MULTY MEDICAL SKILLED NURSING FACILITY

AMERICO MIRANDA AVE ENTRADA PRINCIPAL CENTRO, RIO PIEDRAS, PR 00935 (787) 754-0194
For profit - Corporation 35 Beds Independent Data: November 2025
Trust Grade
40/100
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Last Inspection: September 2024

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

Overview

Multy Medical Skilled Nursing Facility in Rio Piedras, Puerto Rico has a Trust Grade of D, which means it is below average and has some concerning issues. It currently ranks #None of None in Puerto Rico and #None of None in San Juan County, indicating that there are no other facilities to compare it to in the area. The facility is new with its first inspection on record, which revealed a total of 69 issues, including 51 concerns that could potentially harm residents. Staffing appears to be a strength, with a turnover rate of 0%, which is well below the Puerto Rico average, and no fines have been recorded. However, the facility has been cited for failing to ensure compliance with resident rights, such as not having personnel assigned to monitor these rights and not providing necessary documentation when requested. Overall, while staffing is stable, the significant number of concerns raises red flags for potential residents and their families.

Trust Score
D
40/100
In Puerto Rico
#112/223
Top 50%
Safety Record
Low Risk
No red flags
Inspections
Too New
0 → 69 violations
Staff Stability
○ Average
Turnover data not reported for this facility.
Penalties
✓ Good
No fines on record. Clean compliance history, better than most Puerto Rico facilities.
Skilled Nurses
○ Average
RN staffing data not reported for this facility.
Violations
⚠ Watch
69 deficiencies on record. Higher than average. Multiple issues found across inspections.
☆☆☆☆☆
0.0
Overall Rating
☆☆☆☆☆
0.0
Staff Levels
☆☆☆☆☆
0.0
Care Quality
☆☆☆☆☆
0.0
Inspection Score
↔
Stable
: 0 issues
2024: 69 issues

The Good

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

Facility shows strength in fire safety.

The Bad

No Significant Concerns Identified

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

The Ugly 69 deficiencies on record

Sept 2024 69 deficiencies
CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on nine records reviewed on 09/24/2024 at 9:00 AM to 12:00 PM, it was determined that the facility failed to ensure the ri...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on nine records reviewed on 09/24/2024 at 9:00 AM to 12:00 PM, it was determined that the facility failed to ensure the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive 1 out of 9 records reviewed. (R.R # 102). Findings include: 1. During the evaluation of the records review on 09/24/2024 at 10:05 AM, the following was found: a. R.R #102 is a [AGE] year-old female admitted on [DATE] for left total hip replacement. Noted in the record review on 09/24/2024 at 10:08 AM, no Advance Directive sheet was found. The facility failed to establish in writing the right of residents to formulate advance directives, including the right to accept or refuse medical or surgical treatment, and to ensure that staff follow such policies and procedures.
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 observations, records reviewed (RR), staff interview and review of policies and procedures performed during the survey ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, records reviewed (RR), staff interview and review of policies and procedures performed during the survey process from 09/24/2024 thru 09/25/2024 from 8:30 AM thru 4:30 PM, it was determined that the facility failed to provide the resident and their representative with a summary of the baseline care plan within 48 hours of the resident's admission This deficient practice was identified in 1 out of 8 residents receiving services at the facility (RR #51). Findings include: 1. RR# 51 is [AGE] year-old female resident admitted on [DATE] with a diagnosis of General Weakness after a Cerebro Vascular Accident, Hyperlipidemia, Coronary Artery Disease and Chronic Kidney Disease Stage 4. Initial pool process was performed on 09/25/24 from 8:45 AM through 10:00 AM on the first day of the survey, screening residents, to identify the resident sample pool and seeking information related with choices residents have with regard to their daily life, any activities they partake in, and other issues revolving around dignity, abuse, resident-to-resident interaction, privacy, the accommodation of physical needs, and staffing levels. On this initial pool process the surveyor asked the resident if a written copy of the baseline care plan was provide to her after admission, RR #51 stated on interview that no copy of the baseline care plan was provide to her after admission, she stated that she receive verbal information related with the treatment and services that she is going to receive while was admitted to the facility, but no written copy of the baseline care plan was provide to her after admission. Review of the medical record on 09/25/2024 at 10:39 AM with nursing personnel (employee #7) evidence that verbal information related to the treatment and services that resident is going to receive while was admitted to the facility, was provided but no written copy of the baseline care plan was provided. No copy of the baseline care plan developed and implemented was found filed as part of the medical record of this resident.
CONCERN (E)

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

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected multiple residents

Based on observations, review of policies procedures and interview with infection control officer (employee # 1), performed during the survey process from 09/24/2024 through 09/25/2024 from 8:30 AM th...

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Based on observations, review of policies procedures and interview with infection control officer (employee # 1), performed during the survey process from 09/24/2024 through 09/25/2024 from 8:30 AM through 4:30 PM , it was determined that facility failed to develop and implement policies, procedures and structure to comply with Influenza and pneumococcal immunizations. Findings include: During interview on 09/25/2024 at 9:35 AM the infection control officer (employee #1) stated the following in relation to the compliance of the facility with influenza and pneumococcus immunizations: 1. Facility did not have available Influenza vaccines. 2. Facility did not have available Pneumococcus vaccines. 3. The facility did not present policies and procedures developed and implemented to ensure their residents and staff have been educated and offered vaccines for potentially respiratory preventable diseases. 4. Facility had not have any contract or agreement with another entity to make available influenza and pneumococcus vaccines and to vaccinate the residents if they want to receive the vaccine. 5. No mechanism had been implemented since July, 2024 of natural year 2024 when facility begun to offer services at the Skilled Nursing Facility (SNF) to residents for screening influenza and pneumococcal vaccination status. The medical record did not include documentation that indicates that the resident or resident representative was provided education with influenza and pneumococcus virus and vaccination. 6. No mechanism had been implemented since July of natural year 2024 when facility begun to offer services at the SNF to ensure every resident and staff member is offered the influenza and pneumococcus vaccine unless the immunization is medically contraindicated, or staff member and residents has already been immunized or refuse to be immunized.
CONCERN (F)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with resident right and Exercise of right. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident rights and Exercise facility policy and procedure Manual was requested to the facility on [DATE] at 10:00 AM and no evidence was provided. The facility provides different policy and procedure related to resident right that was in English language only as: a. Policy #4000 Resident Care policies that were in the administrative Manual. b. Policy #4005 Resident Right policies, 2 pages that were in the administrative Manual. c. Policy #4010 Access Visiting policies 3 pages that was in the administrative Manual, that covers the different tags F563, F564 and F565. d. Policy #4015, 4015.1, 4015.3, 4015.4 Elder / Dependent Adult Abuse policies 9 pages that was in the administrative Manual and was and interpretation of the State Operation Manual.483.12 (b, c) and 483.75 and do not have purpose and policy. e. Policy #4025 Facility Rules and Information that was not a policies 90 pages that was in the administrative Manual, that cover the different tag F551, F555, F557, F567, F568, F569, 570, 571, F576, F578, F585, F604, F605 F606 and F621, F625 and do not have update hot line number. f. Policy #4030 Informed Consent- Psychotherapeutic Medications and Restraint Device policies 10 pages that were in the administrative Manual and was and interpretation of the State Operation Manual 483.10 (c, e). g. Policy #4032 Civil Rights Review policies 2 pages that was in the administrative Manual. h. Policy #4040 Restraint-Physical Policies 10 pages that was in the administrative Manual and was and interpretation of the State Operation Manual.483.12 (a). i. Policy #4041 Restraint-Psychotropics Drug policies 4 pages that was in the administrative Manual and was and interpretation of the State Operation Manual.483.12 (a) and 483.45 (e) (1). j. This sheet provides to the resident the form to perform a complaint however, the Department of Health Assistant Secretary for Public Health Regulation Secretaria Auxiliar para la Regulación de la [NAME] Pública (SARSP) the address and telephone was not updated.
CONCERN (F)

