CENTRO MEDICO WILMA N VAZQUEZ SNF
For profit - Corporation
45 Beds
Independent
Data: November 2025
Trust Grade
35/100
#6 of 6 in PR
Last Inspection: December 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Centro Medico Wilma N Vazquez SNF has a Trust Grade of F, indicating significant concerns about the quality of care provided. They rank #6 out of 6 nursing homes in Puerto Rico, placing them in the bottom tier of facilities in the state. The facility's trend is worsening, with the number of reported issues increasing from 9 in 2023 to 26 in 2024. Staffing is a relative strength with a good rating of 4 out of 5 stars and a turnover rate of 34%, which is average for the area. However, the facility has concerning fines of $29,997, higher than 88% of other facilities in Puerto Rico, suggesting ongoing compliance issues. Specific incidents include a nurse failing to wash hands during medication administration on 19 occasions, which raises infection risk, and the kitchen was found in poor condition with broken equipment and food safety violations, such as improper food temperatures and unsanitary conditions. While the staffing situation is stable, these serious health and safety concerns indicate that families should carefully consider these issues when evaluating this facility for their loved ones.
- Trust Score
- F
- In Puerto Rico
- #6/6
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 34% turnover. Near Puerto Rico's 48% average. Typical for the industry.
- Penalties ✓ Good
- $29,997 in fines. Lower than most Puerto Rico facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 193 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
- 35 deficiencies on record. Higher than average. Multiple issues found across inspections.
35/100
Bottom 1%
No red flags
9 → 26 violations
★☆☆☆☆
1.0
Overall Rating
★★★★☆
4.0
Staff Levels
☆☆☆☆☆
0.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2023: 9 issues
2024: 26 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (34%)
14 points below Puerto Rico average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
1-Star Overall Rating
Below Puerto Rico average (3.5)
Significant quality concerns identified by CMS
Staff Turnover: 34%
11pts below Puerto Rico avg (46%)
Typical for the industry
Federal Fines: $29,997
Below median ($33,413)
Moderate penalties - review what triggered them
The Ugly 35 deficiencies on record
Dec 2024
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations made during the initial pool process and facility staff interview performed on 12/04/2024 through 12/06/20...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations made during the initial pool process and facility staff interview performed on 12/04/2024 through 12/06/2024 to from 8:00 AM through 3:30 PM, it was determined that the facility failed to promote the right of each resident to have personal privacy. This deficient practice had the potential to affect 8 out of 8 residents receiving services.
Findings include:
1. During the initial pool process on 12/04/2024 at 8:55 AM it was observed that the resident located in room [ROOM NUMBER]-B (resident #58) participating in Occupational Therapy treatment.
2. The resident was observed sitting on the edge of the bed.
3. The resident was observed with only clothing from the waist down than the disposable diaper.
4. The curtain was drawn, however personnel failed to provide visual personal privacy before beginning the treatment.
The Nursing supervisor (employee #6) was asked by the surveyor on 12/04/2024 at 9:00 AM if residents had available pajama pants.
The Nursing supervisor stated in an interview on 12/04/2024 that the resident had pajama pants available and that rehabilitation personnel must ensure the resident is dressed before beginning treatment.
The Director of Nursing DON (employee #10) was asked by the surveyor on 12/04/2024 at 10:55 AM in relation to facility policy and procedure to promote personal privacy to residents.
5.The DON stated that the facility does not have a personal privacy policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1.RR # 3 is an [AGE] year-old female resident with Dx of Pneumonia, Muscle Decondition, S/P hip arthroplasty, depression and anx...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1.RR # 3 is an [AGE] year-old female resident with Dx of Pneumonia, Muscle Decondition, S/P hip arthroplasty, depression and anxiety disorder, was admitted on [DATE], due to status post left hip fracture, resident is chronically bedridden.
The resident was visited on 12/04/2024 at 8:53 AM and observed several albuterol pumps (Brand name Proventil - is a bronchodilator that relaxes muscles in the airways and increases air flow to the lungs) on the side of the bed. The resident says that she needs to see them when she wakes up because if she does not see them, she has a panic attack.
Several interviews and investigations were conducted and show the following:
a. There was a total of 6 albuterol pumps (Proventil), 4 empty and 2 in use, all with expiration dates between March and May 2026.
b. On 12/04/2024 at 9:35 AM during interview with the MDS coordinator (employee #7) to request self-administration policy and patient entitlement. Employee #7 provides a policy used in the hospital indicating that patients should not self-administer medications during their stay, except for some cases.
The Interdisciplinary group care plan to address resident conditions and needs to self-administer this respiratory treatment was requested by the surveyor but was not available.
2. On 12/04/2026 at 9:50 AM clinical record is reviewed, and residents have order for Albuterol inhale (Proventil) 2 pumps every 4 hours PRN. There is no medical order to have the medication at the bedside or self-administration.
3. On 12/05/2024 at 10:30 AM Medical director (employee #15) is interviewed regarding what was identified on this resident medical record.
The medical director (employee #15) stated that they have tried several times to remove the pumps from bedside and try another treatment, but the resident refused. She explains that they opted to leave the pump next to the bed so she can see them. She also says that the resident does everything with the help of the nursing staff except for the self-administration of the medication albuterol (Proventil).
4. On 12/06/2024 at 9:10 AM an interview was conducted with the facility pharmacist (employee #14). This to evaluate why the medication regimen review did not include the Albuterol pump (Proventil) as a medication that resident had at bedside, to self-administer it.
The facility pharmacist (employee #14) stated on 12/06/2024 at 9:30 AM that the resident had ordered to use Albuterol in pump as part of her drug regimen, but no to have the medication at bedside to self-administer. She stated that the facility plans to hold a meeting with the interdisciplinary group to discuss resident cases and determine if is appropriate and safe that this resident self-administer this medication.
Based on observations made during the initial pool process, records reviwed (RR) and facility staff interview performed on 12/04/2024 through 12/06/2024 to from 8:00 AM through 3:30 PM, it was determined that the facility failed to ensure that there is documentation of resident capacity and plan of care to have medications at bedside self-administer these medications. This deficient practice was identified in 1 out of 8 residents receiving services (RR#3).
Findings include:
The facility's Policy & Procedures, WNV-FARM-028 Self Administration of Medications last updated March 2023 is reviewed with pharmacist on 12/06/2024 at 9:00 AM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected 1 resident
Based on review of policies, procedures and facility staff interview performed on 12/06/24 to from 8:00 AM through 4:30 PM, it was determined that the facility failed to comply with the policy regardi...
Read full inspector narrative →
Based on review of policies, procedures and facility staff interview performed on 12/06/24 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 on 12/06/2024 at 10:00 AM of facility's policy and procedure Almacenaje, Limpieza y Mantenimiento de Neveras Departamentales, Storage, Cleaning and Maintenance of Departmental Refrigerators stated that all food in the refrigerator must be identified with the resident's initials, room number and date.
