rust particulate in the air conditioner vents was observed in rooms #103, #104, #108, #117, #119
2. Excessive dust behind patients beds and closet doors on rooms #102, #108, # 112, # 113, #115, #117, #119, #120.
3. Peeling paint was observed in rooms #108 and #119
4.Water and humidity stains on ceiling tiles were observed in rooms #104, #107, #108, #114, #117, #118.
5. Bathroom curtain pole were found unsecured in 11 rooms, this represents a fall risk for residents.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 05/13...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 05/13/2024 through 05/15/2024 to from 8:00 AM through 5:00 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 21 out of 21 residents.
Findings include:
Loose handrail was observed in corridor in front of room [ROOM NUMBER] close to the corner.
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 kitchen and physical environment performed on 05/13/2024 through 05/15/2024 from 8:00 AM through 5:00 PM, it was determined that the facility failed maintain an effective ...
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Based on observations of the kitchen and physical environment performed on 05/13/2024 through 05/15/2024 from 8:00 AM through 5:00 PM, it was determined that the facility failed maintain an effective pest control program so that the facility is free of pests. This deficient practice had the potential to affect 21 out of 21 residents.
Findings include:
1. During the flash kitchen tour a live spider and spider webs were obvserved in the dry food storage.
2. Spiders were observed on the lightning fixtures in main corridor.
3. Spiders and spider webs were observed in residents rooms near glass windows leading to main corridor.
Apr 2023
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a recertification survey twelve records reviewed (R.R.), it was determined that the facility failed to ensure that the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a recertification survey twelve records reviewed (R.R.), it was determined that the facility failed to ensure that the Skilled Nursing Facility (SNF) personnel develop a baseline care plan within the first 48 hours of admission which provides instructions for the provision of effective and person-centered care to each resident. This deficiency affects 1 out of 12 record reviews. (Resident #70)
Findings include:
1. Resident #70 is an [AGE] year old male admitted on [DATE] with a diagnosis of deconditioning. admitted for rehabilitation with physical Therapy and Occupational Therapy.
During the record review performed on 04/05/23 at 11:39 AM, it was found that the Baseline Care Plan was left in blank only have the signature of the caregiver. No evidence was found related to the service that was provided, the goals, medication, nutritionist services that is going to have.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on recertification survey, review of twelve medical records, and interviews conducted 4/3/2023 to 4/5/2023 from 8:00AM to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on recertification survey, review of twelve medical records, and interviews conducted 4/3/2023 to 4/5/2023 from 8:00AM to 4:00PM, it was determined that the facility failed to ensure that the resident medication regimen was reviewed in accordance with policy. This deficient practice was identified in 1 out of 12 active cases (Resident Sample #66).
Findings include:
During the medical records on 04/03/2023 at 8:00AM to 4:00PM, it was observed the medication regimen review of each resident was not performed.
1.Resident Sample #66 is a [AGE] year-old male admitted on [DATE] with diagnosis of Descondition. During the record review performed on 04/03/2023 at 3:11PM provide evidence of physician orders and administer medication Xarelto 10 mg 1 tablet oral daily, Lasix 20 mg 1 tablet oral daily, Jardiace 10 mg 1 tablet oral daily, Neurontin 300 mg 1 tablet oral daily, Midodrine 10 mg 1 tablet oral every eight hours, Toprol XL 25 mg 1 tablet oral daily, Pepcid 20 mg 1 tablet oral daily and Colace 100 mg 1 tablet oral daily.
No evidence was found of the License Pharmacist performing a medication regimen since admmition on 3/29/2023 to assess the actual unnecessary medication therapy.