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

Deficiency F0553 (Tag F0553)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility faile...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident has the right to be informed of and participate in his or her treatment. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right to participate in the planning care facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.
CONCERN (F)

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

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility faile...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the residents' right to self-administer medications if the interdisciplinary team has determined that this practice is clinically appropriate. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The resident right to self-administer medications facility policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
CONCERN (F)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility faile...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident has the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: The resident right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences facility policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
CONCERN (F)

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

Deficiency F0559 (Tag F0559)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility faile...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the residents' right to share a room with his or her spouse, share a room with his or her roommate of choice when practicable and receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident has the right to share a room with his or her spouse, share a room with his or her roommate of choice when practicable facility policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
CONCERN (F)

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

Deficiency F0560 (Tag F0560)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident rights to refuse to transfer to another room in the facility. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. The resident right to refuse to transfer to another room facility policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
CONCERN (F)

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

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to comply with the resident right promote and facilitate resident self-determination through support of resident choice. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. The resident right to promote and facilitate resident self-determination through support of resident choice facility policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
CONCERN (F)

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

Deficiency F0562 (Tag F0562)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident right to immedi...

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Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident right to immediate access to any representative of the State, to resident's individual physician, to any representative of the protection and advocacy systems. Findings include: During the survey process it was requested to the facility the resident's rights manual, and it was found the following: 1. The residents right to immediate access to any representative of the State, to resident's individual physician, to any representative of the protection and advocacy systems policies and procedures were requested to the facility Administrator (employee #3). As part of the Resident Right structure facility present on 09/25/2024 at 11:55 AM policies and procedures written in English. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with resident right to be provided to residents. The policies and procedures do not include the date when each policy was created or the approval of the governing body. 2. The resident right to immediate access to any representative of the State, to resident's individual physician, to any representative of the protection and advocacy systems policies and procedures did not include key elements in the policy to ensure clarity and effectiveness like policy purpose and scope, responsibilities and roles of department involved in implementing and enforcing the policy.
CONCERN (F)

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

Deficiency F0563 (Tag F0563)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that the facility failed to establish the structure to comply with the resident right to re...

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Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that the facility failed to establish the structure to comply with the resident right to receive visitors of his or her choosing at the time of his or her choosing Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The resident has the right to receive visitors of his or her choosing at the time of his or her choosing, policies and procedure were requested to the facility Administrator (employee #3). As part of the Resident Right structure facility present on 09/25/2024 at 11:55 AM policies and procedures written in English. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with resident right to be provided to residents. The policies and procedures do not include the date when each policy was created or the approval of the governing body. 2. The resident's right to receive visitors of his or her choosing at the time of his or her choosing policies and procedures did not include key elements in the policy to ensure clarity and effectiveness like policy purpose and scope, responsibilities and roles of department involved in implementing and enforcing the policy.
CONCERN (F)

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

Deficiency F0564 (Tag F0564)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident right to be inf...

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Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident right to be informed of his or her visitation rights and equal visitation privileges. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The resident right to be informed of his or her visitation rights and equal visitation privileges policies and procedure were requested to the facility Administrator (employee #3). As part of the Resident Right structure facility present on 09/25/2024 at 11:55 AM policies and procedures written in English. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with resident right to be provided to residents. The policies and procedures do not include the date when each policy was created or the approval of the governing body. 2. The resident's right to be informed of his or her visitation rights and equal visitation privileges policies and procedures did not include key elements in the policy to ensure clarity and effectiveness like policy purpose and scope, responsibilities and roles of department involved in implementing and enforcing the policy.
CONCERN (F)

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

Deficiency F0565 (Tag F0565)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident right to organi...

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Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident right to organize and participate in resident groups in the facility. Findings include: During the survey process it was requested to the facility the resident right manual and it was found the following: 1. The resident right to organize and participate in resident groups in the facility policies and procedure were requested to the facility Administrator (employee #3). As part of the Resident Right structure facility present on 09/25/2024 at 11:55 AM policies and procedures written in English. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with resident right to be provided to residents. The policies and procedures do not include the date when each policy was created or the approval of the governing body. 2. The resident right to organize and participate in resident groups in the facility policies and procedures did not include key elements in the policy to ensure clarity and effectiveness like policy purpose and scope, responsibilities and roles of department involved in implementing and enforcing the policy.
CONCERN (F)

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

Deficiency F0566 (Tag F0566)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility faile...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident has the right to choose or refuse to perform services for the facility. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The resident right to choose or refuse to perform services for the facility policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
CONCERN (F)

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

Deficiency F0567 (Tag F0567)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility faile...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident has the right to manage his or her financial affairs. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The resident right to manage his or her financial affairs policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
CONCERN (F)

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

Deficiency F0572 (Tag F0572)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility faile...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident has the right to be informed of his or her rights and of all rules and regulations governing resident conduct and responsibilities during his or her stay in the facility. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The resident right to be informed of his or her rights and of all rules and regulations governing resident conduct and responsibilities during his or her stay in the facility policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
CONCERN (F)

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

Deficiency F0573 (Tag F0573)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility faile...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident has the right to access personal and medical records pertaining to him or herself. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The resident right to access personal and medical records pertaining to him or herself policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
CONCERN (F)

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

Deficiency F0574 (Tag F0574)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility faile...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
CONCERN (F)

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

Deficiency F0575 (Tag F0575)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility faile...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident has the right that the facility post, in a form and manner accessible and understandable to residents, at list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. During the tour to the facility 09/24/2024 at 9:15 AM, no evidence was observed that the facility post, in a form and manner accessible and understandable to residents, at list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups 2. The residents have the right to be inform in a form and manner accessible and understandable to residents, resident representatives of a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
CONCERN (F)

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

Deficiency F0577 (Tag F0577)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility faile...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident has the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The resident right to Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
CONCERN (F)

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

Deficiency F0579 (Tag F0579)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility faile...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident has the right to display in the facility written information, and provide to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The resident right to the facility displays inwritten information, and provides to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
CONCERN (F)

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility faile...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the residents has the right to notify changes. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The resident right to notification of changes policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
CONCERN (F)

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

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility faile...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the residents has the right to be Inform in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The resident right to be informed in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
CONCERN (F)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility faile...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the residents has the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The resident right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
CONCERN (F)

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

Deficiency F0586 (Tag F0586)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility faile...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the residents have the right to contact with external entities. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The resident right to contact external entities policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
CONCERN (F)

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident right to be fre...

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Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident right to be free from Abuse, Neglect. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The facility Elder/ Dependent Adult abuse #4015, State Operation Manual Guidance- Abuse and Neglect #4015.1, Abuse Reporting/posting #4015.3 and Abuse and Neglect -Definition #4015.4 policy and procedure provided by the facility Administrator (employee #3) on 09/25/2024 at 11:55 AM. As part of the Resident Right structure facility present policies and procedures written in English base on the State operations Manual. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with resident rights and be provided to residents. The policies and procedures do not include the date when each policy was created or the approval of the governing body. 2. The resident right to be free from Abuse, Neglect policies and procedures did not include key elements in the policy to ensure clarity and effectiveness like policy purpose and scope, responsibilities and roles of department involved in implementing and enforcing the policy. 3. No evidence was provided related to personnel training related to abuse and neglect.
CONCERN (F)

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

Deficiency F0602 (Tag F0602)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident right to be fre...