Approximately at 9:30 AM some snacks (birthday cake and snacks) were observed with no date or labeled in the residents' refrigerator.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 12/04...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 12/04/2024 through 12/06/2024 to from 8:00 AM through 3:30 PM, it was determined that the facility failed to promote the residents right to receive services in a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect 8 out of 8 residents receiving services at areas where the deficient environment and items (equipment) is located.
Findings include:
1. Residents on rooms [ROOM NUMBERS] complained about room temperatures being too cold, when the surveyor took temperature measurement it was noted that room temperatures exceeded the temperature stated in the facility's temperature policy Temperatura y Humedad relativa de las Habitaciones [NAME] Skilled Nursing Facility Temperature and Relative Humidity of the rooms of the Skilled Nursing Facility, which states that room temperature should be between 71- and 80-degrees (º) Fahrenheit (F).
a. 101 - 66º F
b. 104 - 64º F
2. Grab bars in the bathroom on rooms 111, 113 and 117 were observed loose.
3. Headlights cord behind beds were observed tied with ribbons or no cord (rooms 111, 121).
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** 3. During the assembly of the food trays carried out on December 4, 2024, at 11:20 AM, the food had the following temperatures: ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During the assembly of the food trays carried out on December 4, 2024, at 11:20 AM, the food had the following temperatures: vegetable mash (146 Degrees (º) Fahrenheit (F)), meat (162ºF), soup (168ºF), milk (52ºF).
4. Tray was performed on December 4, 2024, at 11:40 AM, the food had the following temperatures: vegetable mash (130 ºF), meat (109ºF), soup (137.7º F), milk (63.5º F), fruit dessert (65.4ºF).
5. Except for soup, hot foods were not covered. All components/food (hot and cold ones) were placed on a Styrofoam disposable tray.
Clinical Nutritionist (employee #1) stated in the interview on 12/04/2024 at 11:20 AM that the temperature parameters for food are 140º F for hot foods and 40º F for cold foods.
Based on initial tour observation, resident interview, observations done during the assembly of the food trays, staff interviews and policies reviewed (Line assembly and delivery of meals or special foods), it was determined that the facility failed to ensure that food and drink is palatable, attractive, and at a safe and appetizing temperature. This deficient practice was identified in 1 out of 8 residents receiving services (sample resident #106).
Findings include:
1. Resident #106 is an [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Right Hip Fracture, on 12/04/2024 at 8:30 AM during resident interview he state that the food came on disposable Styrofoam every time and that when he eats was cold.
2. During the test trays performed on 12/04/2024 at 11:46 AM was observed that all the food came in a Styrofoam tray inside came a match sweat potatoes with chicken thigh that was an open tray, over them came a plastic glass with carrot, a plastic bowl with Stew with rice, plastic cup of milk, and plastic cup of apple sauce. During the temperature test the following was found:
a. Mach sweat potatoes: 140 grade(º) Fahrenheit (F)
b. Chicken Thigh: 109ºF
c. Carrots: 80ºF
d. Stew with rice: 137.7ºF
e. Apple sauce: 65.4ºF
d. Milk: 63.5ºF.
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 12/04/2024 through 12/06/2024 from 8:00 AM through 3:30 PM, it was determined that the fac...
Read full inspector narrative →
Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 12/04/2024 through 12/06/2024 from 8:00 AM through 3:30 PM, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Findings include:
1. During the visual inspection of the kitchen area it was observed that the High Temperature Sanitizing Door-type Dishwasher was inoperable at the time of the survey. This was confirmed by the Nutritional Services Manager (employee #1) who stated Sanitizing Dishwasher has been broken since September 2024.
2. During the visual inspection of the kitchen area it was observed that the Dish washing detergent and Arrex dispenser were inoperable at the time of the survey. This was confirmed by the Nutritional Services Manager (employee #1) who stated that the automatic dispenser has been broken since October 2024.
3. Food remains were observed on the floor below the food line.
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** 5. During the medication pass performed on 12/05/2024 from 8:40 AM through 9:30 AM, the following was identified:
a. Register nu...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. During the medication pass performed on 12/05/2024 from 8:40 AM through 9:30 AM, the following was identified:
a. Register nurse (employee # 2) did not perform handwashing in 19 opportunities while administering medications to five patients under her care.
6. During review of the crash cart on 12/05/2024 at 9:30 AM, with the register nurse (employee # 2), the following was identified:
a. Three Vacuproo safety blood collections had expiration date of June 2024.
b. One blood gas [NAME] had expiration date of May 2023.
Based on observation during the drug pass, it was determined that the facility failed to ensure establish and maintain an infection prevention to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections and hand hygiene procedures be followed by staff involved in direct resident contact for 6 out of 6 observations
Findings include:
1. During the drug pass performed on 12/05/2024 from 08:25 AM till 8:39 AM, it was observed that the registered nurse Registered Nurse (RN) #2 initiate with the drug pass without washing her hand and disinfecting the medication cart.
2. During the medication preparation for resident #106 the nurse put her glove without washing her hand, the resident request to RN #2 to provide a jar of gum in the floor, the RN procced to take the gum jar of the floor placed it over the dinner table, and do not remove her glove and continue administrating the resident medication without removing her gloves and washing her hand.
3. When finish with the RN #2 discard the trash, remove her glove and without washing her hand put on another glove and continue to serve medication of the other residents.
4. The RN #2 failed to wash her hand on 5 out of 5 opportunities to wash her hands.
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 of the physical environment, on 12/04/2024 through 12/06/2024 to from 8:00 AM through 3:30 PM, it was dete...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment, on 12/04/2024 through 12/06/2024 to from 8:00 AM through 3:30 PM, it was determined that the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition. This deficient practice had the potential to affect 8 out of 8 residents receiving services at areas where the deficient environment and items (equipment) is located.
Findings include:
1. Commodes on bathrooms of rooms [ROOM NUMBERS] were observed with rust in component parts.
2. 3 out of 3 four contact points walkers were observed with rust in the base.
3. 1 out of 4 crutches was observed with medical tape on the grab cushion.
Apr 2024
18 deficiencies
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 observations, review of fifteen records reviewed (R.R.) records, and interview with social worker (employee #11), it wa...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of fifteen records reviewed (R.R.) records, and interview with social worker (employee #11), it was determined that the facility failed to comply with the requirements with Advance Directives. This deficient practice was identified in 2 out of 15 records reviewed of selected for the initial pool (RR#1, RR#59).
Findings include:
Review of policy WNV-SNF-Title: Directrices Anticipadas, Advance Directives last update in December 2023, was reviewed on 04/08/2024 at 1:35 PM with Social Worker (employee #11). The policy clearly stated on the procedures that every resident admitted to the facility is oriented by admission personnel in relation to advance directives. In section 6.5 procedures policy establish that in cases where is necessary based on alteration on cognitive status in the resident, that the resident representative accept or refuse medical or surgical treatment facility must notify a physician who will be the professional in charge to take the advance directive.