According to the facility Policy and Procedure; Date 6/23/2021: Number 15.23: Page 1of 1: Procedure 3. The Pharmacist will evaluate the patients during the first three days of the patients being admitted , giving priority to patient with intravenous therapies, patients with changes in drug therapy due to any complications and/or side effects; patients with opioids and anticoagulants; among others.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During the tour in the residents room from 10:00 AM to 12:00 PM, the following was observed:
a. On 4/4/2023 at 10:01 AM resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During the tour in the residents room from 10:00 AM to 12:00 PM, the following was observed:
a. On 4/4/2023 at 10:01 AM residents room [ROOM NUMBER], it was observed the emergency cable tied to the grab bar in the bathroom.
b. On 4/4/2023 At 10:05 AM the residents room [ROOM NUMBER], it was observed the toilet with black spots.
c. On 4/4/2023 at 10:25 AM the resident room [ROOM NUMBER]-A, it was observed stained floor.
d. On 4/4/2023 at 10 :45AM the resident room [ROOM NUMBER]-A, it was observed the bedding with food residues and dirty.
e. On 4/4/2023 at 11:02 AM the resident room [ROOM NUMBER]-A. it was observed that the part under the lamp did not work.
f. On 4/4/2023 at 11:08 AM the resident room [ROOM NUMBER]-C, it was observed in the upper part of the closet with a white and detached stain.
Based on a recertification survey, observations of the physical environment, review of policies procedures and facility staff interview performed on 04/03/2023 through 04/05/2023 to from 8:30 AM through 4:00 PM, it was determined that the facility failed to promote the resident right to receive services in a safe, clean, comfortable and homelike environment. This deficient practice could affects 22 out of 22 residents admitted receiving care at the facility.
Findings include:
1. During observation of facility it was noticed that a glass separation between recreation area and internal patio was removed on 04/04/23. Floor area was observed with irregular levels, this is a potential tripping fall risk far all residents.
2. During the observation tour in corridors leading to rooms, peeling paint on the ceiling was observed, due to humidity and percolation of water.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0924
(Tag F0924)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a recertification survey, observations, review of policies procedures performed on 04/03/2023 through 04/05/2023 to fro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a recertification survey, observations, review of policies procedures performed on 04/03/2023 through 04/05/2023 to from 8:30 AM through 4:00 PM, it was determined that the facility failed to firmly secured handrails on each side. This deficient practice affects 22 out of 22 residents admitted receiving at the facility.
Findings include:
Eight out of 28 loose handrails were noticed representing potencial fall risk in the following areas:
1. In front of room [ROOM NUMBER]
2. Next to door of room [ROOM NUMBER]
3. Corner in front of physical therapy
4. Front of room [ROOM NUMBER]
5. Front of rooms 103, 104, 105
6. Between 104/105
7. Right side of entry door of room [ROOM NUMBER]
8. Loose rail and missing corner cap next to room [ROOM NUMBER]
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected most or all residents
Based on recertification survey and interview with kitchen manager (employee #8) and clinical dietitian (employee #1) on 04/03/2023 through 04/05/2023 to from 8:30 AM through 4:00 PM, it was determine...
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Based on recertification survey and interview with kitchen manager (employee #8) and clinical dietitian (employee #1) on 04/03/2023 through 04/05/2023 to from 8:30 AM through 4:00 PM, it was determined that the facility failed to provide information related with the kitchen staffing pattern. This deficient practice had the potential to affects 22 out of 22 residents admitted receiving at the facility.
Findings include:
1. On 04/03/2022 at 3:50 PM during the recertification survey, the kitchen manager (employee #8) was asked by the surveyor to provide the kitchen staffing pattern, but this document was not provided.
Kitchen manager (employee #8) stated in an interview on 04/04/2023 at 3:50 PM that she does not have the staffing pattern calculation, and that they are not short of employees at that time.
The facility failed to provide the kitchen staffing pattern.
2. On 04/04/2022 at 11:50 AM the clinical dietitian (employee #1) provides a handwritten sheet of paper with the staff calculation of the kitchen staffing pattern.
Clinical dietitian (employee #1) stated on interview on 04/05/2023 at 11:55 AM that since facility contract an outside company to manage the kitchen ( 2-3 years ago) facility has not established who will be the responsible person that will carry out the staffing pattern calculation.