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Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident right to be free from Abuse, Neglect, misappropriation of resident property, and exploitation. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The facility Elder/ Dependent Adult abuse #4015, State Operation Manual Guidance- Abuse and Neglect #4015.1, Abuse Reporting/posting #4015.3 and Abuse and Neglect -Definition #4015.4 policy and procedure provided by the facility Administrator (employee #3) on 09/25/2024 at 11:55 AM. As part of the Resident Right structure facility present policies and procedures written in English base on the State operations Manual. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with resident rights and be provided to residents. The policies and procedures do not include the date when each policy was created or the approval of the governing body. 2. The resident right to be free from Abuse, Neglect, misappropriation of resident property, and exploitation policies and procedures did not include key elements in the policy to ensure clarity and effectiveness like policy purpose and scope, responsibilities and roles of department involved in implementing and enforcing the policy. 3. No evidence was provided related to personnel training related to abuse and neglect.
CONCERN (F)

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

Deficiency F0603 (Tag F0603)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident right to be fre...

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Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident right to be free from Abuse, Neglect, misappropriation of resident property, and exploitation or involuntary seclusion. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The facility Elder/ Dependent Adult abuse #4015, State Operation Manual Guidance- Abuse and Neglect #4015.1, Abuse Reporting/posting #4015.3 and Abuse and Neglect -Definition -Definition 4015.4 policies and procedure provided by the facility Administrator (employee #3) on 09/25/2024 at 11:55 AM. As part of the Resident Right structure facility present policies and procedures written in English base on the State operations Manual. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with residents' rights and be provided to residents. The policies and procedures do not include the date when each policy was created or the approval of the governing body. 2. The resident right to be free from Abuse, Neglect, misappropriation of resident property, and exploitation or involuntary seclusion policies and procedures did not include key elements in the policy to ensure clarity and effectiveness like policy purpose and scope, responsibilities and roles of department involved in implementing and enforcing the policy. 3. No evidence was provided related to personnel training related to abuse and neglect
CONCERN (F)

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

Deficiency F0604 (Tag F0604)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident's right to be f...

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Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident's right to be free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The facility Restraint -Physical, 4040 policies and procedure provided by the facility Administrator (employee #3) on 09/25/2024 at 10:55 AM. As part of the Resident Right structure facility present policies and procedures written in English base on the State operations Manual. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with resident rights and be provided to residents. The policies and procedures do not include the date when each policy was created or the approval of the governing body. 2. The resident right to be free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms policies and procedures did not include key elements in the policy to ensure clarity and effectiveness like policy purpose and scope, responsibilities and roles of department involved in implementing and enforcing the policy. 3. No evidence was provided related to personnel training related to Restraint.
CONCERN (F)

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

Deficiency F0605 (Tag F0605)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident's right to be f...

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Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident's right to be free from chemicals restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms that can affect 8 out of 8 admitted residents. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The facility Restraint -Psychotropic Drug #4041 policies and procedure provided by the facility Administrator (employee #3) on 09/25/2024 at 10:55 AM. As part of the Resident Right structure facility present policies and procedures written in English base on the State operations Manual. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with residents' rights and be provided to residents. The policies and procedures do not include the date when each policy was created or the approval of the governing body. 2. The resident right to be free from chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms policies and procedures did not include key elements in the policy to ensure clarity and effectiveness like policy purpose and scope, responsibilities and roles of department involved in implementing and enforcing the policy. 3. No evidence was provided related to personnel training related to abuse and neglect.
CONCERN (F)

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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that the facility failed to develop and implement written policies and procedures that proh...

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Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, including training to the personnel. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The facility Elder/ Dependent Adult abuse #4015, State Operation Manual Guidance- Abuse and Neglect #4015.1, Abuse Reporting/posting #4015.3 and Abuse and Neglect -Definition #4015.4 policies and procedure provided by the facility Administrator (employee #3) on 09/25/2024 at 10:55 AM. As part of the Resident Right structure facility present policies and procedures written in English base on the State operations Manual. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with resident rights and be provided to residents. The policies and procedures do not include the date when each policy was created or the approval of the governing body. 2. The resident right to be free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms policies and procedures did not include key elements in the policy to ensure clarity and effectiveness like policy purpose and scope, responsibilities and roles of department involved in implementing and enforcing the policy. 3. No evidence was provided related to personnel training related to abuse and neglect.
CONCERN (F)

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected most or all residents

Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to ensure that all alleged violations are thoroughly investigated, and...

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Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to ensure that all alleged violations are thoroughly investigated, and prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The facility Elder/ Dependent Adult abuse #4015, State Operation Manual Guidance- Abuse and Neglect #4015.1, Abuse Reporting/posting #4015.3 and Abuse and Neglect -Definition #4015.4 and Unusual Occurrence Reporting #4021policie and procedure provided by the facility Administrator (employee #3) on 09/25/2024 at 10:55 AM. As part of the Resident Right structure facility present policies and procedures written in English base on the State operations Manual. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with resident rights and be provided to residents. The policies and procedures do not include the date when each policy was created or the approval of the governing body. 2. Facility policies and procedures did not include key elements in the policy to ensure clarity and effectiveness like policy purpose and scope, responsibilities and roles of department involved in implementing and enforcing the policy.
CONCERN (F)

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

Deficiency F0620 (Tag F0620)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility faile...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the Admissions policy. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The facility admissions policy and procedure were requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
CONCERN (F)

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

Transfer Requirements (Tag F0622)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility faile...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the Transfer and discharge. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The facility Transfer and discharge policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
CONCERN (F)

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility faile...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the Notice before transfer. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The facility Notice before transfer policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
CONCERN (F)

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

Deficiency F0624 (Tag F0624)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility faile...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the Orientation for transfer or discharge. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The facility Orientation for transfer or discharge policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
CONCERN (F)

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

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility faile...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the Notice of bed-hold policy and return. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The facility Notice of bed-hold policy and return policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
CONCERN (F)

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

Safe Transfer (Tag F0626)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility faile...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the Permitting residents to return to facility. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The facility Permitting residents to return to facility policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.
CONCERN (F)

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

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

Based on interviews with the Director of Nursing (DON) (employee #6) and Human Resources Officer (employee #5), on 09/24/2024 through 09/25/2024 at 9:00 AM through 4:00 PM, it was determined that the ...

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Based on interviews with the Director of Nursing (DON) (employee #6) and Human Resources Officer (employee #5), on 09/24/2024 through 09/25/2024 at 9:00 AM through 4:00 PM, it was determined that the facility failed to ensure to appoint the services of a full-time Director of Nursing. Findings include: 1. During the interview with the DON (employee #6) on 09/24/2024 at 1:30 PM, she stated that two weeks ago she had been promoted to director of nursing, previously she was a nursing supervisor. 2. The Human Resources Officer (employee #5) on 09/24/2024 at 2:57 PM was interviewed and stated that the employee had been appointed DON, the employee's file was reviewed, and it was noted that she had not been appointed DON, but nursing supervisor on 01/17/2024. The facility failed to designate a registered nurse (RN) to act as a full-time DON.
CONCERN (F)

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

Deficiency F0740 (Tag F0740)

Could have caused harm · This affected most or all residents

Based on observations, staff interview and review of policies and procedures performed during the survey process from 09/24/2024 thru 09/25/2024 from 8:30 AM thru 4:30 PM, it was determined that the f...

