ALTERNATIVE HEALTHCARE SOLUTIONS LLC
For profit - Limited Liability company
22 Beds
Independent
Data: November 2025
Trust Grade
60/100
#1 of 6 in PR
Last Inspection: December 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Alternative Healthcare Solutions LLC in San Juan, Puerto Rico has a Trust Grade of C+, which indicates that the facility is slightly above average but not without its issues. It ranks #1 out of 6 nursing homes in Puerto Rico and #1 out of 2 in San Juan County, placing it in the top tier of local options. Unfortunately, the facility is experiencing a worsening trend in quality, with a slight increase in reported issues from 16 in 2023 to 17 in 2024. Staffing is a strong point, rated 5 out of 5 stars with a turnover rate of 32%, close to the state average, meaning staff are generally stable and familiar with residents. However, the facility has incurred $68,560 in fines, which is concerning and indicates ongoing compliance problems. Specific incidents that raise red flags include the use of Styrofoam trays for meals, leading to food served at unsafe temperatures, and a lack of proper food storage and safety practices, such as unmarked food items and spoiled produce being found in the kitchen. Despite these weaknesses, the high staffing rating suggests there are dedicated caregivers who can provide quality attention to residents. Families should weigh these strengths against the notable concerns when considering this facility for their loved ones.
- Trust Score
- C+
- In Puerto Rico
- #1/6
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 32% turnover. Near Puerto Rico's 48% average. Typical for the industry.
- Penalties ✓ Good
- $68,560 in fines. Lower than most Puerto Rico facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 376 minutes of Registered Nurse (RN) attention daily — more than 97% of Puerto Rico nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 33 deficiencies on record. Higher than average. Multiple issues found across inspections.
60/100
Top 16%
Needs review
16 → 17 violations
★★★★☆
4.0
Overall Rating
★★★★★
5.0
Staff Levels
☆☆☆☆☆
0.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 16 issues
2024: 17 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (32%)
16 points below Puerto Rico average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
Staff Turnover: 32%
14pts below Puerto Rico avg (46%)
Typical for the industry
Federal Fines: $68,560
Well above median ($33,413)
Moderate penalties - review what triggered them
The Ugly 33 deficiencies on record
Dec 2024
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. The Diet department was visited on 12/02/2024 at 10:20 AM. Kitchen the manager (employee #6) was asked by the surveyor in rel...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. The Diet department was visited on 12/02/2024 at 10:20 AM. Kitchen the manager (employee #6) was asked by the surveyor in relation to the availability of yogurt, bananas and prune juice.
Kitchen the manager (employee #6) stated in interview on 12/02/2024 at 10:35 AM that when they purchase the food only apples are available as fresh fruit. She stated that they substitute the fresh fruit for canned fruit without sugar and that also prune juice is not available.
In relation to the yogurt she stated that the document submitted to the diet department stated that resident request yogurt as a snack and not as a food to be included at least two or three times a day, she does not have information in relation to prune juice preference.
e. Kitchen manager (employee #6) stated 12/02/2024 at 10:45 AM, that when residents request food different from the menu cycle and existing food in the storage she proceeds to buy with the available petty cash.
f. Kitchen manager (employee #6) stated in interview on 12/02/2024 at 10:50 AM that there is no problem in buying the bananas and prune juice to please the resident preferences. In relation to yogurt preferences to grant resident preferences to be included at least two or three times a day on food trays there is no problem to comply with this preference.
Based on dining observations, review of policies procedures and facility staff interview performed on 12/02/2024 through 12/03/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to ensure that each resident receives, and the facility provides food and drink that is palatable, attractive, and at a safe and appetizing temperature. This deficiency affects 1 out of 5 cases admitted receiving services (Resident #4).
Findings include:
1. Facility failed to promote residents' food preferences.
a. Resident located in room [ROOM NUMBER]-B this resident stated that she likes to have the same types of food, because she experiences swallowing difficulties since several years ago when she had surgery for a brain tumor. She reports preferences for fresh fruit such as banana and yogurt, to be included at least two or three times a day. Resident also, stated she drinks prune juice twice a week to regulate her gastrointestinal system. Resident stated that those food preferences were not addressed by facility.
b. Resident who was admitted on [DATE] with an order of Regular low salt diet; stated that she reports food preferences to the dietitian when she came to perform the initial evaluation on 11/17/2024.
c. A document received by the diet department dated 12/01/2024 stated that this resident wants yogurt as a snack. The document does not specify that the resident wants yogurt as food to be included at least two or three times a day on the food trays.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Physical enviroment observations, performed on 12/02/2024 through 12/03/2024 to from 8:30 AM through 3:30 PM, it was de...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Physical enviroment observations, performed on 12/02/2024 through 12/03/2024 to from 8:30 AM through 3:30 PM, it was determined that the facility failed to ensure a safe, clean, comfortable and homelike environment for 3 out of 3 rooms observed.
Findings include:
The following was identified durin visual inspection of the facility from 12/02/2024 through 12/03/2024 :
1. Nigth stand on room [ROOM NUMBER] was observed with peeling vinyl cover
2. Gypsum board behind washbasin on room [ROOM NUMBER] was observed with peeled parts.
3. Loose grab bars on bath room of room [ROOM NUMBER]
4. Lamp cords on bed head boards on rooms #702 and #705
5. Broken soap dispenser in the washbasin area on room [ROOM NUMBER]
6. Water stain was observed on wall behind room entrance door
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected most or all residents
Findings include:
The following was identified during the dining services evaluation process:
1. Breakfast and lunch are served in Styrofoam disposable trays. The trays are assembled in a way that hot...
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Findings include:
The following was identified during the dining services evaluation process:
1. Breakfast and lunch are served in Styrofoam disposable trays. The trays are assembled in a way that hot food items and cold items are in contact and cold food items change the temperature of the hot food items and vice versa.
2. During the interview with the kitchen manager (employee #6) on 12/03/2024 at 11:30 AM she stated that the facility is serving food in disposable trays due to lack of available kitchen personnel to process and disinfect dinner trays.
3. Kitchen staffing pattern was requested to the kitchen manager (employee #6) by the surveyor on 12/03/24 at 11:30 AM. In this pattern it was identified that the facility lacks half of the personnel (50%). Since the month of September there have been resignations, which limits the service they offer even more.
4. The efforts made by the facility for recruitment of kitchen personnel are requested by the surveyor to the kitchen manager (employee #6) on 12/03/2024 at 11:35 AM which is presented, and five positions are observed. It was asked the reason why there are only 5 positions approved. She responds that she needs 8 employees but only 5 are authorized by the facility administration.
Based on dining observations, review of staffing pattern and facility staff interview performed on 12/02/2024 through 12/03/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to ensure that facility failed to have sufficient staff to carry out the functions of the food and nutrition services. This deficiency affects 5 out of 5 cases admitted receiving services.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on dining observations, review of policies procedures and facility staff interview performed on 12/02/2024 through 12/03/2...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on dining observations, review of policies procedures and facility staff interview performed on 12/02/2024 through 12/03/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to ensure that each resident receives, and the facility provides food and drinks that are palatable, attractive, and at a safe and appetizing temperature. This deficiency affects 1 out of 5 cases admitted receiving services (Resident #4).