1. During the review of initial pool sample RR # 1 it was identified that this [AGE] year-old female residents was admitted on [DATE] with a diagnosis of General Weakness. Review of medical record evidence that facility did not have any information related with advance directives and there is no information provided by the admission department to resident relatives concerning to the right to accept or refuse medical or surgical treatment as an option and to formulate an advance directive.
Social worker (employee # 11) stated in an interview on 04/09/2024 at 8:25 AM that this resident is not mentally competent and could not formulate advance directives. Social worker also stated that social services department had not been informed that this resident does not have advance directives due to her cognitive status, in order to coordinate with relatives that they establish advance directives for medical decisions.
2. During the review of initial pool sample RR # 59 it was identified that this [AGE] year-old female resident was admitted on [DATE] with a diagnosis of Left Hip Fracture. Review of medical record evidence that facility did not have any information related with advance directives and there is no information provided by the admission department to resident relatives concerning to the right to accept or refuse medical or surgical treatment as an option and to formulate an advance directive.
Social worker (employee # 11) stated in an interview on 04/09/2024 at 9:00 AM that this resident present episodes of altered mental status in where she is observed confused and less alert from normal and she is not able to formulate advance directives. Social worker also stated that social services department had not been informed that this resident does not have advance directives due to her cognitive status, to coordinate with relatives that they establish advance directives for medical decisions.
3. The facility failed to have a mechanism in place to ensure that in cases where there is a change in mental status and could not establish advance directives for medical decisions, relatives or resident representatives were informed of the issue. No information was found documented on the medical record related to medical treatment and care relatives of resident representative make or advance directives formulation.
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** During observational tour of the facicity the following was observed:
10. Resident in room [ROOM NUMBER] A stated that room was...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During observational tour of the facicity the following was observed:
10. Resident in room [ROOM NUMBER] A stated that room was too cold.
11. Beds are noted with rust and some broken components (hand rails) throughout the facility.
12. Three commodes were found with broken arm rest and sharp edges on rooms 103, 106, 115.
13. Holding grip next to toilet in room [ROOM NUMBER] was observed loose
Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 04/08/2024 through 04/09/2024 to from 8:00 AM through 5:30 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 had the potential to affect 19 out of 21 residents receiving services at areas where the deficient environment and items (equipment) is located.
Findings include:
During initial observational tour the following was observed related with environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, and bathrooms:
1. Night tables located on resident rooms 107-A,107-B, and 110, were observed with the front door out of square.
2. The bed, located in room [ROOM NUMBER]-B, was observed with rust on the metal areas of the base.
3. Bedside rest chairs located in rooms 104-B and 110-A were observed with rust on the metal areas.
4. Doors of room [ROOM NUMBER],107, 108 and 110 squeak when open.
5. Weight scale was observed with rust.
6. Floor of rooms 104,107,108 and 110 were observed with dark spots.
7. The area in the wall where the air conditioning is located is observed with paint with pockets of moisture.
8. One of the closet doors located in room [ROOM NUMBER]-B does not have a knob.
9. room [ROOM NUMBER]-A does not have a night table.
During the interview on 04/07/2024 at 9:00 AM a resident (initial pool resident #159 ) located on this area stated that she would like to have a night table to organize her belongings there.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R.R #208 is an [AGE] year-old female admitted on [DATE] to the facility with a diagnosis of Right Total Hip Replacement due t...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R.R #208 is an [AGE] year-old female admitted on [DATE] to the facility with a diagnosis of Right Total Hip Replacement due to fracture. This resident stated in an interview on 04/07/2024 at 11:00 AM that her weight was not taken when she was admitted to the facility. She stated that the facility food is very good, and she has a good appetite. She stated that she is eating very well, and she is sure that she has not lost weight since admission. She also stated that nursing personnel informed her that they are going to weigh her next Tuesday.
Policy and procedure review on 04/08/2024 at 1:45 PM related to resident weight referred that resident are weight on admission and every Tuesday.
4. R.R.#155 A is a [AGE] year-old female admitted on [DATE] to the facility with a diagnosis of Right Knee Replacement, reviewed on 04/09/24 1:15 PM, during interview with the resident on 04/07/2024 at 9:00 AM she states that she was not weight when arrived. No evidence was found that the resident was weight on 04/04/2024 in the weight log.
5. R.R.#106 is a [AGE] year-old female admitted on [DATE] to the facility with a diagnosis of Right Knee Replacement, review 04/09/24 1:25 PM. During the interview with the resident on 04/07/2024 at 9:15 AM state that she was not weigh when arrived. No evidence was found that the resident was weight on 04/04/2024 in the weight log.
6. R.R.#108 is a [AGE] year-old male admitted on [DATE] to the facility with a diagnosis of Lumbar Stenosis, review on 04/09/24 1:00 PM. During an interview with the resident on 04/07/2024 at 10:35 AM he states that he was not weight when arrived. No evidence was found that the resident was weight on 04/05/2024 in the weight log.
Based on records reviewed (RR), review of policies procedures and facility staff interview performed on 04/07/2024 through 04/09/2023 to from 8:00 AM through 5:30 PM, it was determined that the facility failed to maintain systematic approach on resident weight status during admission such as usual body weight or desirable body weight range while receiving services at the facility. This deficient practice was identified in 6 out of 21 residents receiving services at the facility. (RR #106, #108, #155, #157, #159, and #208).
Findings include:
The policy WNV-SNF-Title: Peso de Residente, Residents Weight was reviewed on 04/08/2024 at 1:35 PM with Clinical Dietitian (employee #8). Policy clearly stated on the procedures that every resident admitted to the facility weight must be taken when admitted and then every Tuesday on weekly basis.
1. RR # 159 is a female resident admitted on [DATE] with a diagnosis of Right Knee Replacement. This resident stated in an interview on 04/07/2024 at 9:25 AM that her weight was not taken when she was admitted to the facility. She stated that she is eating very well, and she is sure that she has not lost weight since admission. She also stated that nursing personnel informed her that they are going to weigh her next Tuesday.
2. RR #157 is a female resident admitted on [DATE] with a diagnosis of Left Knee Replacement. This resident stated in an interview on 04/07/2024 at 10:55 AM that her weight was not taken when she was admitted to the facility. She stated that the facility's food is very good, and she has a good appetite. She stated that she is eating very well, and she is sure that she has not lost weight since admission. She also stated that nursing personnel informed her that they are going to weigh her next Tuesday.
During an interview on 04/08/2024 at 10:35 AM clinical dietitian (employee #8) stated that facility policy stated that on the procedures that every resident admitted to the facility weight must be taken when admitted and then on weekly basis. She stated that she had not been informed of the resident's weight during admission or if there was any situation that do not permit to weight residents when admitted receiving services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 04/07...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 04/07/2024 through 04/09/2024 to from 8:30 AM through 4:00 PM, it was determined that the facility failed to promote a safe, and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This deficient practice had the potential to affect 21 out of 21 residents receiving services at the facility. The facility failed to ensure promote the cleaning and maintenance, guaranteeing a safe and infection free environment.