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Based on observations, staff interview and review of policies and procedures performed during the survey process from 09/24/2024 thru 09/25/2024 from 8:30 AM thru 4:30 PM, it was determined that the facility failed to demonstrate that has an organized behavioral health care and services program, to promote the maintenance of highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care to residents with mental and substance use disorders. Findings include: 1. On survey procedures behavioral health care and services program policies and procedures were requested to the facility Administrator (employee #3). As part of the behavioral health care and services program structure facility present on 09/25/2024 at 3:55 PM policies and procedures written in English. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with behavioral health care services to be provided to residents. The policies and procedures do not include the date when each policy was created or the approval of the governing body. 2. Behavioral health care and services program policies and procedures did not include key elements in the policy to ensure clarity and effectiveness like policy purpose and scope, responsibilities and roles of department involved in implementing and enforcing the policy. 3. Policy and procedure did not have the core or essence and did not clearly describe how the behavioral services are going to be provided by the facility; accordingly, to issues related with mental and substance use disorders, if any presented by residents.
CONCERN (F)

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

Deficiency F0741 (Tag F0741)

Could have caused harm · This affected most or all residents

Based on observations, staff interview and review of policies and procedures performed during the survey process from 09/24/2024 thru 09/25/2024 from 8:30 AM thru 4:30 PM, it was determined that the f...

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Based on observations, staff interview and review of policies and procedures performed during the survey process from 09/24/2024 thru 09/25/2024 from 8:30 AM thru 4:30 PM, it was determined that the facility failed to demonstrate that has an organized program with sufficient staff assigned to provide direct services to residents to promote the maintenance of highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care to resident's with mental and substance use disorders. Findings include: 1. On survey procedures behavioral health care and services program contract with a psychiatrist was presented by the facility Administrator (employee #3) on 09/25/2024 at 3:55 PM. 2. Psychiatrist contract was presented by facility Administrator (employee #3) on 09/25/2024 at 11:00 AM to comply with provisions §483.40 Behavioral Health program, including general information related to contractual agreement with a psychiatrist. 3. Facility did not present information related to the mechanism to be implemented if a resident need services from a psychologist, counselor or how the facility plans to have the staff needed to offer those services. 4. Facility administrator (employee #3) explains on 09/25/2024 at 4:00 PM that the facility develops policies and procedures to implement a Behavioral health services program, in a manner that if services are needed, the resident is going to be transferred to a psychiatric facility rather than provide services at the facility. 5. Facility failed to demonstrate that it has available all resources to assist residents on promoting and managing behavioral health services while receiving services.
CONCERN (F)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R.R #52 is a [AGE] year-old female admitted on [DATE] for Left total hip replacement. Review record on 09/24/2024 at 9:03 AM,...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R.R #52 is a [AGE] year-old female admitted on [DATE] for Left total hip replacement. Review record on 09/24/2024 at 9:03 AM, it was found that he is using Elequis 2.5 mg one tablet twice daily (BID) per physician's order. The medication regimen documented by the pharmacy staff was not found in the medical record. 3. R.R # 102 is a [AGE] year-old female admitted on [DATE]f for Right total replacement. Review record on 09/24/2024 at 10:08 AM, it was found that the medication regiment documented by the pharmacy staff was not found in the medical record. The facility failed to ensure that the pharmacy staff performed the medication regimen with the objective of minimizing adverse consequences and potential risks associated with the medications. 4. Resident #51 is a [AGE] years old female admitted to the facility on [DATE] with a diagnosis of Lumbar interbody Fusion. During record review performed on 09/24/24 02:41 PM, no evidence was found that the pharmacist performed the medication regimen review (MRR). During interview with the SNF pharmacist employee #10 on 09/24/2024 at 3:00 pm she state that did not know about medication regimen review and did not give precise information in relation with policy and procedure for the MRR. Based on observations, staff interview and review of policies and procedures performed during the survey process from 09/24/2024 thru 09/25/2024 from 8:30 AM thru 4:30 PM, it was determined that the facility failed to review resident drug regimen review, identify irregularities that requires actions to protect the resident, to promote the highest practical well-being and to prevent or minimizes adverse consequences related to the medication therapy in 5 out of 8 residents receiving services at the facility (resident sample #51, #52, #101, #102 and #201). Findings include: 1. A mechanism to ensure that facility provides oversight of each resident medication regimen review to improve condition, reduce risks or decline in status were not promoted, not performed accordingly with the following findings: a. Resident #101 is [AGE] years old female resident was admitted on [DATE] with a diagnosis of Right Ischemic Cerebrovascular Accident. Review of resident medical record on 09/24/2024 at 2:45 PM revealed that resident had order for Insulin Lantus subcutaneous 100 units at bedtime and Eliquis 5 mgs PO BID since 09/23/2024 when was admitted to the facility. A medication review performed by the pharmacist to identify if there any irregularities related to the medication regimen were not found documented on the medical record. Information related to medication regimen review was requested to the Pharmacist (employee #10) on 09/24/2024 at 3:15 PM. Pharmacist (employee #11) stated on interview on 09/24/2024 at 3:20 PM that the resident did not have a medication regimen review. b. Resident #201 is [AGE] years old male resident was admitted on [DATE] with a diagnosis of Right Hip Replacement. Review of resident medical record on 09/24/2024 at 1:15 PM revealed that resident had order for Cefadroxil 500 mgs PO since 09/20/2024, Eliquis 2.5 mgs PO BID and Oxycodone-Acetaminophen 5/325 mgs daily PRN. A medication review performed by the pharmacist to identify if there any irregularities related to the medication regimen were not found documented on the medical record. Information related to medication regimen review was requested to the Pharmacist (employee #10) on 09/24/2024 at 2:15 PM. Pharmacist (employee #10) stated on interview on 09/24/2024 at 2:40 PM that the resident did not have a medication regimen review. c. Pharmacist (employee #10) stated that she is covering the SNF pharmacist because the pharmacist is not available on 09/24/2024 and she does not know about Medication Regimen Review (MRR). She does not give precise information in relation to a policy and procedure for the MRR. d. A policy who establishes how the facility is going to maintain a medication regimen oversight to promote the well-being of the residents receiving high risk medication was not provided or evidence on 09/24/2024. e. On 09/25/2024 at 1:00 PM a pharmaceutical services & medication review policy was created on 04/02/2024. This policy was provided by the facility pharmacist (employee # 11). In this policy it is established that a monthly drug regimen review is going to be performed at least once per month to every resident admitted receiving services at the facility. f. On 09/25/2024 at 3:00 PM it was informed to the facility pharmacist (employee #11) that the facility is requesting a provider number to begin to participate in the Medicare program as a skilled nursing facility. It was explained to him that most cases that facility is going to have once begin to participate in the Medicare program as a provider will be rehabilitation and short stay cases. These cases will receive rehabilitation services and not necessarily are going to have a stay at the facility for a month or more. The surveyor asked to the facility pharmacist (employee #11) on 09/25/2024 at 3:10 PM that if pharmacy had develop a procedure to be ensure that a medication review is performed to every resident admitted receiving services during the period of time that was admitted receiving services to protect the resident, to promote the highest practical well-being and to prevent or minimizes adverse consequences related to the medication therapy. Facility pharmacist (employee #11) stated that the policy can be modified to comply with the requirement and include residents that will receive rehabilitation services and not necessarily are going to had a stay at the facility of a month or more time.
CONCERN (F)

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

Deficiency F0800 (Tag F0800)

Could have caused harm · This affected most or all residents

Based on an observational tour of the facility's kitchen performed from 09/24/2024 through 09/25/2024, from 8:30 AM through 4:30 PM and interview with Administrator (employee #3) , it was identified t...