Findings include:
During the initial pool process on survey on 12/02/2024 from 8:34 AM through 3:30 PM to screen residents the following findings were identified:
1. Facility failed to ensure that food and drink provided to residents maintain an appetizing temperature.
a. Resident #4 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Right Hip Replacement. On 12/02/2024 at 8:40 AM during resident interview she state that that the food came on disposable Styrofoam every time and that when she eats it was cold.
b. Test tray was performed on 12/03/2024 at 11:28 AM. This test tray was performed to determine if food delivered to residents maintain appetizing temperature after surveyors noticed that food is brought by the diet department in Styrofoam disposable trays due to lack of sufficient kitchen personnel to sanitize and process trays.
c. During the test tray on 12/02/2024 at 11:55 AM these were the findings: [NAME] rice temperature is- 158.6 degrees(º) Fahrenheit (F), beef stew-159.3ºF, canned mandarin orange -56.5ºF, beets -52.5ºF and milk-56.8ºF.
For the cold items the acceptable delivery temperature (milk and mandarin orange) must be 40-55ºF.
d. In addition to not complying with temperature, the Styrofoam trays are full; all food items containers (cold and hot), all of which contribute to a poorly presented that is not appetizing.
2. Lack of support personnel in the kitchen has its effect on the provision of meals trays and dinner in a way that maintains cold or hot when provided to the resident.
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 flash tour and kitchen observations, performed on 12/02/2024 through 12/03/2024 from 8:30 AM through 4:30 PM, it was determined that the facility failed to ensure that facility failed to stor...
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Based on flash tour and kitchen observations, performed on 12/02/2024 through 12/03/2024 from 8:30 AM through 4:30 PM, it was determined that the facility failed to ensure that facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This deficiency affects 5 out of 5 cases admitted receiving services
Findings include:
1.During a visual tour of the kitchen area with the Dietary Service Manager (employee #6) on 12/02/2024 at approximately 8:19 AM the following was observed:
a. A package of ham was observed open and not dated on the refrigerator.
b. Cabbages (repollo) were observed in fridge with rotten leafs.
c. Dietary Department Coordinator did not have hair net while working the food line.
d. Ceiling near the food line was observed with perforations due to water damage.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on announces recertification survey, during the observation procedure by the staff on 12/02/2024, it was determined that t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on announces recertification survey, during the observation procedure by the staff on 12/02/2024, it was determined that the facility failed to ensure follow accepted standards of practice to prevent the transmission of infections and communicable disease for 2 out of 5 Resident. (Resident #4 and #111)
Findings include:
1. During the observations made to the nursing staff on 12/02/2024, the following was observed:
a. Resident #111-B is an [AGE] year-old female admitted on [DATE] for Lower left leg extremities ulcer. On 12/02/2024 at 10:37 AM, registered nurse (employee #3) was observed donning gloves to check residents' IV without first washing her hands or using hand sanitizer and registered nursing (employee # 4) was observed at the time of donning her gown, the gown touched the contaminated waste container twice.
b. Resident #4 -B is a [AGE] year-old female admitted on Right total hip replacement. On 12/02/2024 at 9:24 AM, physical therapy staff (employee #7) was observed on two occasions putting on gloves without washing their hands or using hand sanitizer before and after giving therapies.
The facility failed to ensure maintain an infection prevention to provide a safe and sanitary.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment and facility staff interview performed on 12/02/2024 through 12/03/2024 from 8...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment and facility staff interview performed on 12/02/2024 through 12/03/2024 from 8:00 AM through 4:00 PM, it was determined that the facility failed to ensure to provide the residents a safe, funtional, sanitary and comfortable environment.
Findings include:
1. During the tour of the rooms, the following was observed:
a. On 12/02/2024 at 9:10 AM, observed commode toilet seat with dark stains, exhaust duct with lack of cleanliness and humidity on the wall in the sink in room [ROOM NUMBER].
b. On 12/02/2024 at 9:00 AM, stained acoustics were observed in room [ROOM NUMBER].
c. On 12/02/2024 at 9:24 AM, the washbasin was observed to be detached from the wall in room [ROOM NUMBER].
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on unannounced recertification survey, during the observation conducted at the nursing desk on 12/02/2024, it was determined that the facility failed did not ensure that the following informatio...
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Based on unannounced recertification survey, during the observation conducted at the nursing desk on 12/02/2024, it was determined that the facility failed did not ensure that the following information was provided daily postings.
Findings include:
1. During arrival at the facility on 12/02/2024 at 8:00 AM, the following was observed:
a. On 12/2/2024 at 8:00AM, it was noted that the facility's post was not up to date. The staff post was dated 11/29/2024 and had a census of 4 residents when there were 5 residents.
b. On 12/2/2024 at 11:14 AM, we interviewed Supervisor (employee #8) and Nursing Director (employee #1), who stated that the person in charge of entering the personnel postings is the secretary at 7:00 AM from Monday to Friday, and on Saturdays and Sundays it is done by the nursing shift leader.
The facility failed to have the updated postdate and resident census information accessible to residents and visitors.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0883
(Tag F0883)
Minor procedural issue · This affected most or all residents
Based on records reviewed (RR) and observations on 12/02/2024, it was determined that the facility failed to ensure that education was provided to residents on the benefits and side effects of Covid-1...
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Based on records reviewed (RR) and observations on 12/02/2024, it was determined that the facility failed to ensure that education was provided to residents on the benefits and side effects of Covid-19, influenza and pneumococcal vaccines.
Findings include:
During the evaluation of the files, it was observed that in the resident and/or family education sheet in the immunization area, the nursing personnel were not marking the orientations given to residents and/or family members on Covid-19, Influenza or pneumococcal.
Apr 2024
8 deficiencies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment, review of policies and procedures and facility staff interview performed on 0...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment, review of policies and procedures and facility staff interview performed on 04/17/2024 through 04/18/2024, from 8:00 AM through 5:00 PM, it was determined that the facility failed to promote the resident right to receive services in a safe, clean, comfortable, and homelike environment.
Findings include:
During observational tour of facility on 04/17/2024 the following was noticed:
Review of policy Temperatura de Habitaciones room temperatures should be the stablished parameters norm of 71 to 81 degrees. The policy also stated that patients with skin leisure's room should be between 66 and 68 degrees, at the moment of survey no patients with skin leisure's was admitted .
1. Three residents complained about cold temperatures in room (706A, 708A, 709A).
During document review of room temperature log 04/14/24, it was found that daily measurements of temperatures exceeds the stablished parameters norm of 71 to 81 degrees.
2. During observational tour it was observed in room [ROOM NUMBER] that wall behind door had peeling paint due to water damage.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on eleven records reviewed (RR) resident interview, and interview with the Nursing Supervisor (employee #2) performed from...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on eleven records reviewed (RR) resident interview, and interview with the Nursing Supervisor (employee #2) performed from 04/17/2024 thru 04/18/20234 from 8:30 AM thru 4:30 PM, it was determined that the facility failed to ensure to develop and implement a baseline care plan that includes the instructions needed to provide the local care to the right power line. This deficient practice was identified in 1 out of 2 residents with central line (RR #8).
Findings include:
Record review #8 is a [AGE] year-old male resident admitted [DATE] with a diagnosis of Lumbar Discitis plus Osteomyelitis. Resident was admitted for complete 90 days of antibiotic therapy. This resident was admitted with a power central line in the right subclavian to be used to administer antibiotic therapy. While reviewing the medical record on 04/18/2024 at 10:00 AM with Nursing Supervisor (employee #2) it was identified that the baseline care plan does not include the local care of the power central line.