Findings include:
1. On 04/07/2024 at 8:50 AM a ceiling of resident room [ROOM NUMBER] was observed with yellow spots directly over the resident bed.
Bed superior rails were observed with peeling paint.
2. The Occupational Room was visited on 04/08/2024 at 10:35 AM and was observed with dirty floor, dust, and stains.
3. Unlabeled refrigerator, no daily temperature registry, with plastic containers on the interior without lids containing raw meat, supermarket bags, with ice in the borders of the shelves and dust, mold and dirt on the outside.
4. Second refrigerator with bottles of soft drinks, water, groceries, no daily temperature record, entire ceiling with yellow stains from humidity, dust on the outside.
5. Deteriorated cardboard boxes with dust.
6. Trash disposal without bag and without lid containing garbage and plastic bottles.
7. Dusty wheelchairs near the refrigerator.
8. Moldy shelf both inside and outside, dirty, and dusty with different items inside the drawer, edibles such as cookies, glasses, protective gowns, screws, and funnels.
9. The base of the shelves is made of wood and is lined with deteriorated blue adhesive paper and absence of plastic on the edges with exposed wood.
10. Dusty metal chairs.
11. File with abundant presence of mold, paint, and detached material on the file a cardboard box with a sign that says ''Enfamil Standard - Flow Soft Nipples'' inside loose papers with documentation content were observed.
12. In the interior of a small broken and open box labeled ''Cotton Tipped Applicators'', slats with mold and dust.
13. Wooden shelf with different materials and items to use with residents in the craft area.
14. Column in the main entrance area that goes directly to the floor with absence of baseboard, evidence of dust and dirt and absence of paint and cement.
15. Door frame with evidence of open space between frame and column.
16. Computer cables exposed, tied, and caught with binder [NAME] clip.
17. On 04/08/2024 the administrator (employee #1) was visiting the Occupational Therapy area, and he was surprised when visit this area and immediately ordered to provide cleaning and maintenance of the room.
18. No documentation or log registry was provided with documentation related to equipment cleaning disinfection after being used with residents.
19. No evidence of daily log registry temperature of the Occupational Therapy Room.
20. Facility failed to ensure that this Occupational Therapy Room used per residents daily was maintained with rusty equipment, dust and dirty is being used with residents who are on contact and transmission-based precautions. Rusty irregular surfaces are more likely to harbor dangerous bacteria and could contribute to cross contamination or an outbreak if are not properly cleaned disinfected after use.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
Based interview with the Director of nursing on 04/07/2024 through 04/09/2024 from 8:00 AM to 4:00 PM, it was determined that the facility failed to provide evidence of resident's categorization of de...
Read full inspector narrative →
Based interview with the Director of nursing on 04/07/2024 through 04/09/2024 from 8:00 AM to 4:00 PM, it was determined that the facility failed to provide evidence of resident's categorization of dependence needs to be used to determine numbers each type of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans for 21 out of 21 residents.
Findings include:
1.Director of Nursing (DON) (employee #2) was interviewed on 04/07/2024 at 8:00 AM and was asked for the categorization of residents admitted to the facility.
DON stated that they did not have it available. DON explained that the person in charge of patient categorization is the facility supervisor, and this person has been suspended from duty since 04/05/2024. DON is trying to perform resident categorization; however, she was unsure whether to categorize residents daily or weekly and also does not know the exact procedure performed by nursing supervisor to perform the categorization.
On 04/07/2024 at 10:00 AM during the interview with the DON referred when there is no staff in the same area, they look for resources in other hospital departments to cover the needs of the residents. The DON knows they are not complying with Payroll Based Journal, but the priority is to meet the needs of the residents.
During survey procedures on 04/07/24 through 04/09/24 facility DON was unable to provide the categorization of residents admitted to the facility.
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 observations of the Kitchen, review of policies procedures and facility staff interview performed on 04/08/2024 through 04/09/2024 to from 8:00 AM through 5:30 PM, it was determined that the ...
Read full inspector narrative →
Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 04/08/2024 through 04/09/2024 to from 8:00 AM through 5:30 PM, it was determined that the facility failed to provide each resident with a nourishing, palatable,special dietary needs.
Findings include:
During observation of the food service it was noted that food was served in Styro foam containers, these containers do not assure that food will get to residents in correct temperatures.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 04/08/2024 through 04/09/2024 to from 8:00 AM through 5:30 PM, it was determined that the ...
Read full inspector narrative →
Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 04/08/2024 through 04/09/2024 to from 8:00 AM through 5:30 PM, it was determined that the facility failed to ensure there is sufficient and qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services for 24 out of 24 residents admitted .
Findings include:
After review of the personnel roster with Kitchen Supervisor ( employee #17), it was determined that facility does not have an Administrative Dietitian or to that effect a Kitchen Manager.
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 of the Kitchen, review of policies procedures and facility staff interview performed on 04/08/2024 through 04/09/2024 to from 8:00 AM through 5:30 PM, it was determined that the ...
Read full inspector narrative →
Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 04/08/2024 through 04/09/2024 to from 8:00 AM through 5:30 PM, it was determined that the facility failed to ensure there is sufficient and qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services.
Findings include:
1. The surveyor requested the kitchen staffing pattern to Kitchen Supervisor (employee #17) on 04/07/2024 at 11:00 AM , after 3 days of survey it was not provided.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 04/08/2024 through...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 04/08/2024 through 04/09/2024 to from 8:00 AM through 5:30 PM, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Findings include:
1. During the visual inspection, the defrosting sink was observed that the hoses were covered by cloths. This accumulates water and promotes the generation of bacteria.
The facility's policy Lavabo a [NAME] en Fregadero de 3 Compartimientos was provided by Kitchen Supervisor(employee #17) and reviewed on 04/08/2024.
During observation of the preparation of the 3 compartment lavatory it was observed that the first compartment was prepared with VEL dish soap,and was not prepared as stated in the policy with a temperature of 110 degrees.
The preparation of the third compartment (sanitation compartment) was observed and tested for Arrex consentration and did not reach the 200 ppm measuremet ( 100 ppm). The facility's policies and procedures regarding the use of the 3 compartment lavatory was not followed to ensure correct sanitation of kitchen utensils.
2. High temperature dish washer wash observed on 04/07/2024 and found unoperational due to lack of cleaning product.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Data
(Tag F0851)
Could have caused harm · This affected most or all residents
Based on interview with the Administrator (employee#1) on 04/07/2024 at 12:13 PM, it was determined that the facility failed to ensure complete and accurate information related with Payroll Based Jour...
Read full inspector narrative →
Based on interview with the Administrator (employee#1) on 04/07/2024 at 12:13 PM, it was determined that the facility failed to ensure complete and accurate information related with Payroll Based Journal (PBJ) was submitted accordingly with CMS requirements in addition to other verifiable and auditable data in according with specifications established.