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
2. During a visual inspection it was observed that the area of the kitchen boilers the floor was cracked exposing bare concrete were water and soap accumulates, rust stains are also noted on the floor...
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2. During a visual inspection it was observed that the area of the kitchen boilers the floor was cracked exposing bare concrete were water and soap accumulates, rust stains are also noted on the floor.
Three compartment sink faucets did not close completely permiting water to continue flow, altering the chemical concentration for the desinfection of utenziles.
Based on a recertification survey, observations and facility staff interview performed on 04/03/2023 through 04/05/2023 to from 8:30 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 deficient practice affects 22 out of 22 residents admitted receiving services at the facility.
Findings include:
1. Ultra-High Temperature (UHT) milk boxes were observed stored at the kitchen area at the right side of the kitchen dishwashing area.
During an interview on 04/03/2023 at 3:30 PM kitchen manager (employee #8) stated that UHT milk was stored outside dry food storage area because in dry food storage area there is not enough space.
Dry food storage located inside the kitchen area is observed in need of cleaning and maintenance. The floor had tiles broken, air condition vents cover is incorrectly positioned, and entrance door does not closed properly and had chipped wood on the surface.
Windows located at the top area behind tray washing machine were observed in need of cleaning and maintenance.
The floor located under the 3-food steamer area is observed with dark greenish and yellow stains. This floor is made of cement does not have floor tiles and did not have a surface that can be easily cleaned.
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 a recertification survey, observations and facility staff interview performed on 04/03/2023 through 04/05/2023 to from 8:30 AM through 4:00 PM, it was determined that the facility failed to h...
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Based on a recertification survey, observations and facility staff interview performed on 04/03/2023 through 04/05/2023 to from 8:30 AM through 4:00 PM, it was determined that the facility failed to have in place a policy regarding use and storage of food brought to residents by family and other visitors to assure safe and sanitary storage and handling before consumption was not performed. This deficient practice affects 22 out of 22 residents admitted receiving at the facility.
Findings include:
1.Policies and procedures were requested by the surveyor on 04/05/2023 at 10:39 AM for food brought to residents by family and other visitors. to assure safe and sanitary storage and handling before consumption was
Nursing supervisor (employee #9) stated on interview on 04/05/2023 at 10:39 AM that if a resident, resident relative or visitor brings food or drink items, the nursing personnel were instructed to put the item in a plastic zip lock bag with residents' name and room number and store in a refrigerator located behind the nursing station.
She also stated that once the food or drink item is stored on a daily basis the nursing personnel advise the resident regarding the food or drink item's availability. Food and drink items are reviewed on an ongoing basis to ensure consistency and expiration date. If food or drink item expires or consistency is compromised nursing personnel inform the resident before discarding the item.
The Licensed clinical dietitian (employee #1) also stated in an interview on 04/05/2023 at 1:10 PM that no policy or procedure is established to guide the process to follow when food or drink items are brought by resident family members or visitors.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Three spare regular washing machines were observed in need of maintenance. They presented rust in the top covering part. The ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Three spare regular washing machines were observed in need of maintenance. They presented rust in the top covering part. The surveyors were told these machines are used as spares when main washing machines break.
The surveyor entered a room habilitated as an office, upon entry a wood board was observed laying on the floor, when the safety officer was asked, he stated that underneath the wood panel lied the washing main drainpipe. When lifted for inspection some cockroaches were observed.
Five fire extinguishers were observed on the floor near the entrance of the folding room. They were not fastened to any wall nor had any stand for sturdiness.
The men's bathroom was habilitated as linen (Curtains) warehouse.
4. Kitchen
During observation of the three compartments sink during sanitation process, temperature of water was not measured in accordance to due process this represents a mismanagement of procedures and represents a health risk for patients.
During observation of the kitchen cleaning chemical warehouse room, it was found opened with no lock and observed black mold spots on walls and ceiling. Kitchen equipment (Baking pans) were found inside cardboard box exposed to water and humidity.