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Based on an observational tour of the facility's kitchen performed from 09/24/2024 through 09/25/2024, from 8:30 AM through 4:30 PM and interview with Administrator (employee #3) , it was identified that the facility failed to maintain kitchen production area in good condition in order to promote sanitary conditions and the prevention of foodborne illness. This deficient practice has the potential to affect 8 out of 8 admitted residents. (R#1 through #8). Findings include: 1. On 09/24/2024 from 8:30 AM through 4:30 PM during the observational tour to the kitchen it was determined the following: a. The kitchen area is observed in bad condition. B. Poor condition in which the kitchen equipment and environment it does not promote that high standards of cleanliness are maintained. ac. Kitchen equipment and environment conditions were discussed with facility Administrator (employee #3) on 09/24/2024 from 11:30 AM. The Administrator (employee #3) stated that the kitchen is managed by an outside contractor company. She stated that based on the fact that they are at a hospital facility, they must contract the services from the kitchen located in the hospital. Facility had considered the possibility of contracting kitchen and food services from an outside company but at this moment, due to the costs, and the complexity to have this service provided by an outside premises to meet the unique needs of a healthcare environment; company they were going to maintain the contract by this hospital facility kitchen.
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

Based on observations, staff interview and review of policies and procedures performed during the survey process from 09/24/2024 thru 09/25/2024 from 8:30 AM thru 4:30 PM, it was determined that the f...

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Based on observations, staff interview and review of policies and procedures performed during the survey process from 09/24/2024 thru 09/25/2024 from 8:30 AM thru 4:30 PM, it was determined that the facility failed to ensure that food and drink are in an appetizing temperature. Findings include: During test tray performed by surveyors it was noticed that temperatures on food brought by the diet department were not up to standards.
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 08/24/2024 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 08/24/2024 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 09/24/2024 at 9:30 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 100 ppm and the requirement is 200 ppm. Overuse of the sanitizing agent could be harmful. 2. Dry warehouse was observed with black mold spots on ceiling and rice grains on floor. 3. Kitchen equipment was found to be in bad condition.
CONCERN (F)

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

Garbage Disposal (Tag F0814)

Could have caused harm · This affected most or all residents

Based upon a Physical Environment survey performed on 09/24/24 at 8:00 AM through 4:00 AM, to evaluate facility, it was determined that the facility failed to dispose of garbage and refuse properly. F...

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Based upon a Physical Environment survey performed on 09/24/24 at 8:00 AM through 4:00 AM, to evaluate facility, it was determined that the facility failed to dispose of garbage and refuse properly. Findings include: During the observation of the kitchen area, it was noticed that a tilt truck was overflowed with trash, cardboard boxes and bags on floor located on an area were kitchen utensils were kept.
CONCERN (F)

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

Deficiency F0841 (Tag F0841)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical records obtained on [DATE], it was determined that the facility failed to secure designate a physician to serve...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical records obtained on [DATE], it was determined that the facility failed to secure designate a physician to serve as medical director. Findings include: 1. During the review of the medical faculty file on [DATE] at 9:15 AM in the medical director's file (employee #4), a medical faculty appointment was found at the hospital's rehabilitation center as category: Active Medical Staff, but not as medical director. 2. On [DATE] at 9:20 AM, the medical director's file contained a criminal record that expired on [DATE]. The facility failed to make the appointment with its job description as medical director.
CONCERN (F)

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

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

Based on observations, staff interviews and review of policies and procedures performed during the survey process from 09/24/2024 through 09/25/2024 from 8:30 AM through 4:30 PM it was determined that...

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Based on observations, staff interviews and review of policies and procedures performed during the survey process from 09/24/2024 through 09/25/2024 from 8:30 AM through 4:30 PM it was determined that the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Findings include: During the review of infection control program created on June 2024, content and components on 09/25/2024 at 8:55 AM till 10:00 AM during observational tour and evaluation of policies and activities performed by the infection control program officer (employee #1) the following was identified: 1. Infection control program policies and procedures manual did not have a table of contents who gives the reader an overview of the manual contents. 2. Infection control program policies and procedures manual does not include the date when each policy was created and the approval of the governing body or infection control committee. 3. Infection control program policies and procedures manual did not have a reference who gives de reader an overview of the recognized entity used to guide the procedures based on best practices and evidenced based recommendations. 4. Infection control program policies and procedures manual did not include key elements in the policy to ensure clarity and effectiveness like policy purpose and scope, responsibilities and roles of department involved in implementing and enforcing the policy. 5. Infection control program policies and procedures manual did not outline how the facility will fulfill infection control program components such as education, training and monitoring of infection control practices. 6. Infection control program policies and procedures manual did not have an organized delineated structure who describe the function of the infection control program including surveillance, isolation, resident care and employee's health. 7. Infection control program policies and procedures manual did not have information or structure related to nosocomial infections such as urinary tract infections, respiratory tract infections, skin and tissue infections and other infections such as gastrointestinal infections. 8. During the interview on 09/25/2024 at 10:00 AM the infection control officer stated that when he was appointed on 01/18/2024 as the infection control officer and Minimum Data Set Coordinator, when he was appointed, the infection control program policies and procedures manual was already created and no revisions were made to its content. 9. No plan for the education of employees, residents, family members and caregivers who guide the provision of infection control principles and procedures was presented. Some educative in-service activities related with infection control were presented, however the facility did not include a full approach related with protocols for addressing resident care issues and prevention of infections caused by urinary tract care, respiratory tract care, and infusion therapy infectious transmissible diseases. principles and procedures were presented.
CONCERN (F)

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

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected most or all residents

Based on observations, review of policies procedures and interview with infection control officer (employee # 1), performed during the survey process from 09/24/2024 through 09/25/2024 from 8:30 AM th...

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Based on observations, review of policies procedures and interview with infection control officer (employee # 1), performed during the survey process from 09/24/2024 through 09/25/2024 from 8:30 AM through 4:30 PM, it was determined that facility failed to develop and implement policies, procedures, structure and requirements related to comply with COVID-19 immunizations. Findings include: During the interview on 09/25/2024 at 9:35 AM the infection control officer (employee #1) stated the following in relation with the compliance of the facility with COVID-19 immunizations: 1. Facility did not have available COVID-19 vaccines. 2. Facility had not had any contract or agreement with another entity to make available COVID-19 vaccines if a resident want to receive the vaccine. 3. The facility did not present policies and procedures developed and implemented to ensure their residents and staff have been educated and offered vaccines for COVID-19 respiratory preventable disease. 4. The facility did not present policies and procedures or structure to ensure that all staff are fully vaccinated for COVID-19. 5. No mechanism had been implemented since July of natural year 2024 when facility begun to offer services at the Skilled Nursing Facility (SNF) to residents for screening COVID-19 vaccination status. 6. The medical record did not include documentation that indicates that the resident or resident representative was provided education with COVID-19 virus and vaccination. 7. No mechanism had been implemented since July of natural year 2024 when facility begun to offer services at the SNF to ensure every staff member is offered the COVID-19 vaccine unless the immunization is medically contraindicated, or staff member has already been immunized. 8. No mechanism had been implemented since July of natural year 2024 when facility begun to offer services at the SNF to ensure the COVID-19 vaccine status of staff and related information indicated by National Healthcare Safety Network (NSHN) is collected. The facility did not demonstrate that it is collecting data to comply with reporting requirements established that every CMS- SNF facility must comply.
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** 6. On 09/24/2024 at 9:18 AM, lack of cleanliness of windows and shower detached from the bathroom wall in room [ROOM NUMBER]. 7....