Findings include:
1. On 04/07/2024 at 12:13 PM the Administrator stated on interview that facility was not reviewing and auditing correctly information related with the PBJ and other verifiable data before transmitting to CMS in order to identify errors that could be corrected before transmission. He stated that he has been involved in the system of data collection and data entry to the computerized system and had identified errors that must be corrected before the final transmission of the information. He also stated that last quarter (2023) data was transmitted with errors, and he communicate with CMS to identify if data could be corrected, but it was impossible. He stated that the facility identified that quantity reported the last quarter (2023) was transmitted with errors related with nursing hours of care and other information were incongruent with days and services provided. However, data errors could not be corrected during this quarter because the errors were identified when data entry and transmission it had already been done.
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 observations, review of policies procedures, review of facility documents and facility staff interview performed on 04/7/2024 through 04/09/2024 to from 8:00 AM through 5:30 PM, it was determ...
Read full inspector narrative →
Based on observations, review of policies procedures, review of facility documents and facility staff interview performed on 04/7/2024 through 04/09/2024 to from 8:00 AM through 5:30 PM, it was determined that the facility failed to maintain a Quality Assurance and Performance Improvement Program (QAPI). Each LTC facility, including a facility that is part of a multiunit chain, must develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality.
Findings include:
On 04/07/2024 2:00 PM during interview with the Skilled Nursing Facility-( SNF) Administrator (employee #1) on 04/08/2024 at 9:30 AM related to the Quality Committee meetings of Skilled Nursing Facility he stated that the last meeting of the QAPI of the Skilled Nursing Facility was done on July 20 of 2022. He refers to the fact that the SNF did not have a Quality Committee for one year.
1.There is no evidence of later meetings until present. It is important to point out that the person in charge of these functions resigned from her position as the Director of Quality and Risk Management on August 13, 2023, and the position has been vacant since then.
During interview with the administrator, he states that since he has been the hospital administrator and of the SNF, they began the review process of the Quality Improvement Program and the Institution Programs for which he has developed initiatives to review quality indicators. The communications with directors, managers, and supervisors on January 3, 2024, about the department's quality processes and indicators reviews, are included. On September 5, 2023, a committee to transform the Institutional Programs was created. We are now in the process of establishing the meetings according to the calendar. On September 6, 2023, I schedule a meeting to give continuity of Quality Improvement Committee.
However, as of the day of the survey the facility did not have a QAPI and QAA committee.
B. On 09/04/2024 at 10:15 AM on interview with the Quality and Risk Manager Coordinator (employee #7) she stated: '' On November 1/2022, I received a letter from the Human Resources Department informing me that effective October 31, 2022, I will be appointed as a full-time Quality and Assurance Coordinator. '' this document also indicates that I would be in ninety-day probationary period which would end on January 30, 2023, and I would be evaluated by my immediate supervisor (employee #18) and then I would become a regular employee. I am currently the quality and assurance coordinator of the entire hospital and skilled nursing facility following the resignation of the former employee of the Quality Assurance and Quality Committee on August 13, 2023. ''Since the doctor's resignation we have not established a QAPI and QAA committee.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
Based on observations, review of policies procedures and facility staff interview performed on 04/7/2024 through 04/09/2024 to from 8:00 AM through 5:30 PM, it was determined that the facility failed ...
Read full inspector narrative →
Based on observations, review of policies procedures and facility staff interview performed on 04/7/2024 through 04/09/2024 to from 8:00 AM through 5:30 PM, it was determined that the facility failed to maintain a Quality Assurance and Performance Improvement Program (QAPI). The facility failed to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life.
Findings include:
1.The SNF failed to collect and maintain data, develop indicators to monitor and improve quality of life, quality of care and safety through an effective QAPI program and was unable tpo provide documentation and evidence of quality indicators the committee had identified, monitored, and evaluated for improvement. In addition, they were unable to provide evidence that key facility staff from each department was in attendance and actively participating in SNF QAPI meeting. The facility did not provide evidence of Annual Monitoring Plan, quality indicators, meetings and other information related to the Skilled Nursing Facility for present year 2024.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on review of policies procedures, facility documents and facility staff interview performed on 04/7/2024 through 04/09/2024 to from 8:00 AM through 5:30 PM, it was determined that the facility f...
Read full inspector narrative →
Based on review of policies procedures, facility documents and facility staff interview performed on 04/7/2024 through 04/09/2024 to from 8:00 AM through 5:30 PM, it was determined that the facility failed to maintain a Quality Assurance and Performance Improvement Program (QAPI),Committee failed to conduct Quarterly meetings exclusively for the Skilled Nursing Facility (SNF), and when they did, not all required committee members were in attendance as required by Federal Regulations.
Findings include:
On 04/07/2024 2:00 PM During interview with the Hospital Administrator and Skill Nursing Facility Administrator (employee #1) on 04/08/2024 at 9:30 AM related to the Quality Committee of meetings of Skilled Nursing Facility he stated that the Skill Nursing Facility did not have a Quality Committe for more than one year. The last meeting of the Quality Improvement Committee of the Skilled Nursing Facility was done on July 20 of 2022.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0924
(Tag F0924)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 04/08...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 04/08/2024 to from 8:00 AM through 5:30 PM, it was determined that the facility failed to equip corridors with firmly secured handrails on each side.
Findings include:
Two hand rails on the main corridor between room [ROOM NUMBER] and 110 were observed loose and with plastic cover stiking out of base.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 04/0...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 04/08/2024 to from 8:00 AM through 5:30 PM, it was determined that the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents.
Findings include:
Seven mouse traps were observed on the dry storage, during interview with the Kitchen supervisor (employee #17) stated that some time ago a [NAME] was found and that they requested more mouse traps.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0577
(Tag F0577)
Minor procedural issue · This affected most or all residents
Based on observations, it was determined that the facility failed to ensure to have results of the survey conducted by Federal or State surveyors and any plan of correction made respecting the facilit...
Read full inspector narrative →
Based on observations, it was determined that the facility failed to ensure to have results of the survey conducted by Federal or State surveyors and any plan of correction made respecting the facility during the past preceding years, available for any individual to review upon request; and Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.
Findings include:
During the initial tours it was observed that the facility's result of the last survey conducted by Federal or State surveyors in 2023 when request was not available and posted for the residents and public. The facility last survey result that they had available was performed in April 2022.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0679
(Tag F0679)
Minor procedural issue · This affected most or all residents
Based on observations, and interview with recreative therapist (employee # 10), it was determined that the facility failed to maintain an activity program that contains varied activities to promote an...
Read full inspector narrative →
Based on observations, and interview with recreative therapist (employee # 10), it was determined that the facility failed to maintain an activity program that contains varied activities to promote and improve resident's physical, mental, and psychosocial well-being for 24 out of 24 admitted residents.