Based on a recertification survey, observations, review of policies procedures and facility staff interview performed on 04/03/2023 through 04/05/2023 to from 8:30 AM through 4:00 PM, 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 related to lack of handwashing procedures implementation before the use of gloves and failure to provide clean and safe environment at the linen washing and drying laundry area. This deficient practice affects 22 out of 22 residents admitted receiving at the facility.
Findings include:
1. On 04/03/2023 at 11:59 AM the following was observed when a kitchen personnel (employee #3 and employee #4) provide the lunch tray during dining procedures observations:
a. kitchen personnel (employee #3) were observed giving residents lunch trays in rooms 113 through room [ROOM NUMBER]. This employee puts on a new pair of gloves every time she is going to provide a lunch tray to a resident. After she delivered the lunch tray to the resident, she discarded gloves and without performing handwashing she put a new pair of gloves and proceeded to provide the lunch tray to another resident in another room.
b. kitchen personnel (employee #4) was observed giving residents lunch trays in rooms 101 through room [ROOM NUMBER]. This employee puts on a new pair of gloves every time she is going to provide a lunch tray to a patient. After she deliver the lunch tray to the resident, she discards gloves and without perform handwashing she put a new pair of gloves and proceed to provide the lunch tray to another resident on another room.
c. During interview on 04/03/2023 at 3:30 PM (employee #8) kitchen manager stated that personnel that provide lunch trays to residents are instructed to use gloves when providing lunch trays to residents. She also stated that these personnel are instructed to perform hand washing with soap and water or the use of hand sanitizer when changing gloves and between residents' rooms.
2. On 04/04/2023 at 9:00 AM the following was observed at the linen washing and drying laundry area:
a. Proper maintenance is not provided to the physical environment and physical plant where facility wash and dry linens. The physical condition in which the environment of the linen washing and drying laundry area has the potential to affect the handling, storage and processing the linens.
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
Based on a recertification survey, observations performed on 04/03/2023 through 04/05/2023 to from 8:30 AM through 4:00 PM, it was determined that the facility failed to maintain all patient care equi...
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Based on a recertification survey, observations performed on 04/03/2023 through 04/05/2023 to from 8:30 AM through 4:00 PM, it was determined that the facility failed to maintain all patient care equipment in safe operating condition. This deficient practice affects 22 out of 22 residents admitted receiving at the facility.
Findings include:
1. During a visual inspection of the equipment in the physical therapy area, it was observed that of 19 wheelchairs observed, 12 of these had peeling paint and signs of rust, three of them had duct tape on the arm rests.
It was also observed that of 21 walkers available, 14 of them showed signs of rust and wear and tear.
Of 3 canes observed, two of them were observed with signs of rust.
2. Kitchen
During initial brief tour performed on 04/03/2023 and follow up visit performed on 04/04/2023 to the kitchen, four ovens were observed with out of order sings, an additional electric oven also was rotulated as out of service.
Evaluation of the use of the three-compartment sink was carried out, the PPM test was carried out for the chemical sanitation compartment and the consentration levels were out of range (300 PPM). This implies that the chemical sanitation process is done incorrectly. Also the temperature of water was not measured in acordance to due process.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a recertification survey, observations, review of policies procedures performed on 04/03/2023 through 04/05/2023 to fro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a recertification survey, observations, review of policies procedures performed on 04/03/2023 through 04/05/2023 to from 8:30 AM through 4:00 PM, it was determined that the facility failed to promote the resident right to receive services in a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. This deficient practice affects 22 out of 22 residents admitted receiving at the facility.