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. On 09/24/2024 at 9:18 AM, lack of cleanliness of windows and shower detached from the bathroom wall in room [ROOM NUMBER]. 7. On 09/24/2024 at 11:32 AM, lack of cleanliness in the window of room [ROOM NUMBER]. Based upon a Physical Environment survey performed on 09/24/24 at 8:00 AM through 4:00 AM, to evaluate facility, 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 can affect 8 out of 8 residents and visitors. Findings include: 1.During the observation of the residents' rooms, rust was observed on 12 of 35 beds. 2. During the observation of room [ROOM NUMBER] it was observed that on bed B the head rest of the bed was broken. 3. Some walls were observed with peeled wallpaper 4. Some residents report it takes around 2 minutes for the water in the shower to heat up. 5. During visual observation on residents' rooms bathrooms, 3 out of 25 rooms (810, 811, 812) were observed with a slope exceeding 1/2-inch elevation to enter shower. These thresholds, even at 1/2, can cause trips, slips and falls, as well as potentially preventing life-saving mobility if one of those accidents were to occur.
MINOR (C)

Minor Issue - procedural, no safety impact

Report Alleged Abuse (Tag F0609)

Minor procedural issue · This affected most or all residents

Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to ensure that alleged violations involving abuse, neglect, exploitati...

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Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to ensure that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The facility Elder/ Dependent Adult abuse #4015, State Operation Manual Guidance- Abuse and Neglect #4015.1, Abuse Reporting/posting #4015.3 and Abuse and Neglect -Definition #4015.4 and Unusual Occurrence Reporting #4021policie and procedure provided by the facility Administrator (employee #3) on 09/25/2024 at 10:55 AM. As part of the Resident Right structure facility present policies and procedures written in English base on the State operations Manual. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with resident rights and be provided to residents. The policies and procedures do not include the date when each policy was created or the approval of the governing body. 2. Facility policies and procedures did not include key elements in the policy to ensure clarity and effectiveness like policy purpose and scope, responsibilities and roles of department involved in implementing and enforcing the policy.
MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0685 (Tag F0685)

Minor procedural issue · This affected most or all residents

Based on an interview with the Compliance Office (employee #2) on 09/24/2024 at 1:50 PM, it was determined that the facility failed to ensure it had a policy and procedure that the residents received ...

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Based on an interview with the Compliance Office (employee #2) on 09/24/2024 at 1:50 PM, it was determined that the facility failed to ensure it had a policy and procedure that the residents received appropriate treatment and assistive devices to maintain their visual and hearing abilities. Findings include: 1. During the review of the procedures manual, the device to maintain the hearing and vision policy and procedures was not found. The Compliance Officer (employee #2) interviewed to see if they could find it in the manual, which they indicated that they did not have it available. The facility did not ensure compliance with maintenance targets for hearing and visual devices.
MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0687 (Tag F0687)

Minor procedural issue · This affected most or all residents

Based on interview with the Compliance Office (employee #2) on 09/24/2024 at 1:56 PM, it was determined that the facility failed to ensure that residents receive proper treatment and care to maintain ...

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Based on interview with the Compliance Office (employee #2) on 09/24/2024 at 1:56 PM, it was determined that the facility failed to ensure that residents receive proper treatment and care to maintain mobility and good foot health in accordance with professional standards of practice. Findings include: 1. During the review of the procedure manual, the foot care policy and procedures was not found. The Compliance Officer (employee #2) were interviewed to see if they could find it in the manual, which they indicated that they did not have it available. The facility did not ensure compliance with maintenance foot care and treatment, in accordance with professional standards of practice.
MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0691 (Tag F0691)

Minor procedural issue · This affected most or all residents

Based on review of policies and procedures with the Compliance Officer (employee #2) on 09/24/2024 1:50 PM, it was determined that the facility failed to ensure have a policy and procedure so that res...

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Based on review of policies and procedures with the Compliance Officer (employee #2) on 09/24/2024 1:50 PM, it was determined that the facility failed to ensure have a policy and procedure so that residents receive care consistent with the standard of professional practice, necessary care and treatment including medical and nursing care and services when they need a urostomy. Findings include: 1. During the review of the procedure's manual, the policy and procedure with professional standards of Urostomy practice. The Compliance Officer (employee #2) was interviewed to see if they could find it in the manual. The facility failed to not ensure that the comprehensive resident-centered care plan, goals and care, necessary treatment, care, medical and nursing services when urostomy care is needed.
MINOR (C)

Minor Issue - procedural, no safety impact

Respiratory Care (Tag F0695)

Minor procedural issue · This affected most or all residents

Based on review of policies and procedures with the Compliance Officer (employee #2) on 09/24/2024 1:55 PM, it was determined that the facility failed to ensure have a policy and procedure so that res...

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Based on review of policies and procedures with the Compliance Officer (employee #2) on 09/24/2024 1:55 PM, it was determined that the facility failed to ensure have a policy and procedure so that residents receive care consistent with the respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences. Findings include: 1. During the review of the procedure's manual, the policy and procedure with professional standards of respiratory care practice. The Compliance Officer (employee #2) was interviewed to see if they could find it in the manual. The facility failed to not ensure that the comprehensive resident-centered care plan, goals and care, necessary treatment, care, and medical services when respiratory care is needed.
MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0696 (Tag F0696)

Minor procedural issue · This affected most or all residents

Based on review of policies and procedures with the Compliance Officer (employee #2) on 09/24/2024 at 1:12 PM, it was determined that the facility failed to ensure that residents who have a prosthetic...

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Based on review of policies and procedures with the Compliance Officer (employee #2) on 09/24/2024 at 1:12 PM, it was determined that the facility failed to ensure that residents who have a prosthetic device receive care and assistance in the resident's goals and preferences in accordance with the comprehensive plan of care for wearing and using the prosthesis. Findings include: 1. During the review of the procedure's manual, the policy and procedure with professional standards of protheses practice. The Compliance Officer (employee #2) was interviewed to see if they could find it in the manual. The facility failed to not ensure that it had a standard of practice on the plan of care and goals for getting the patient to use the prosthesis.
MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0698 (Tag F0698)

Minor procedural issue · This affected most or all residents

Based on review of policies and procedures with the Compliance Officer (employee #2) on 09/24/2024 at 1:17 PM, it was determined that the facility failed to ensure that residents who require dialysis ...

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Based on review of policies and procedures with the Compliance Officer (employee #2) on 09/24/2024 at 1:17 PM, it was determined that the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Findings include: 1. During the review of the procedure's manual, the policy and procedure with professional standards of dialysis practice. The Compliance Officer (employee #2) was interviewed to see if they could find it in the manual. The facility failed to not ensure that it had a standard of practice on the plan of care and goals for getting the patient to use the dialysis.
MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0699 (Tag F0699)

Minor procedural issue · This affected most or all residents

Based on reviwe of policies and procedures with the Compliance Officer (employee #2) on 09/24/2024 at 1:21 PM, it was determined that the facility failed to ensure that trauma-survivor residents recei...

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Based on reviwe of policies and procedures with the Compliance Officer (employee #2) on 09/24/2024 at 1:21 PM, it was determined that the facility failed to ensure that trauma-survivor residents receive competent, trauma-informed care in accordance with professional standards and mitigate triggers that may re-traumatize the resident. Findings include: 1. During the review of the procedure's manual, the policy and procedure with professional standards of trauma informed care practice. The Compliance Officer (employee #2) was interviewed to see if they could find it in the manual, to which they indicated that it was not available, did they find any mitigation in the manual. 2. We did not find how staff recognize and respond to the effects of all types of traumas recognizes the pervasive impact and signs and symptoms of trauma on residents and incorporates trauma awareness into plans, policies, procedures, and practices to prevent retraumatization.
MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0700 (Tag F0700)

Minor procedural issue · This affected most or all residents

Based on review of policies and procedures with the Compliance Officer (employee #2) on 09/24/2024 at 1:28 PM, it was determined that the facility failed to ensure the risks and benefits of bedrails f...