During an interview on 04/18/2024 at 1:10 PM Nursing Supervisor (employee #2) stated that this case does not have plan of care for power central line due to this was inserted in another facility and that the resident had it when he was admitted . Nursing Supervisor (employee #2) also stated during interview on 04/18/2024 at 1:20 PM that nursing personnel provide local care and change bandages every 72 hours on an ongoing basis.
Resident #8 was interviewed on 04/17/2024 at 11:35 AM and stated that he was admitted to the facility to complete antibiotics due to an infection in his back area. He stated that he went to the facility with a power line in the right subclavian place 2-3 days previous the admission and that nursing personnel provide local care to the area and change bandages every 72 hours.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R. R #8 is a [AGE] year-old male resident admitted [DATE] with a diagnosis of Lumbar Discitis plus Osteomyelitis. Resident wa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R. R #8 is a [AGE] year-old male resident admitted [DATE] with a diagnosis of Lumbar Discitis plus Osteomyelitis. Resident was admitted to complete 90 days of antibiotic therapy. This resident was admitted with a power central line in the right subclavian to be used to administer antibiotic therapy. While reviewing the medical record on 04/18/2024 at 10:00 AM with Nursing Supervisor (employee #2) it was identified that no order for the care to the power line was found.
During interview on 04/18/2024 at 1:10 PM Nursing Supervisor (employee #2) stated that this case does not have an order for the care to the power line and that this vascular access was inserted in another facility and that the resident had it when he was admitted . Nursing Supervisor (employee #2) also stated in an interview on 04/18/2024 at 1:20 PM that nursing personnel provide local care and change bandages every 72 hours on an ongoing basis.
Resident #8 was interviewed on 04/17/2024 at 11:35 AM and stated that he was admitted to the facility to complete antibiotics due to an infection in his back area. He stated that he went to the facility with a power line in the right subclavian place 2-3 days previous the admission and that nursing personnel provide local care to the area and change bandages every 72 hours.
Based on eleven records reviewed (R.R.), resident interview and interview with the Nursing Supervisor (employee #2) performed from 04/17/2024 thru 04/18/20234 from 8:30 AM thru 4:30 PM, it was determined that the facility failed to ensure care provided to a peripherally inserted central catheter (PICC) is performed in accordance with a physician order. This deficient practice was identified in 2 out of 11 R.R. (RR #6 and RR #8).
Findings include:
2.R.R #6 is a [AGE] year-old male resident admitted [DATE] with a diagnosis of Intraspinal abscess and granuloma. Resident was admitted for rehabilitation services, and to receive antibiotic therapy. This resident was admitted with a PICC line on his left arm that is to be used to administer antibiotic therapy.
While reviewing the medical record on 04/18/2024 at 11:50 AM with Nursing Supervisor (employee #2) it was identified that no order for the care to the PICC line was found.
During interview on 04/18/2024 at 1:10 PM Nursing Supervisor (employee #2) stated that this case does not have an order for the care to the PICC line and that this vascular access was inserted in another facility and that the resident had it when he was admitted . Nursing Supervisor (employee #2) also stated in an interview on 04/18/2024 at 1:20 PM that nursing personnel provide local care and change bandages every 72 hours on an ongoing basis.
Resident #6 was interviewed on 04/17/2024 at 10:55 AM and stated that he was admitted to the facility to complete antibiotics due to an infection in his back area. He stated that he went to the facility with a PICC line on his left arm on 03/21/2024 and that nursing personnel provide local care to the area and change bandages every 72 hours.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected most or all residents
4. Information related to the competence certification and skills of nursing personnel who are interacting with residents who had PICC lines was not provided or evidenced during survey procedures on 0...
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4. Information related to the competence certification and skills of nursing personnel who are interacting with residents who had PICC lines was not provided or evidenced during survey procedures on 04/17/2024 through 04/18/2024 from 8:00 AM to 4:30 PM.
Based on an interview with the Director of Nursing (DON) employee #3 on 04/17/2024 through 04/18/2024 from 8:00 AM to 4:30 PM, it was determined that the facility failed to ensure that care and management of peripherally inserted central catheter (PICC) lines is provided by competent and trained nursing staff. Which can affect 2 out of 2 residents with PICC lines. (RR#6 and #8)
Findings include:
1. Competence certification who include information related to the skills of nursing personnel who are interacting with residents who had PICC lines was requested to the DON on 04/18/2024 at 10:55 AM.
2. Information related to the competence certification and skills of nursing personnel who are interacting with residents who had PICC lines was not provided or evidenced during survey procedures on 04/17/2024 through 04/18/2024 from 8:00 AM to 4:30 PM.
3. DON stated in an interview on 04/18/2024 at 1:30 PM that the competence of skills of nursing personnel (12 nurses) who are providing care to residents who had PICC lines was not performed on year 2024.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected most or all residents
Based on observations and interview with the Dietitian (employee #1) performed from 04/17/2024 thru 04/18/2024, from 8:00 AM thru 4:00 PM, it was determined that the facility failed to provide suffici...
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Based on observations and interview with the Dietitian (employee #1) performed from 04/17/2024 thru 04/18/2024, from 8:00 AM thru 4:00 PM, it was determined that the facility failed to provide sufficient support for personnel safely and effectively carry out the functions of the food and nutrition service.
Findings include:
During an interview with the Dietitian performed on 04/17/2024 she stated that the facility did not have covered the dishwasher position. The Dietitian stated that this makes difficult the function of the kitchen because she must use a TSA for the dishwashing functions.
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 04/17/2024 to from 8:00 AM through 4:00 PM, it was determined that the facility failed to ...
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Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 04/17/2024 to 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 Limpieza y Desinfección en Fregadero de Tres Compartimientos , Cleaning and Disinfection of three compartment Sinks regarding the process of cleaning and sanitization of kitchen equipment was reviewed on 04/17/2024 at 10:30 AM and it says that compartment one (1) must have a temperature of 110º F, on compartment two (2) temperature must be at 75º F and on compartment three (3) temperature must be at least 75º F 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. In turn, it was requested that the concentration of sanitizer be taken on the third compartment and the concentration measurement read 600 ppm and the requirement is 200 ppm. Overuse of the sanitizing agent could be harmful.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected most or all residents
Based on review of policies, procedures and facility staff interview performed on 04/17/2024 to from 8:00 AM through 4:30 PM, it was determined that the facility failed to comply with the policy regar...
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Based on review of policies, procedures and facility staff interview performed on 04/17/2024 to from 8:00 AM through 4:30 PM, it was determined that the facility failed to comply with the policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.
Findings include:
Review of facility's policy and procedure ND-0003 Almacenaje de los alimentos en la nevera de los residentes, stated that all food in the refrigerator must be identified with the resident's initials, room number and date. Approximately at 1:30 PM some snacks ( juice, desserts and vegetables(carrots) were observed with no date or labeled in the residents' refrigerator.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations performed from 04/17/2024 through 04/18/2024, from 8:20 AM through 4:30 PM, it was determined that the fac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations performed from 04/17/2024 through 04/18/2024, from 8:20 AM through 4:30 PM, it was determined that the facility failed to maintain equipment in a safe operating condition.