Findings include:
a. During observation inspection with Safety Officer (employee #6 ) a connected line water heater was observed connected an functioning on the men's bathroom of the physical therapy area. The electrical equipment was placed on the floor unattached to the wall and right next to the bathroom sink exposing it to be in contact to falling water. This is a potential risk to patients and staff. Acoustic tile When asked the Safety Officer replied that he did not have knowledge of the precedence of the equipment.
b. During visual inspection of patients sleeping rooms water stains were observed in the ceiling tiles: Rooms #104, #105, #116, #118.
c. During visual inspection in the corridor area it was noticed that a ceiling tile in front of the physical therapy area was missing, and exposed cables were seen unprotected.
d. During visual inspection of patients sleeping rooms the closet door either did not close properly or presented damaged wood parts: Rooms #101, #105, #110, # 116
e. During visual inspection of patients' sleeping rooms: room [ROOM NUMBER] a hand washing station located next to closet door affecting the integrity of wood and causing water damage and humidity accumulation.
f. During visual inspection in the corridor area, water drop stains on walls and flaking paint was observed on the ceiling due to water percolation.
g. During visual inspection of patients sleeping rooms aisle ceiling lamps hand defective bulbs.
Rooms: #109, #111, #117.
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 a recertification survey, observations, and review of policies procedures and pest control documents on 04/03/2023 through 04/05/2023 to from 8:30 AM through 4:00 PM, it was determined that t...
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Based on a recertification survey, observations, and review of policies procedures and pest control documents on 04/03/2023 through 04/05/2023 to from 8:30 AM through 4:00 PM, it was determined that the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents. This deficient practice affects 22 out of 22 residents admitted receiving at the facility.
Fndings include:
1. During visual inspection of the facility a two bulb UV light insect machine was observed with only one of the bulb functioning.
2. During visual inspection of the facility outside corridors were observed with spiderwebs and spiders between the upper part of walls and acustic ceiling tiles.
Evidence of pest control was requested by surveyors, administrator first provided a in house log of fumigator visits to facility, surveyor solicited a breakdown of services rendered by company and materials used in visit and administration could not provide this information. Administrator informed they will ask for breakdown of service from now on. No licence number of supplier was noticed in documnets provided.
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.
- • 8% annual turnover. Excellent stability, 40 points below Puerto Rico's 48% average. Staff who stay learn residents' needs.
Concerns
- • 41 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.
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About This Facility
What is Ryder Memorial Hospital Inc's CMS Rating?
CMS assigns RYDER MEMORIAL HOSPITAL INC an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Puerto Rico, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Ryder Memorial Hospital Inc Staffed?
CMS rates RYDER MEMORIAL HOSPITAL INC's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 8%, compared to the Puerto Rico average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Ryder Memorial Hospital Inc?
State health inspectors documented 41 deficiencies at RYDER MEMORIAL HOSPITAL INC during 2023 to 2025. These included: 41 with potential for harm.
Who Owns and Operates Ryder Memorial Hospital Inc?
RYDER MEMORIAL HOSPITAL INC 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 62 certified beds and approximately 27 residents (about 44% occupancy), it is a smaller facility located in HUMACAO, Puerto Rico.
How Does Ryder Memorial Hospital Inc Compare to Other Puerto Rico Nursing Homes?
Compared to the 100 nursing homes in Puerto Rico, RYDER MEMORIAL HOSPITAL INC's overall rating (4 stars) is above the state average of 3.5, staff turnover (8%) is significantly lower than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Ryder Memorial Hospital 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 Ryder Memorial Hospital Inc Safe?
Based on CMS inspection data, RYDER MEMORIAL HOSPITAL 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 4-star overall rating and ranks #1 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 Ryder Memorial Hospital Inc Stick Around?
Staff at RYDER MEMORIAL HOSPITAL INC tend to stick around. With a turnover rate of 8%, the facility is 38 percentage points below the Puerto Rico average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 12%, meaning experienced RNs are available to handle complex medical needs.
Was Ryder Memorial Hospital Inc Ever Fined?
RYDER MEMORIAL HOSPITAL 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 Ryder Memorial Hospital Inc on Any Federal Watch List?
RYDER MEMORIAL HOSPITAL 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.