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Based on review of policies and procedures with the Compliance Officer (employee #2) on 09/24/2024 at 1:28 PM, it was determined that the facility failed to ensure the risks and benefits of bedrails for residents. The facility must ensure the proper installation, use and maintenance of bedrails. Findings include: 1. During the review of the procedure's manual, the policy and procedure with professional standards of bedrails practice. The Compliance Officer (employee #2) were interviewed to see if they could find it in the manual. The facility did not ensure that the handrail restrictions included risk review and consent to meet the resident's needs.
MINOR (C)

Minor Issue - procedural, no safety impact

Staffing Information (Tag F0732)

Minor procedural issue · This affected most or all residents

Based on reviewed of policy and procedure (P&P) on 09/25/2024 at 1:49 PM, it was determined that the facility failed to establish retention of daily nurse staffing data for a minimum of 18 months. Fin...

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Based on reviewed of policy and procedure (P&P) on 09/25/2024 at 1:49 PM, it was determined that the facility failed to establish retention of daily nurse staffing data for a minimum of 18 months. Findings include: 1. During the interview of the director of nursing (DON) (employee #6) about how long the daily nursing notes data would be kept and she stated that it would be kept for a few months. The surveyor requested the policies and procedure, and it was found the following: a. 09/25/2024 at 2:10 PM, the DON provided the P&P for the Daily Personnel Submission, and it was noted that she did not have how long the nursing station data would be retained. The facility failed to ensure the Maintenance of Daily Nursing Personnel Data posted for a minimum of 18 months within their policies and procedures.
MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0757 (Tag F0757)

Minor procedural issue · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R.R #52 is a [AGE] year-old female admitted on [DATE] for Left total hip replacement. Review record on 09/24/2024 at 9:03 AM,...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R.R #52 is a [AGE] year-old female admitted on [DATE] for Left total hip replacement. Review record on 09/24/2024 at 9:03 AM, it was found that she is using Elequis 2.5 mg one tablet twice daily (BID) per physician's order. The medication regimen documented by the pharmacy staff was not found in the medical record. The facility did not ensure that the pharmacy staff performed the medication regimen with the goal of unnecessary medications, excessive doses, and adverse consequences. 3. Resident #51 is a [AGE] years old female admitted to the facility on [DATE] with a diagnosis of Lumbar interbody Fusion. During record review performed on 09/24/24 02:41 PM, no evidence was found that the pharmacist performed the medication regimen review (MRR). During interview with the SNF pharmacist employee #10 on 09/24/2024 at 3:00 PM she state that did not know about medication regimen review and did not give precise information in relation with policy and procedure for the MRR. Based on observations, staff interview and review of policies and procedures performed during the survey process from 09/24/2024 through 09/25/2024 from 8:30 AM through 4:30 PM, it was determined that the facility failed to ensure that each resident's drug regimen is free from unnecessary drugs. This deficient practice is identified in 4 out of 8 residents (R) receiving services at the facility (R #51, # 52, #101, and #201). Findings include: 1. A mechanism to ensure that facility provide oversight of each resident medication regimen review to ensure resident's drug regimen is free from unnecessary drugs: a.Resident #101 is [AGE] years old female resident was admitted on [DATE] with a diagnosis of Right Ischemic Cerebrovascular Accident. Review of resident medical record on 09/24/2024 at 2:45 PM revealed that resident had order for Insulin Lantus subcutaneous 100 units at bedtime and Eliquis 5 mgs PO BID since 09/23/2024 when was admitted to the facility. A medication review performed by the pharmacist to identify if resident medication regimen review, resident's drug regimen is free from unnecessary drugs was not found documented on the medical record. Information related to medication regimen review was requested to the Pharmacist (employee #10) on 09/24/2024 at 3:15 PM. Pharmacist (employee #10) stated on interview on 09/24/2024 at 3:20 PM that the resident did not have a medication regimen review. b. Resident #201 is [AGE] years old male resident was admitted on [DATE] with a diagnosis of Right Hip Replacement. Review of resident medical record on 09/24/2024 at 1:15 PM revealed that resident had order for Cefadroxil 500 mgs PO since 09/20/2024, Eliquis 2.5 mgs PO BID and Oxycodone-acetaminophen 5/325 mgs daily PRN when admitted to the facility. A medication review performed by the pharmacist to identify if resident medication regimen review, resident's drug regimen is free from unnecessary drugs was not found documented on the medical record. Information related to the medication regimen review was requested to the Pharmacist (employee #10) on 09/24/2024 at 3:30 PM. Pharmacist (employee #10) stated on interview on 09/24/2024 at 3:40 PM that the case did not have a medication regimen review c. Pharmacist (employee #10) stated that she is covering the SNF pharmacist because the pharmacist is not available on 09/24/2024 and she do not know about Medication Regimen Review (MRR). She does not give precise information in relation to a policy and procedure for the MRR. d. A policy who establishes how the facility is going to maintain a medication regimen to ensure that each resident's drug regimen is free from unnecessary drugs, was not provided or evidence on 09/24/2024. e. On 09/25/2024 at 1:00 PM a pharmaceutical services & medication review policy was created on 04/02/2024. This policy was provided by the facility pharmacist (employee #11). In this policy it is established that a monthly drug regimen review is going to be performed at least once per month to every resident admitted receiving services at the facility. f. On 09/25/2024 at 3:00 PM it was informed to the facility pharmacist (employee #11) that the facility is requesting a provider number to begin to participate in the Medicare program as a skilled nursing facility. It was explained to him that most residents that facility is going to have once beginning to participate in the Medicare program as a provider will be rehabilitation and short stay residents. These residents will receive rehabilitation services and not necessarily are going to have a stay at the facility for a month or more. The surveyor asked to the facility pharmacist (employee #11) on 09/25/2024 at 3:10 PM that if pharmacy had developed a procedure to be sure that a medication review is performed to every resident admitted during the period that was admitted receiving services to protect the resident, so that each resident's drug regimen is free from unnecessary drugs. Facility pharmacist (employee #11) stated that the policy can be modified to comply with the requirement and includes residents that will receive rehabilitation services and not necessarily are going to have a stay at the facility for a month or more time.
MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0790 (Tag F0790)

Minor procedural issue · This affected most or all residents

Based on interviews with administrator (employee #3) and review of facility policies and procedures, it was determined that facility failed to determine if they are going to have a relationship with a...

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Based on interviews with administrator (employee #3) and review of facility policies and procedures, it was determined that facility failed to determine if they are going to have a relationship with any dental services in obtaining routine and 24-hour emergency dental care (by contract) in order to provide those services at the facility. Findings include: 1. Facility administrator (employee #3) was interview on 09/25/2024 at 1:15 PM and it was requested information to him in relation of a dental services as an option to be provided by their facility. 2. The Facility administrator (employee #3) stated in an interview on 09/25/2024 at 1:20 PM that at the moment the facility have a contract with a dental service in order to make available dental services in according to the scope permitted to a SNF. 3. Facility did not provide evidence of a dental contract with a physician dentist. 4. The facility provides evidence of a letter send to the Dentist services and the facility policies and procedure on 09/25/2024 at 1:20 PM, related to this services and states that in an emergency that the dentist office is not available we will refer the patient to emergency room near to the facility, these policies do not meet with Skill Nurse Facility regulation 483.55 Dental Services.
MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0802 (Tag F0802)

Minor procedural issue · This affected most or all residents

Based on observations, staff interview and review of policies and procedures performed during the survey process from 09/24/2024 through 09/25/2024 from 8:30 AM through 4:30 PM it was determined that ...