Findings include:
During observational tour of facility, the following was noticed:
1. Electrical cord (plug) on residents beds A and B of room [ROOM NUMBER] were observed with broken plastic covering.
2. Alcohol-based hand rub (ABHR) dispenser was found to be broken in room [ROOM NUMBER].
3. Window shade cover was observed broken and in the floor on room [ROOM NUMBER].
May 2023
16 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a recertification survey, review of eleven medical records, resident interview and interview with the Nursing Superviso...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a recertification survey, review of eleven medical records, resident interview and interview with the Nursing Supervisor (employee #2) performed from 05/01/2023 thru 05/02/2023, from 8:30 AM thru 4:30 PM, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment related to did not individualized and review each plan of care. This deficient practice was identified in 1 out of 11 cases reviewed. (RR #65).
Findings include:
1. Record review #65 is a [AGE] year-old male resident admitted [DATE] with a diagnosis of Left heel Infected Ulcer with Osteomyelitis. Resident was admitted for rehabilitation services, wound care and to receive antibiotic therapy.
Resident #65 was interviewed on 05/01/2023 at 10:55 am and stated that he was admitted to the facility to complete 21 days of antibiotic due to an infection in his left heel.
During the record review performed on 05/02/2023 at 7:42 AM, it was identified that the Interdisciplinary group (Physician, Nutritionist, Physical Therapist, Recreative Therapist and Occupational Therapist) sign the plan of care for Pain, and for Falls on 04/29/2023 and 05/1/2023 however, no evidence was found that the plan of care for pain and falls was activate and individualized according to patient needs. The resident was admitted to complete 21 days of antibiotic therapy, however the plan of care for Resident with Antibiotic Therapy was left in blank.
No evidence was found that the nurse develops and implements the plan of care for pain, falls and Antibiotic Therapy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on recertification survey, performed on 5/01/2023 to 5/2/2003 at 8:00 AM to 4:00 PM, observation and interview of resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on recertification survey, performed on 5/01/2023 to 5/2/2003 at 8:00 AM to 4:00 PM, observation and interview of residents, who cannot perform activities of daily living. It was determined that the facility failed to ensure that the resident received services to maintain personal hygiene. The deficient practice was identified in 1 out of 11active cases (Resident Case #63).
Findings include:
During the investigations and observations on 01/5/2023 at 2:25 PM by the Nursing Supervisor (employee #2) and Licensed Practical Nurses (Employee # 5 and Employee #6), the following were identified:
1. Resident Sample # 63 is a [AGE] year-old male admitted on 4/11/2023 with diagnosis of Pressure Ulcer of Sacral Region, Stage 4. It was observed that the resident had not shaved for several days, was asked if he normally trims hair on his face, he stated that he only kept his mustache. He was asked by the surveyor if the facility had offered to shave him, he indicated no, that his grandson is the one who shaves him. Also was asked by the surveyor if he had been bathed, he said yes, the nails of both hands were observed dirty and long.
The Licensed Practical Nurses (Employee #5 and Employee #6) were interviewed and affirmed that the relative (grandson) is the one who shaves the resident, and they are not allowed to cut the nails by order of the Medical Director (Employee #3).
The nursing supervisor (Employee #2) was interviewed if the bath procedure includes nails and shaving, the nursing supervisor stated nail cleaning and shaving services were provided and gave the surveyor the policies and procedures.
The policies and procedures that were reviewed do not establish the residents' shave and how they will handle residents who are observed with long fingernails.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on recertification survey, interview of eleven medical records, and interview conducted 5/01/2023 to 5/02/2023 from 8:00 A...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on recertification survey, interview of eleven medical records, and interview conducted 5/01/2023 to 5/02/2023 from 8:00 AM to 4:00 PM, it was determined that the facility failed to ensure that the resident medication regimen is performed to identified irregularity and unnecessary medication therapy. The deficient practice was identified in 1 out of 11 active case (Resident Sample # 63)
Findings include:
During the medical records on 5/01/2023 to 5/02/2023 at 8:00 AM to 4:00 PM, it was observed the medication regimen review of each resident was not performed.
1. Resident Sample # 63 is a [AGE] year-old male admitted on [DATE] with diagnosis of pressure ulcer of sacral region, stage 4 infected.
During the record review performed 5/2/2023 at 1:43 PM provide evidence of physician orders and administer medication: Tylenol 1gm oral every six hours for pain, Klonopin 0.5 mg one tablet oral hour sleep, Merrem 500 mg intravenous every eight hours, Levaquin 750 mg intravenous daily, Ferrous sulfate 325 mg one tablet oral daily, folic acid 1 mg one tablet daily, Xarelto 10 mg one tablet oral daily, Pre- Protein 30 ml oral daily, Famotidine 20 mg one tablet oral daily, Furosemide 20 mg intravenous daily and Hydralazine HCL 10 mg intravenous every four hours PRN.
It was found the mediation regimen incomplete and that the Licensed Pharmacist had not performed a medication regimen since admission on [DATE] to assess for unnecessary medication therapy.
Interviewed the Nursing Supervisor (Employee #2) to verify why the medication regimen was incomplete, stated that she would call the Licensed Pharmacist, but never came.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a recertification survey, observations, review of 9 clinical records, two closed records ,3 random sample, and intervie...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a recertification survey, observations, review of 9 clinical records, two closed records ,3 random sample, and interview with Minimum Data Set (MDS) Coordinator (employee #1 ), it was determined that the facility failed to comply with the requirements specified in 42 CFR part 489, subpart I related with Advance Directives. This deficient practice was identified in 2 out of 9 active cases of resident sample (RS) (RS #8 and #62).
Findings include:
1. A mechanism to ensure that facility provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment as an option and to formulate an advance directive, was not performed accordingly with these findings identified during survey procedures performed from 05/01/2023 thru 05/02/23, from 8:00 AM thru 6:00 PM:
a. It was identified during medical record review on two sample selection cases records during survey procedures from 05/01/2023 thru 05/02/23, from 8:00 AM thru 4:00 PM that facility did not provide written information to all adult residents or resident's representatives concerning the right to accept or refuse medical or surgical treatment as an option and to formulate an advance directive at the time the resident is admitted .
b. Resident Sample case #8 was admitted on [DATE] had evidence documented on the medical record of the orientation and provision of information concerning the right to accept or refuse medical or surgical treatment and signed on admission but it does not specify which of the items identified in the document the resident will choose, nor does it identify that they do not want advance directives. Then, on April 27, 2023, another guidance sheet signed by the resident's sister appeared, indicating that she did not want advance directives.
c. Resident Sample case #62 was admitted on [DATE] the medical record was reviewed on 05/01/23 at 1:15 PM and no evidence of orientation related to ''Advance Directives. '' The document was signed on 05/01/2023 two days after admission.
MDS Coordinator (employee # 1) stated on interview on 05/01/2023 at 1:30 PM that all residents were oriented concerning the right to accept or refuse medical or surgical treatment as an option and to formulate an advance directive when admitted to the facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a recertification survey, observations of the physical environment, review of policies procedures and facility staff in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a recertification survey, observations of the physical environment, review of policies procedures and facility staff interview performed on 05/01/2023 through 05/02/2023 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to promote the resident right to receive services in a safe, clean, comfortable, and homelike environment. This deficient practice affects 2 out of 11 residents admitted receiving care at the facility.