Findings include:
1. During the initial observational tour at the facility performed on 04/07/2024 at 8:30 AM it was observed that the monthly activity calendar located in facility main hallway wall was empty and did not contain any activity for the month of April 2024.
2. It was asked to the recreative therapist (employee #10) on 04/08/2024 at 10:00 AM the reason why the monthly activity calendar located in facility main hallway wall was empty and did not contain any activity for the month of April 2024.
She stated in an interview that she did not prepare the monthly activity calendar for the month of April 2024 because there are not available materials to coordinate activities that involve arts and crafts. She stated that she sent a requisition to the finances department to buy materials for arts and crafts in the month of February 2024 and until now this department did not inform her if they are going to buy those materials. She stated that the recreation department did not have materials for arts and crafts, she just offers activities who involve lectures, listening to music, watching television, alphabet soup and crosswords.
She stated that since October 2023 there is only one recreational therapist on the program. When the program had two recreational therapists it was easier to coordinate recreational activities on weekends and holidays. She stated that at this moment recreational program coordinate only individual recreational activities who involve lecture, listen to music, watch television, alphabet soup and crosswords for weekends and holidays, and she depends on that nursing personnel help residents providing those recreational activities. She stated that this is going to be like this until the facility recruits another recreational therapist.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0838
(Tag F0838)
Minor procedural issue · This affected most or all residents
Based on interview with facility administrator (employee#1), the facility failed to develop a required Facility Assessment. This deficient practice had the potential to affect 21 ot of 21 residents in...
Read full inspector narrative →
Based on interview with facility administrator (employee#1), the facility failed to develop a required Facility Assessment. This deficient practice had the potential to affect 21 ot of 21 residents in the facility.
Findings include:
During the entrance conference performed on 04/07/2024 at 10:00 AM with the Administrator, the surveyors request the facility assessment, at 2:00 PM the Administrator state that he is the administrator of the facility since 1.5 years and he do not find the facility assessment. He is going to initiate and developed the facility assessment.
Apr 2023
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a recertification survey, observations of the physical environment, review of policies procedures and facility staff in...
Read full inspector narrative →
**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 04/16/2023 through 04/18/2023 to from 8:30 AM through 4:00 PM, it was determined that the facility failed to maintain systematic approach on resident weight status during admission to receive services and such as usual body weight or desirable body weight range while receiving services at the facility. This deficient practice was identified in 1 out of 19 residents receiving services at the facility. (RR 68).
Findings include:
1. Resident review # 68 is a female resident admitted on [DATE] with a diagnosis of General Weakness and status post Myocardial Infarction. This resident stated on interview on 04/17/2023 at 9:12 AM that she wants to know if she loss weight since admission, to the facility. She stated that due to her cardiovascular condition she knows that she need to change the way she ate to maintain her cholesterol levels on acceptable parameters. She stated that after her admission nutritionist evaluate her and educate about diet requirements and food preferences. She stated that since her admission on [DATE] she thinks that she did not lose weight but want to know her actual weight and that in the facility personnel did not weight her.
a. On 04/17/2023 at 9:50 AM Nursing Supervisor (employee #2) was asked by the surveyor in relation with the weight of resident #68. Nursing Supervisor (employee #2) stated that this resident weight was not taken when admitted to the facility because facility is in the process of remodeling of some facility areas, and it was necessary to remove the resident weighting scale from the room where it was previously located.
b. Case RR #68 was discussed with Licensed Dietitian (employee #11) on 04/17/2023 at 11:27 AM. She stated that she evaluates the resident when admitted to the facility on [DATE]. She stated she use for the resident nutritional evaluation the usual weight referred by the resident during nutritional evaluation. Licensed Dietitian (employee #11) was asked by the surveyor on 04/17/2023 at 11:55 AM if she knows that the resident weight was not taken because it was necessary to remove the resident weighting scale from the room where it was previously located. Licensed Dietitian (employee #11) stated on 04/17/2023 at 12:15 PM that she does not know that it was necessary to remove the resident weighting scale from the room where it was previously located due to remodeling.
c. Facility policy WNV-SNF-010-Title: Peso de Residente was review on 04/17/2023 at 3:35 PM with Nursing Supervisor. Policy clearly stated on the procedures that every resident admitted to the facility weigh must be taken on weekly basis.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a recertification survey and interviews conducted on 4/16/2023 through 4/18/2023 at 8:30 AM through 4:00PM, it was dete...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a recertification survey and interviews conducted on 4/16/2023 through 4/18/2023 at 8:30 AM through 4:00PM, it was determined that the facility failed to ensure to review menus and nutritional adequacy based on cultural and religious preferences at the time of resident's admission 1 of 10 sample (sample # 60).
Findings include:
During the interviews on 4/16/2023 to 4/18/2023 at 8:30 AM to 4:00 PM, it was investigated:
1. Resident #60 is a [AGE] year-old male of Egyptian Nationality admitted at 4/14/2023 for Rehabilitation Service with Status Post Total Right Knee replacement. History of High Blood Hypertension, Chronic Kidney disease Stage 4, Depression and Anxiety.
a. On 4/16/2023 at 12:22 PM, it was observed that the Resident of room # 107-B did not eat lunch. The Resident said that do not like the food they bring. The Resident wife brings him food and water since he was admitted . Due to the culture and religions, the resident does not consume pork, cheese, canned food, among others.
b. On 4/16/2023 at 3:13 PM, the Nursing Supervisor (Employee # 2) was interviewed regarding the diet of Resident of room [ROOM NUMBER]-B and indicated that they are waiting to recruit a dietitian and that would make arrangements for the Clinical Nutritionist (Employee # 11) to evaluate the resident first thing in the morning.
c. On 4/17/2023 at 9:30 AM, the Clinical Nutritionist (Employee # 11) visit the resident to make adjustments to his diet.
d. On 4/18/2023 at 2:22 PM, the Resident room [ROOM NUMBER]-B was interviewed for follow-up regarding nutrition and indicated that he likes the food that is brought to him.
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** During the tour in the residents room on 4/16/2023 to 4/18/2023 from 8:30 AM to 4:00 PM, the following was observed:
11. Residen...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During the tour in the residents room on 4/16/2023 to 4/18/2023 from 8:30 AM to 4:00 PM, the following was observed:
11. Resident room [ROOM NUMBER]-A, it was observed that the closet doors do not close and the formica was broken.
12. Resident room [ROOM NUMBER]-A, it was observed that the closet doors do not close and the formica was broken.
13. Resident room [ROOM NUMBER]-B, it was observed that the formica closet door was broken.
14. Bed located on room [ROOM NUMBER] A was observed with pealing paint on side rails and mold.
Based on a recertification survey, observations of the physical environment, review of policies procedures and facility staff interview performed on 04/16/2023 through 04/18/2023 to from 8:30 AM through 4:00 PM, it was determined that the facility failed to promote the resident right to receive services in a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect 12 out of 12 residents receiving services at areas were the deficient environment and items (equipment) is located.