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Based on observations, staff interview and review of policies and procedures performed during the survey process from 09/24/2024 through 09/25/2024 from 8:30 AM through 4:30 PM it was determined that the facility failed to provide evidence of a process to estimate staffing needs in the kitchen through a kitchen staffing pattern. This deficient practice had the potential to affect 8 out of 8 residents admitted receiving at the facility. Findings include: 1. The staffing pattern calculation was requested by the surveyor to the kitchen manager (employee #12) on 09/24/2024 at 11:20 AM. The kitchen staffing pattern calculation was not provided. 2. A staffing pattern who include the number of personnel of the food and nutrition department needed to safely carry out all the functions, was not provided, not evidence during the survey process from 09/24/2024 through thru 09/25/2024 from 8:30 AM through 4:30 PM. 3. Facility failed to evidence that had a mechanism established to determine the quantity of staff needed to prepare and serve meals in a timely manner and to maintain food safety management.
MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0838 (Tag F0838)

Minor procedural issue · This affected most or all residents

Based on observations, staff interview and review of policies and procedures performed during the survey process from 09/24/2024 through 09/25/2024 from 8:30 AM through 4:30 PM it was determined that ...

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Based on observations, staff interview and review of policies and procedures performed during the survey process from 09/24/2024 through 09/25/2024 from 8:30 AM through 4:30 PM it was determined that the facility failed to a required Facility Assessment. This deficient practice had the potential to affect 8 of 8 residents in the facility. Findings include: 1. During the entrance conference performed on 09/24/2024 at 9:00 AM with the Administrator, the surveyors request the facility assessment, as one of the documents that they must provide within four hours of the entrance conference. 2. On 09/25/2024 at 2:30 PM during interview the Administrator (employee #3) stated that facility is in the process of development of the facility assessment. 3. The Administrator (employee #3) provides evidence of an attendance list on 09/25/2024 at 2:45 PM of a meeting performed on 09/15/2024 where facility personnel discuss the requirement of facility assessment. 3. The Administrator (employee #3) stated on 09/25/2024 at 2:35 PM that the facility is in the process of contracting personnel to collect data and prepare the facility assessment. 4. Facility failed to provide information on the evaluation of its resident population and to identify the resources needed to provide the necessary care and services the residents require during both day-to-day operations and emergencies (including nights and weekends) and emergencies.
MINOR (C)

Minor Issue - procedural, no safety impact

Staffing Data (Tag F0851)

Minor procedural issue · This affected most or all residents

Based on review of the policy and procedures manual with the Nursing Supervisor (employee #6) on 09/25/2024, it was determined that the facility failed to have policies and procedures in place regardi...

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Based on review of the policy and procedures manual with the Nursing Supervisor (employee #6) on 09/25/2024, it was determined that the facility failed to have policies and procedures in place regarding the electronic reporting and submission of the Payroll Based Journal to CMS. Findings include: 1. During an interview with the nursing supervisor (employee #6) on 09/25/2024 at 1:08 PM, stated that she did not have a Payroll Based Journal policy available.
MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0868 (Tag F0868)

Minor procedural issue · This affected most or all residents

Based on reviewed of the quality assessment performance improvement (QAPI) program conducted on 09/24/2024 through 09/25/2024 and interview with Compliance Officer (employee #2), it was determined tha...

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Based on reviewed of the quality assessment performance improvement (QAPI) program conducted on 09/24/2024 through 09/25/2024 and interview with Compliance Officer (employee #2), it was determined that the facility did not demonstrate Nursing Director and Infection Control participation in its quality assurance committee. Findings include: b. on 09/24/2024 at 3:10 PM, it was observed the signature of the director of nursing (DON) (employee #6) was observed in the quality manual, but the appointment of the DON was not found in the file. c. On 09/25/2024 at 2:50 PM, it was noted in the quality improvement manual that the quality committee did not include the director of nursing and infection control in the activities and evaluations of the Multy Medical Skilled Nursing Facility.
MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0895 (Tag F0895)

Minor procedural issue · This affected most or all residents

Based on interview with the compliance officer (employee #2) and review of facility policies and procedures, it was determined that facility failed to develop and implement a compliance and ethics pro...

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Based on interview with the compliance officer (employee #2) and review of facility policies and procedures, it was determined that facility failed to develop and implement a compliance and ethics program, with respect to a facility. Findings include: 1. Facility compliance officer (employee #2) was interviewed on 09/25/2024 at 11:45 AM and information in relation to policies and procedures was requested and the implementation of the compliance and ethics program at the facility. 2. Facility compliance officer (employee #2) stated on interview on 09/10/2024 at 11:55 AM that facility provide the training's required to comply with the ethics program. 3. No policies and procedures who include the structure, purpose and details on how the facility will fulfill the compliance and ethics program components with respect to a facility was provided.
MINOR (C)

Minor Issue - procedural, no safety impact

Room Equipment (Tag F0908)

Minor procedural issue · This affected most or all residents

Based on observations made at the nurse's station with Nursing Supervisor (employee #6) on 09/25/2024, it was determined that the facility failed to maintain all mechanical, electrical, and patient ca...

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Based on observations made at the nurse's station with Nursing Supervisor (employee #6) on 09/25/2024, it was determined that the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition. Findings include: 1. During the tour of the nursing station in the company of the nursing supervisor (employee #6), the following was found: a. On 09/25/2024 a las 2:26 PM, the Oxygen tank was observed in the crash cart with the pressure gauge indicating zero, when the tank was evaluated, the flow meter was not properly positioned. The Compliance Officer (employee #2) promptly replaced the Oxygen tank.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

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

Our Honest Assessment

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

About This Facility

What is Multy Medical Skilled Nursing Facility's CMS Rating?

MULTY MEDICAL SKILLED NURSING FACILITY does not currently have a CMS star rating on record.

How is Multy Medical Skilled Nursing Facility Staffed?

Detailed staffing data for MULTY MEDICAL SKILLED NURSING FACILITY is not available in the current CMS dataset.

What Have Inspectors Found at Multy Medical Skilled Nursing Facility?

State health inspectors documented 69 deficiencies at MULTY MEDICAL SKILLED NURSING FACILITY during 2024. These included: 51 with potential for harm and 18 minor or isolated issues. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.

Who Owns and Operates Multy Medical Skilled Nursing Facility?

MULTY MEDICAL SKILLED NURSING FACILITY is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 35 certified beds and approximately 0 residents (about 0% occupancy), it is a smaller facility located in RIO PIEDRAS, Puerto Rico.

How Does Multy Medical Skilled Nursing Facility Compare to Other Puerto Rico Nursing Homes?

Comparison data for MULTY MEDICAL SKILLED NURSING FACILITY relative to other Puerto Rico facilities is limited in the current dataset.

What Should Families Ask When Visiting Multy Medical Skilled Nursing Facility?

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 Multy Medical Skilled Nursing Facility Safe?

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

Do Nurses at Multy Medical Skilled Nursing Facility Stick Around?

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

Was Multy Medical Skilled Nursing Facility Ever Fined?

MULTY MEDICAL SKILLED NURSING FACILITY 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 Multy Medical Skilled Nursing Facility on Any Federal Watch List?

MULTY MEDICAL SKILLED NURSING FACILITY 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.

MULTY MEDICAL SKILLED NURSING FACILITY

AMERICO MIRANDA AVE ENTRADA PRINCIPAL CENTRO, RIO PIEDRAS, PR 00935 | (787) 754-0194

D
Trust Grade (40/100)
3.0
CMS Rating
69
Deficiencies

Strengths

  • Licensed facility

Concerns

  • 69 deficiencies

Ask about: Rn Coverage

nursinghomedata.org | Data: CMS November 2025