Findings include:
1. On 05/01/2023 from 8:30 AM through 11:30 AM during the initial pool survey task the following was identified:
a. On room [ROOM NUMBER]-B the temperature of the thermostat indicates room temperature of 63.1 Degree (º) Fahrenheit (F). Resident located in this room had a cognitive pattern that does not permit to interview her to identify room temperature preferences.
b. On room [ROOM NUMBER] temperature on the thermostat indicate room temperature of 67.5º F. Resident located at this room refer that he is cold and that he wants a warmer temperature. Resident stated that anytime he wants a warmer environment in his room it takes a lot of time for personnel to adjust room temperature. He also stated that once the temperature is set based on his preferences he does not know why, the thermostat gets out of control again and the temperature goes down again.
c. On 05/01/2023 at 1:00 PM it was requested to the Nursing Supervisor (employee #2) to adjust the room temperature of room [ROOM NUMBER] accordingly with resident preferences and to review room temperature of room [ROOM NUMBER]-B.
d. On 05/01/2023 at 1:05 PM Nursing Supervisor (employee #2) stated on interview that to adjust the room temperature she needs to call physical environment personnel who are responsible to communicate with air conditioning personnel who may adjust room temperature.
e. On 05/01/2023 at 4:50 PM resident room temperatures policy and procedures were reviewed with Nursing Supervisor (employee #2). Upon review it was identified that policy clearly stated that room temperature must be maintained between 71-81º F or based on resident preferences.
f. Nursing Supervisor (employee #2) was asked on 05/01/2023 at 5:00 PM why resident room temperature does not correspond with facility policy and procedure. She stated that since this Skill Nursing Facility is hospital based and is located on the seventh floor of the hospital, room temperature was set accordingly with hospital policy who is between 65-71ºF. She also stated that this is the reason why she needs to call physical environment personnel who are responsible for communicating with air conditioning personnel who may adjust room temperature.
g. On 05/01/2023 at 5:20 PM it was identified that the room temperature of room [ROOM NUMBER] was set at 71º F according with resident's preferences.
h. On 05/01/2023 at 5:10 PM it was identified that the temperature of room [ROOM NUMBER]-B was set at 71º F.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review #65 is a [AGE] year-old male resident admitted [DATE] with a diagnosis of Left heel Infected Ulcer with Osteomy...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review #65 is a [AGE] year-old male resident admitted [DATE] with a diagnosis of Left heel Infected Ulcer with Osteomyelitis. Resident was admitted for rehabilitation services, wound care and to receive antibiotic therapy.
Resident #65 was interviewed on 05/01/2023 at 10:55 AM and stated that he was admitted to the facility to complete 21 days of antibiotic due to an infection in his left heel.
During the record review performed on 05/02/2023 at 7:42 AM, it was identified that Resident Assessment Instrument comprehensive assessment was performed and completed on 05/02/2023. Pressure ulcer was not triggered, however pressure ulcer plan of care was developed and implemented when resident was admitted to the facility on [DATE].
Nursing Supervisor (employee #2) stated on interview on 05/02/2023 at 9:50 AM that plan of care of residents with pressure ulcer must be review every 14 days in order to address changing goals, preferences and needs of the resident and in response to current interventions.
Plan of care of pressure ulcer of case #65 was developed and implemented, however did not individualized the goals accordance to resident needs and was review on 05/04/2023, no further evaluation of the ulcer plan of care was performed and documented in the medical record.
Based on a recertification survey, review of eleven medical records, resident interview and interview with the Nursing Supervisor (employee #2) performed from 05/01/2023 thru 05/02/2023, from 8:30 AM thru 4:30 PM, it was determined that the facility failed to revise resident's care plan based on changing goals, preferences and needs of the resident and in response to current interventions. This deficient practice was identified in 2 out of 11cases admitted receiving care at the facility. (RR #65 and #68).
Findings include:
1 .Record review #68 is a [AGE] year-old female resident admitted [DATE] with a diagnosis of Left Heel Ulcer and Gluteal Ulcer. Resident was admitted for rehabilitation services, wound care and to receive antibiotic therapy. During the record review performed on 05/02/2023 at 8:40 AM, it was identified that Resident Assessment Instrument comprehensive assessment was performed on 04/14/2023. Pressure ulcer was not triggered, however pressure ulcer plan of care was developed and implemented when resident was admitted to the facility on [DATE].
Nursing Supervisor (employee #2) stated on interview on 05/02/2023 at 9:50 AM that plan of care of residents with pressure ulcer must be review every 14 days in order to address changing goals, preferences and needs of the resident and in response to current interventions. Plan of care of pressure ulcer of case #68 was reviewed on 04/16/2023, no further evaluation of the ulcer plan of care was performed and documented in the medical record.
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 a Recertification survey and review of Beneficiary Protection Notification of the past 6 month, it was determined that ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a Recertification survey and review of Beneficiary Protection Notification of the past 6 month, it was determined that the facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC) is given by the facility to all Medicare beneficiaries at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending. Beneficiary Protection Notification (BPN) of the 3 out of 71 discharges
Findings include:
During the entrance conference the surveyor request the past 6-month discharge resident to review facility meet with the Medicare beneficiary Notification:
On 05/01/2023 at 3:30 PM the Nurse Director employee #1 provide evidence that the Beneficiary Protection Notification of the 3 out of 71 discharges in the last 6 month and provide evidence of the following:
1. Random discharge resident #1 was admitted on [DATE] and the Beneficiary Protection Notification was provided to the resident on 4/18/2023, the resident was discharged home on 4/28/2023 and no evidence was found that the resident was reoriented of the BPN at least two days before the discharge.
2. Random discharge resident #2 was admitted on [DATE] and the Beneficiary Protection Notification was provided to the resident on 02/01/2023, the resident was discharge to home on [DATE] and no evidence was found that the resident was reoriented of the BPN at least two days before the discharge.
3. Random discharge resident #3 was admitted on [DATE] and the Beneficiary Protection Notification was provided to the resident on 01/16/2023, the resident was discharge to home on [DATE] and no evidence was found that the resident was reoriented of the BPN at least two days before the discharge.
4. The facility policies and procedure Advanced Beneficiary Notice of Non-Coverage reviewed on 05/01/2023 at 3:40 PM indicate in the item #3 that in or before 48 hour previous to the discharge date of the services, the assigned personnel notified to the resident or authorized representative about the discharge date through the reorientation of the Advanced Beneficiary Notice of Non-Coverage and the procedure stablished by Medicare to appeal the determination of discharge from services.
The facility failed to ensure that the Notice of Medicare Non-Coverage was provided to the resident before 48 hour previous to the discharge date of the services.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Record review #5 is an [AGE] year-old male admitted on [DATE] with diagnosis of Descondition. The resident was admitted for r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Record review #5 is an [AGE] year-old male admitted on [DATE] with diagnosis of Descondition. The resident was admitted for rehabilitation services. During the record review on 5/02/2023 at 9:11 AM, it was observed and identified that the Baseline Care Plan was incomplete, the initial goals were not established, medical orders and physical therapy.
On 4/05/2023 at 7:40 PM it was observed that the initial medical order was made by telephone by the nursing staff and there was no face-to-face admission process by the physician.
The Nursing Supervisor (Employee #2) was interviewed regarding the medical order taken by the nursing staff via telephone, she asserted that it was the medical order.
The Medical Director (Employee #3) was interviewed and said that the admission was electronic, but they did not provide the surveyor evidence of the electronic admission.