Findings include:
During initial observational tour the following was observed related with environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, and bathrooms:
1. Closet doors on rooms 103-B, 102-B, 104- A,104-B, 106-B,108-B and 115-A were observed with broken Formica on doors and door edge.
2. Beds located on rooms 108-B, 111 and 115-B were observed with rust on side rails.
3. Beds located on rooms 117-A and 117-B had the footboard with chipped broken areas and sharp edges.
4. Patient eating table located on room [ROOM NUMBER]-B is observed with Formica broken and sharp edges on borders
5. In room [ROOM NUMBER]-A the lamp located inside the bathroom above the handwashing sink is observed with rust.
6.Beds located on rooms 110-A and 106-B were observed with chipped peeling paint on side rails.
7. A refrigerator located inside resident room [ROOM NUMBER] is observed with a lot of rust on the bottom area of the door.
8. Dried out sticker stains were observed located in every electrical outlet and receptacle of control panel and wall oxygen areas. Facility failed to make sure the stain is completely removed before posted a new one.
9. A resident lifter located inside isolation room [ROOM NUMBER] is observed with rust on metal mast area and sling bars.
10. A Formica cabinet located in the anteroom (changing area before entering to the isolation room [ROOM NUMBER] is observed with broken Formica.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During the tour of the facilities, it was observed that the folder where the daily controls are documented is not being atten...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During the tour of the facilities, it was observed that the folder where the daily controls are documented is not being attended to, in accordance with the glucometer policy. Infection Control Coordinator (Employee #5) it was interviewed on 04/18/2023 at 1:32 PM stated that the laboratory keeps a record of the monthly controls.
Devoceid: 194041119074
a.On 4/18/2023 at 1:48 PM, it was observed that no glucometer controls were documented in the month of January:
1/1/2023, 1/2/2023, 1/6/2023, 1/14/2023, 1/15/2023, 1/22/2023, 1/23/2023, 1/24/2023, 1/25/2023, 1/27/2023, 1/28/2023, 1/29/2023, 1/30/2023 and 1/31/2023.
b. On 4/18/2023 at 1:48 PM, it was observed that no glucometer controls were documented in the month of February:
2/1/2023, 2/2/2023, 2/3/2023, 2/4/2023, 2/5/2023, 2/10/2023, 2/11/2023, 2/13/2023, 2/14/2023, 2/17/2023, 2/18/2023, 2/19/2023, 2/20/2023, 2/22/2023, 2/24/2023, 2/25/2023, 2/26/2023, 2/27/2023, and 2/28/2023.
c. On 4/18/2023 at 1:48 PM, it was observed that no glucometer controls were documented in the month of March:
3/2/2023, 3/2/2023, 3/4/2023, 3/5/2023, 3/7/2023, 3/8/2023, 3/9/2023, 310/2023, 3/11/2023, 3/12/2023, 3/13/2023, 3/14/2023, 3/15/2023, 3/16/2023, 3/17/2023, 3/18/2023, 3/19/2023, 3/20/2023, 3/21/2023, 3/22/2023, 3/23/2023, 3/24/2023, 3/25/2023, 3/27/2023, 3/28/2023, 3/29/2023, 3/30/2023 and 3/31/2023.
Deviceid: 195030621308
a. On 4/18/2023 at 1:48 PM, it was observed that no glucometer controls were documented in the month of January:
1/1/2023, 1/2/2023, 1/6/2023, 1/14/2023, 1/15/2023, 1/22/2023, 1/23/2023, 1/24/2023, 1/25/2023, 1/27/2023, 1/28/2023, 1/29/2023 and 1/31/2023.
b. On 4/18/2023 at 1:48 PM, it was observed that no glucometer controls were documented in the month of February:
2/1/2023, 2/2/2023, 2/3/2023, 2/4/2023, 2/5/2023, 2/6/2023, 2/8/2023, 2/9/2023, 2/10/2023, 2/11/2023, 2/13/2023, 2/14/2023, 2/17/2023, 2/18/2023, 2/19/2023, 2/20/2023, 2/22/2023, 2/24/2023, 2/25/2023, 2/26/2023, 2/27/2023 and 2/28/2023.
c. On 4/18/2023 at 1:48 PM, it was observed that no glucometer controls were documented in the month of March:
3/2/2023, 3/3/2023, 3/4/2023, 3/5/2023, 3/7/2023, 3/8/2023, 3/9/2023, 3/10/2023, 3/11/2023, 3/12/2023, 3/13/2023, 3/14/2023, 3/15/2023, 3/16/2023, 3/17/2023, 3/18/2023, 3/18/2023, 3/19/2023, 3/20/2023, 3/21/2023, 3/22/2023, 3/23/2023, 3/24/2023, 3/27/2023, 3/28/2023, 3/29/2023, 3/30/2023 and 3/31/2023.
5. The facility policy and procedure was observed: Applicable regulations and standards: Law 101 Health Department Regulation 9184, CMS F880 Infection Prevention & Control: Procedure; 6.16. The control process (Low and High) of the glucometer is taken daily and when required by the glucometer system. 6.17. The controls will be documented in the folder provided by each department.6.18. The laboratory staff maintains records of the controls that are systematically sent on a monthly basis and in their department. 6.18. The laboratory staff keeps a record of the controls that are sent systematically on a monthly basis and in their department.
Based on a recertification survey, observations of the physical environment, review of policies procedures and facility staff interview performed on 04/16/2023 through 04/18/2023 to from 8:30 AM through 4:00 PM, it was determined that the facility failed to ensure resident care equipment is in safe operating condition. This deficient practice had the potential to affect 7 out of 12 residents receiving services at areas where the deficient environment and items (equipment) is located.
Findings include:
1. Three beds located on room [ROOM NUMBER]-A, 110-A, 121-A and 121-B does not have the biomedical services inspection and certification of functioning and routine inspection and maintenance. Beds located on room [ROOM NUMBER]-A, 121-A and 121-B are being used and assigned to residents on those rooms. There is no resident on room [ROOM NUMBER]-A.
2. Evidence of resident's beds biomedical certification functioning, and routine inspection and maintenance not provided when requested on 04/17/2023 at 9:35 AM to facility biomedical staff (employee #1).
3. During interview on 04/17/2023 at 11:55 AM the facility biomedical staff (employee #1) stated that facility work with an outside company named CIRACET ' s Medical Equipment Services who is a biomedical services contracted company that is in charge to assign a control number to any resident bed and once the control number is assigned facility proceed to test , provide maintenance and certify the bed functioning and level of safety and quality. He also stated that for beds located on rooms 105-A, 110-A, 121-A and 121-B the contracted company did not assign the control number yet.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
Based on a recertification survey, observations of the physical environment, review of policies procedures and facility staff interview performed on 04/16/2023 through 04/18/2023 from 8:30 AM through ...