7. Record review #63is a [AGE] year-old male admitted on [DATE] with diagnosis of Pressure Ulcer of Sacral Region, Stage 4. During the record review on 5/01/2023 at 5:10 PM, it was observed and identified that the Baseline Care Plan was incomplete, the initial goals were not established, medical orders, physical therapy and there was signature of the resident or representative.
On 4/11/2023 at 2:30 PM it was observed that the initial medical order was made by telephone by the nursing staff and there was no face-to-face admission process by the physician.
The Nursing Supervisor (Employee #2) was interviewed regarding the medical order taken by the nursing staff via telephone, she asserted that it was the medical order.
The Medical Director (Employee #3) was interviewed and said that the admission was electronic, but they did not provide the surveyor evidence of the electronic admission.
4. Record review #4 is a [AGE] year-old female resident admitted [DATE] with a diagnosis of Right Foot Infected Surgical Wound with Osteomyelitis. Resident was admitted for rehabilitation services, wound care and to receive antibiotic therapy. During the record review performed on 05/02/2023 at 9:38 AM, it was identified that the Baseline Care Plan was performed on 04/06/2023 the resident was oriented however, did not have established initial goals for treatment based on the admission orders.
Nursing Supervisor (employee #2) stated in an interview on 05/02/2023 at 4:35 PM that in this case #4 a copy of the baseline care plan was prepared and provided to the resident representative within 48 hours of resident admission to the facility incomplete. She stated that this initial plan of care lacks the initial goals for treatment based on admission orders.
5. Record review #65 is a [AGE] year-old male resident admitted [DATE] with a diagnosis of Left heel Infected Ulcer with Osteomyelitis. Resident was admitted for rehabilitation services, wound care and to receive antibiotic therapy. During the record review performed on 05/02/2023 at 7:42 AM, it was identified that the Baseline Care Plan was performed on 04/28/2023 the resident was oriented however, did not have established the Occupational Therapist and Social worker intervention for treatment based on the admission orders.
Based on a recertification survey, review of eleven medical records, resident interview and interview with the Nursing Supervisor (employee #2) performed from 05/01/2023 thru 05/02/2023, from 8:30 AM thru 4:30 PM, it was determined that the facility failed to develop and implement a complete baseline care plan within 48 hours of a resident's admission in order to promote the continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services. This deficient practice was identified in 6 out of 11 cases reviewed. (RR #4, #5, #63, #65, #66 and #68).
Findings include:
1.Record review #66 is a [AGE] year-old female resident admitted [DATE] with a diagnosis of Sacral Ulcer Stage 4 with Osteomyelitis. Resident was admitted for rehabilitation services, wound care and to receive antibiotic therapy. During the record review performed on 05/01/2023 at 4:30 PM, it was identified that the Baseline Care Plan did not have established initial goals for treatment based on the admission orders.
Nursing Supervisor (employee #2) stated in an interview on 05/01/2023 at 4:35 PM that in this case #66 a copy of the baseline care plan was prepared and provided to the resident representative within 48 hours of resident admission to the facility incomplete. She stated that this initial plan of care lacks the initial goals for treatment based on admission orders. She stated that the baseline care plan must reflect the resident's stated goals and objectives, and include interventions that address his or her current needs. Nursing supervisor (employee #2) explain that this baseline care plan must be based on the admission orders, information about the resident available from the transferring provider, and discussion with the resident and resident representative, if applicable.
2. Record review #68 is a [AGE] year-old female resident admitted [DATE] with a diagnosis of Left Heel Ulcer and Gluteal Ulcer. Resident was admitted for rehabilitation services, wound care and to receive antibiotic therapy. During the record review performed on 05/02/2023 at 8:40 AM, it was identified that the Baseline Care Plan did not have established initial goals for treatment based on the admission orders.
Nursing Supervisor (employee #2) stated in an interview on 05/02/2023 at 9:00 AM that in this case #68 a copy of the baseline care plan was prepared and provided to the resident within 48 hours of resident admission to the facility incomplete. She stated that this initial plan of care lacks the initial goals for treatment based on admission orders. She stated that the baseline care plan must reflect the resident's stated goals and objectives and include interventions that address his or her current needs. Nursing supervisor (employee #2) explain that this baseline care plan must be based on the admission orders, information about the resident available from the transferring provider, and discussion with the resident and resident representative, if applicable.
3. Upon review of facility policy and procedure Plan de Cuidado Inicial with Nursing Supervisor (employee #2) on 05/02/2023 at 10:00 AM it was identified that policy clearly establish that the initial plan of care must to address, at a minimum initial goals based on admission orders, Physician orders, dietary orders therapy services and social services.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on a recertification survey, observational tour of the facility's kitchen performed from 05/01/2023 thru 05/02/2023, from 8:40 AM thru 4:30 PM and interview with administrative dietitian (employ...
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Based on a recertification survey, observational tour of the facility's kitchen performed from 05/01/2023 thru 05/02/2023, from 8:40 AM thru 4:30 PM and interview with administrative dietitian (employee # 9), it was identified that the facility failed to store and prepare food in accordance with professional standards for food service safety and maintain kitchen areas in good condition in order to promote sanitary conditions and the prevention of foodborne illness. This deficient practice has the potential to affect 11 out of 11 admitted residents.
Findings include:
1. On 05/01/2023 from 8:40 AM through 4:30 PM during the initial brief tour to the kitchen the following was observed:
a. Turkey pieces were observed defrosting in a kitchen sink at the side of the kitchen production area at 9:15 AM. Water is running directly on the frozen pieces of turkey from 9:15 AM through 11:20 AM. At 11:30 AM turkey beef is still frozen.
b. There are not any employees checking the temperature of the water in the sink compartment.
c. Facility policy and procedure for thaw frozen turkey pieces last updated in August 2022 was review with administrative dietitian (employee # 9) on 05/01/2022 at 11:55 AM. During the review the administrative dietitian (employee # 9) stated on interview that if turkey pieces is going to be defrost in running water, kitchen personnel must make sure that water is maintained at 70 degrees Fahrenheit.
d. A walking freezer located at the dry food storage area is observed with rust on the floor area and in the shelves.
e. Dairy refrigerator is observed with rust on shelves.
f. Frozen vegetables storage refrigerator is observed in need of cleaning.
g. Beef storage refrigerator is observed with rust on shelves.
h. Cooking sauce, fresh condiments sauerkraut (dill cabbage) was observed in the refrigerator without label who indicates the date when was prepared and stored.
i. A 3.78-liter mayonnaise container is observed on the refrigerator without label who indicates the date when was opened.
j. A spray dispenser bottle without indicating the percentage of dilution of Clorox is observed at the food preparation area.
k. Men's and women's kitchen employee bathroom were observed with peel paint in the toilet seat and ceiling tiles in bad condition.
l. A roll of toilet paper out of the dispenser is observed at the men's kitchen employee bathroom.
m. A urinal located at the men's kitchen employee bathroom is observed out of service.
n. Musty odor is perceived at the men's kitchen employee bathroom.
o. All kitchen equipment made of stainless steel (tables, counters, refrigerators doors, steam table and shelves) were observed in need of cleaning and maintenance.
2. On 05/02/2023 from 9:00 AM through 10:25 AM during the follow-up visit to the kitchen the following was observed:
a. In the kitchen area where personnel put the rack with clean and disinfected food trays to be used to transport food to residents the ceiling area is observed in bad condition. This ceiling was observed with peeling paint, has lost its original shape, and appears to have a leak.
b. The cover area (panels) of motor in tray washing machine was observed covered full in rust.
c. A cart used to store clean resident food trays was observed with rust on the shelves.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected most or all residents
Based on recertification survey, performed on 05/01/23 through 05/02/23 from 8:00 AM till 4:30 PM review of Quality Assessment Performance Improvement (QAPI) program documentation and interview with D...
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Based on recertification survey, performed on 05/01/23 through 05/02/23 from 8:00 AM till 4:30 PM review of Quality Assessment Performance Improvement (QAPI) program documentation and interview with Director of Nursing (employee #1) and Medical Director (employee #3), it was determined that facility failed to implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. This deficiency had the potential to affect 11 out of 11 admitted residents receiving services at the facility.
Findings include:
1.The following was identified while reviewing Quality Assessment Performance Improvement (QAPI) program documentation and activities on 05/02/2023 at 11:45 AM:
a. Accordingly with information provided by Director of Nursing (employee #1) and Medical Director (employee #3) on interview on 05/02/2023 at 11:50 AM as an established rule QAPI committee meeting must be performed every three months to discuss indicators and measurement(s) of facility performance.
b. During the natural year 2022 no QAPI committee meetings were not evidence as performed on the months of May, June, July, or August.
c. Accordingly with information provided by Director of Nursing (employee #1) during interview on 05/02/2023 at 11:55 AM QAPI officer resign in June 2022 and facility begin to look for an employee for this position.
d. Data collection and analysis were performed at regular intervals; however, documentation demonstrating development, implementation and evaluation of corrective actions or performance improvement activities based on indicators and measurement(s) of facility performance was not found documented or evidenced for the months of May, June, July or August of year 2022.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on recertification survey, performed on 05/01/23 through 05/02/23 from 8:00 AM till 4:30 PM review of Quality Assessment Performance Improvement (QAPI) program documentation and interview with D...
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Based on recertification survey, performed on 05/01/23 through 05/02/23 from 8:00 AM till 4:30 PM review of Quality Assessment Performance Improvement (QAPI) program documentation and interview with Director of Nursing (employee #1) and Medical Director (employee #3), it was determined that facility failed to evidence the participation of the Infection Preventionist and Medical Director on their quality assessment and assurance committee. This deficiency had the potential to affect 11 out of 11 admitted residents receiving services at the facility.
Findings include:
1.The following was identified while reviewing Quality Assessment Performance Improvement (QAPI) program documentation and activities on 05/02/2023 at 11:45 AM:
a. No participation of medical director was identified after reviewing QAPI committee meeting documentation and QAPI committee meeting attendance list on September 6, 2022.
b. No participation of infection preventionist was identified after reviewing QAPI committee meeting documentation and attendance list on October 17, 2022, January 31, 2023, and April 04, 2023.
c. No attendance list was found as part of the QAPI committee meeting documentation for the meeting performed on January 31, 2023.
d. Accordingly with information provided by Director of Nursing (employee #1) during interview on 05/02/2023 at 12:05 PM infection prevention officer resigns in June 2022 and facility begins to look for an employee for this position. She also stated that the former facility infection preventionist continue providing services as a contractor employee until the month of March 2023. In March 2023 a current facility employee finishes the infection prevention course and facility appoint this current facility employee as infection preventionist.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Record review #65 is a [AGE] year-old male resident admitted [DATE] with a diagnosis of Left heel Infected Ulcer with Osteomy...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Record review #65 is a [AGE] year-old male resident admitted [DATE] with a diagnosis of Left heel Infected Ulcer with Osteomyelitis. Resident was admitted for rehabilitation services, wound care and to receive antibiotic therapy.
During resident interview performed on 05/01/23 at 10:55 AM it was observed that the bandage of the left heel was with abundant exudate resident state that today they are going to provide the wound care by the nurse.
On 05/01/23 05:47 PM during the wound care provided by RN employee #4, it was observed that during the procedure the RN have 11 opportunity to wash his hand and failed to wash his hand in 8 out of 11 opportunity.
Based on a recertification survey, observations of ulcers care procedures performed on 05/01/2023 through 05/02/2023 at 8:00 AM to 4:00 PM and interview with the infection preventionist (IP) (employee #12), it was determined that the facility failed to ensure that infection prevention practice and hand hygiene procedures are followed as required when direct care and procedures are performed to residents. This deficient practice affects 2 out of 11 residents (R#62 and R#65)
Findings include:
1. Record review #62 is a [AGE] year-old female resident admitted [DATE] with a diagnosis of Deconditioning. Right thigh ulcer. Resident was admitted for rehabilitation services physical and occupational therapy.
a. During resident interview performed on 05/01/23 at 9:30 AM it was observed that the resident has adhesive gauze on the right thigh. Resident state that today they are going to provide the wound care and the skin nurse evaluation was pending.
b. On 05/01/23 at 2:45 PM during the wound care provided by RN employee #12, it was observed that during the procedure the RN had 12 opportunities to wash her hands or used hand sanitizer and failed to wash her hands in 10 out of 12 opportunities.
c. During the treatment process, the nurse only washed her hands before and after performing the wound local care. The nurse removed the bandage, and a thick yellow exudate and blood was observed. The nurse performed open the sterile gauze and applied Derma wound cleanser and provide local care per two times, she did not remove gloves and applied Silver Alginate, then measured the ulcer and cleaned blood draining from the ulcer and applied collagen for two occasions. Then she removed gloves and left outside the room to take gauze from the cart of materials. She entered the room, put on a pair of gloves, opened sterile gauze and dried blood that came out of the ulcer, then placed two sterile gauzes covered with adhesive pad and label the bandage.
d. On 05/01/2023 at 1:15 PM the nurse (employee #12) failed to change her gloves and failed to perform hand hygiene with soap and water when performed the ulcer local care of the right thigh. Only performed the hand hygiene before and after the ulcer local care.
2. On 05/01/2023 at 8:20 AM in the interior of the bathroom designated for Occupational therapy, a plastic cart was observed in the interior of the bathtub. On the first shelf a plastic bag with an air mattress was observed. One chair, a trash can without a bag and two commodes were observed. This bathroom does not have a sink when the resident or staff uses the toilet, they have to open the door without washing their hands and use the sink that is located near the ice machine in the area where occupational therapy activities are offered to residents. This practice constituted high risk of cross contamination.
3. The designated infection control nurse employee (#12) was interviewed on 05/02/2023 at 9:10 AM. She stated I am a general nurse and I have been in the skilled nursing facility (SNF) for three years. I cover the floor as a nurse at different times and I am also designated as an Infection Control nurse in March this year. The nurse who was in infection control resign in August 2022. Before leaving, he was guiding me for several days for approximately three weeks. I have been here since March of this year, and I cover shifts in the SNF from 7:00 AM to 7:00 PM including Saturdays and Sundays. The educational workshops were given by the nurse who resigned. Now I give them based on the needs of the employee. Monitoring the employee and if any malpractice is identified, action is taken. ''
4. The Nurse Director (DON) employee (#1) was interviewed on 05/02/2023 at 10:00 AM related to the (employee #12) designated as an infection control nurse and she said: ' The nurse who was the infection control resign in August 2022. He/she was hired and offered counseling services to the new designated nurse (employee #12) for approximately three weeks.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on recertification survey, performed on 05/01/23 through 05/02/23 from 8:00 AM till 4:30 PM review of Infection Control program documentation and interview with Director of Nursing (DON) (employ...
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Based on recertification survey, performed on 05/01/23 through 05/02/23 from 8:00 AM till 4:30 PM review of Infection Control program documentation and interview with Director of Nursing (DON) (employee #1) and the Infection Preventionist Nurse (IPN) (employee #12), it was determined that facility failed to evidence the participation of the infection control committee. This deficiency had the potential to affect 11 out of 11 admitted residents receiving services at the facility.
Findings include:
1. The Nurse Director (DON) employee (#1) was interview on 05/02/2023 at 10:00 AM related to the (employee #12) designated as an infection control nurse and she said: '' The nurse who was in infection control resign in August 2022. Employee #12 was hired, and counseling services were offered to designated nurse for approximately three weeks in March 2023.
2. The designated infection control nurse employee #12 was interviewed on 05/02/2023 at 9:10 AM. She stated 'I am a general nurse and I have been in the skilled nursing facility (SNF) for three years. I cover the floor as a nurse at different times and I am also designated as an Infection Control nurse in March this year. The nurse who was in infection control resign in August 2022. Before leaving, he was guiding me for several days until March. I have been here since March of this year, and I cover shifts in the SNF from 7:00 AM to 7:00 PM including Saturdays and Sundays. The educational workshops were given by the nurse who resigned. Now I give them based on the needs of the employee. Monitoring the employee and if any malpractice is identified, action is taken. In March 2023 a current facility employee finish the infection prevention course and the facility appoint this current facility employee as infection preventionist.
3. The designated infection control nurse employee #12 failed to provide evidence of the infection control committee. No evidence of who are the members of the committee and lacks evidence of meeting minutes.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on recertification survey, performed on 05/01/23 through 05/02/23 from 8:00 AM till 4:30 PM observations and interview with Information Technician (employee #7) it was identified that facility f...
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Based on recertification survey, performed on 05/01/23 through 05/02/23 from 8:00 AM till 4:30 PM observations and interview with Information Technician (employee #7) it was identified that facility failed to comply with §483.35(g) Nurse Staffing Information and §483.35(g)(4) Facility data retention requirements.
Findings include:
1.The following was identified performing initial observational tour at the facility on 05/01/2023 at 10:00 AM:
a. Staffing information at the facility is posted on a computer screen at the entrance to the facility.
b. This staffing information did not include the date to which it corresponds the information.
c. This staffing information did not include the total number and the actual hours worked by registered nurses and licensed practical nurses responsible for resident care per shift.
d. During the interview on 05/01/2023 at 1:30 PM Information Technician (employee #7) stated that information posted through this computerized system were not store for minimum of 18 months. He stated that every day, new posting information is written once the previous one is deleted.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0740
(Tag F0740)
Minor procedural issue · This affected most or all residents
Based on recertification survey review of policies and procedures, record review, and interview, with Medical Director (employee #3), it was determined that the facility failed to have an organized be...
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Based on recertification survey review of policies and procedures, record review, and interview, with Medical Director (employee #3), it was determined that the facility failed to have an organized behavioral health care and services program, to promote the maintenance of highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care to residents with mental and substance use disorders.
Findings include:
On survey procedures behavioral health care and services program policies and procedures were requested to the facility Medical Director.
During interview on 05/02/2023 at 1:00 PM Medical Director (employee #3), stated that facility did not have an organized Behavioral health services program or policies and procedures of a Behavioral health services. He stated that if a resident needs a Behavioral health services program due to a mental and substance use disorders, they proceed to consult the case with their hospital psychiatrist (this is a hospital based SNF) or make an appointment with psychiatrist and Skill Nursing Facility personnel accompanies the resident to the appointment. In relation to psychology services if needed he stated that facility proceeds to procure the services from an outside resource and that facility makes sure that resident receive the services.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0741
(Tag F0741)
Minor procedural issue · This affected most or all residents
Based on recertification survey review of policies and procedures, record review, and interview, with Medical Director (employee #3), it was determined that the facility failed to have an organized pr...
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Based on recertification survey review of policies and procedures, record review, and interview, with Medical Director (employee #3), it was determined that the facility failed to have 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:
On survey procedures behavioral health care and services program personnel roster schedule were requested to the facility Medical Director (employee #3).
During interview on 05/02/2023 at 1:20 PM Medical Director (employee #3) stated that facility did not have an organized Behavioral health services program or policies and procedures of a Behavioral health services. He stated that if a resident needs a Behavioral health services program due to a mental and substance use disorders, they proceed to consult the case with their hospital psychiatrist (this is a hospital based SNF). In relation to psychology services if needed she stated that facility proceeds to procure the services from an outside resource and that facility makes sure that resident receive the services or make an appointment with psychiatrist and Skilled Nursing Facility personnel accompanies the resident to the appointment.
Medical Director (employee #3) explains on 05/02/2023 at 1:30 PM that once facility develops policies and procedures to implement a Behavioral health services program, is going to be determine if the staff needed to implement those services from the facility or as an outside contractor.
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
- • 32% turnover. Below Puerto Rico's 48% average. Good staff retention means consistent care.
Concerns
- • 33 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • $68,560 in fines. Extremely high, among the most fined facilities in Puerto Rico. Major compliance failures.
Bottom line: Mixed indicators with Trust Score of 60/100. Visit in person and ask pointed questions.
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About This Facility
What is Alternative Healthcare Solutions Llc's CMS Rating?
CMS assigns ALTERNATIVE HEALTHCARE SOLUTIONS LLC an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Puerto Rico, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Alternative Healthcare Solutions Llc Staffed?
CMS rates ALTERNATIVE HEALTHCARE SOLUTIONS LLC's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 32%, compared to the Puerto Rico average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Alternative Healthcare Solutions Llc?
State health inspectors documented 33 deficiencies at ALTERNATIVE HEALTHCARE SOLUTIONS LLC during 2023 to 2024. These included: 28 with potential for harm and 5 minor or isolated issues.
Who Owns and Operates Alternative Healthcare Solutions Llc?
ALTERNATIVE HEALTHCARE SOLUTIONS LLC 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 22 certified beds and approximately 12 residents (about 55% occupancy), it is a smaller facility located in SAN JUAN, Puerto Rico.
How Does Alternative Healthcare Solutions Llc Compare to Other Puerto Rico Nursing Homes?
Compared to the 100 nursing homes in Puerto Rico, ALTERNATIVE HEALTHCARE SOLUTIONS LLC's overall rating (4 stars) is above the state average of 3.5, staff turnover (32%) is significantly lower than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Alternative Healthcare Solutions Llc?
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 Alternative Healthcare Solutions Llc Safe?
Based on CMS inspection data, ALTERNATIVE HEALTHCARE SOLUTIONS LLC has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Puerto Rico. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Alternative Healthcare Solutions Llc Stick Around?
ALTERNATIVE HEALTHCARE SOLUTIONS LLC has a staff turnover rate of 32%, which is about average for Puerto Rico nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Alternative Healthcare Solutions Llc Ever Fined?
ALTERNATIVE HEALTHCARE SOLUTIONS LLC has been fined $68,560 across 15 penalty actions. This is above the Puerto Rico average of $33,764. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Alternative Healthcare Solutions Llc on Any Federal Watch List?
ALTERNATIVE HEALTHCARE SOLUTIONS LLC 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.