Read full inspector narrative →
Based on a recertification survey, observations of the physical environment, review of policies procedures and facility staff interview performed on 04/16/2023 through 04/18/2023 from 8:30 AM through 4:00 PM, it was determined that the facility failed to have a level of nursing staff to promote quality of care delivered to residents admitted receiving services. This deficient practice has the potential to affect 12 out of 12 residents receiving services.
Findings include:
1.On 04/17/2023 10:00 AM it was requested to the Director of Nursing (DON) (employee #4) facility nursing staffing pattern. DON was asked by the surveyor if she had knowledge that facility has infraction dates due to no Register Nurses Hours and a Failure to have Licensed Nursing coverage 24 hour/day on CASPER Report 1705D on the Quarter of October 1-December 31, 2022.
Director of Nursing (employee #4) stated on interview on 04/17/2023 10:57 AM that accordingly with facility calculations for Register Nurse (RN) and Licensed Practical Nurses (LPN) they must assigned 3 register nurses and 3 licensed practical nurses with a census who fluctuates between 22-25 residents. She also stated that there are some shifts where the facility did not have licensed practical nurses and the duties that must be performed by the licensed practical nurses are assigned to the register nurses in charge of residents.
2. On 04/17/2023 11:20 AM, the surveyor asked the DON (employee #4) if facility had knowledge and consider when calculate the RN and LPN staffing pattern the Payroll Based Journal collected data. It was explained to her that when transmitted the Payroll Based Journal data is combined with other resident census information and is used to identify if the level of staff in each facility is appropriate to assure the quality of care delivered to residents. On 04/17/2023 11:40 AM the Director of Nursing (employee #4) stated that the facility did not calculate the RN and LPN staffing pattern considering the Payroll Based Journal (PBJ) collected and transmitted data.
3. The facility failed to have sufficient nursing staff RN's and LPN's accordingly with CASPER Report 1705D on the Quarter of October 1-December 31, 2022. Infraction dates related of No RN hours were reported on dates 10/02/2022, 10/08/2022,10/15/2022, 10/16/2022, 10/29/2022, 11/06/2022, 11/12/2022,11/13/2022,11/19/2022, 11/20/2022,11/26/2022 ,11/27/2022, 12/03/202212/04/2022, 12/10/2022, 12/11/2022,12/17/2022,12/18/2022,12/24/2022,1225/2022 and 12/31/2022. All infraction dates related with No RN hours reported in CASPER Report 1705D correspond to weekends days (Saturday and Sunday)
4. The facility failed to have sufficient nursing staff RN's and LPN's accordingly with CASPER Report 1705D on the Quarter of October 1-December 31, 2022. Infraction dates related of Infraction dates related of failure to have Licensed nursing Coverage 24 Hours/Day were reported on 10/01/2022,10/02/2022,10/08/2022,10/09/2022,
10/15/2022,10/16/2022, 1022/2022, 10/23/2022,10/29/2022, 10/30/2022,11/05/2022,11/06/2022,11/08/2022,11/12/2022, 11/13/2022,11/19/2022, 11/20/2022,11/25/2022,11/26/2022,11/27/2022,12/03/2022,12/04/2022,12/10/2022, 12/11/2022,12/17/2022, 12/18/2022, 12/24/2022,12/25/2022 and 12/31/2022.
Many of the infraction dates related to failure to have Licensed nursing Coverage 24 Hours/Day reported in CASPER Report 1705D correspond to weekends days (Saturday and Sunday).
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, observations and facility staff interview performed on 04/16/2023 through 04/18/2023 from 8:30 AM through 4:00 PM, it was determined that the facility failed to stor...
Read full inspector narrative →
Based on a recertification survey, observations and facility staff interview performed on 04/16/2023 through 04/18/2023 from 8:30 AM through 4:00 PM, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice affects 19 out of 19 residents admitted receiving services at the facility.
Findings include:
1. On 04/16/2023 at 8:45 AM during the initial brief tour of the kitchen the following was identified:
a. In the water, juice, and bread dry storage it was observed that the air conditioning ducts are leaking. Kitchen personnel put a bucket to collect the liquid leakage that apparently came from the air conditioning duct.
b. On the shelf were the bucket to collect the air conditioning duct leak it was observed several packages of bottled water and 7 packages of sliced sandwich bread.
c. On this water, juice and bread dry storage area it was observed that kitchen personnel stored a large amount of boxes of kitchen hair nets and gloves to be used on the kitchen production areas.
d. On this water, juice, and bread dry storage area it was observed a large roll of cloth kitchen towels with a base fixed to the wall. Accordingly with information provided by kitchen Coordinator (employee #10) on 04/16/2023 at 9:15 AM personnel access this storage when need a new cloth to be used at the kitchen production area.
e. One of the coolers located in the production area is observed with a lot of rust on the inside area were the door gasket seal when the cooler is closed.
2. On 04/18/2023 at 8:57 AM during the follow-up visit to the kitchen the following was identified:
a. Two carts to storage resident trays were observed with rust on metal areas and on the bottom area and the wheels.
b. Walking refrigerator door gasket was not properly aligned and was observed sticking outdoor area.
c. Walking freezer door gasket was broken and was observed.
sticking outdoor area.
d. Walking freezer entrance and ceiling area is observed with ice build- up. A broken door gasket could cause this ice build-up, however no information was provided related with notification to a refrigeration technician in order to diagnose and fix the issue of the ice build- up.
e. A handwashing sink located at the side of the food production area is observed with blue-green hard water stains. This sink had a faucet that does not close properly and is dripping water.
f. In the men's kitchen employee bathroom is observed a metal footlocker used by personnel to store personal belongings. This footlocker is observed with a lot of rust.
g. In the women's kitchen employee bathroom is observed 2 metal footlockers used by personnel to storage personal belongings. This footlocker is observed with a lot of rust.
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** 9. During the tour of the facility, it was observed in the folder that documents the cleaning of the glucometer daily, it is not...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. During the tour of the facility, it was observed in the folder that documents the cleaning of the glucometer daily, it is not being attended.
The Nursing Supervisor (Employee#2) was interviewed and stated that the employees did not write the dates for cleaning the glucometer.
a. On 4/17/2023 at 3:41 PM, it was observed in the month of January there was no cleaning of the glucometer: 1/1/2023, 1/2/2023, 1/3/2023, 1/6/2023. 1/14/2023, 1/15/2023, 1/22/2023, 1/23/2023, 1/24/2023, 1/24/2023, 1/27/2023, 1/28/2023, 1/28/2023, 1/29/2023, 1/30/2023 and 1/31/2023.
b. On 4/17/2023 at 3:41 PM, it was observed in the month of February there was no cleaning of the glucometer: 2/1/2023, 2/2/2023, 2/3/2023, 2/4/2023, 2/5/2023, 2/6/2023, 2/8/2023, 2/9/2023, 2/10/2023, 2/11/2023, 2/13/2023, 2/14/2023, 2/17/2023, 2/18/2023, 2/19/2023, 2/20/2023, 2/21/2023, 2/22/2023, 2/24/2023, 2/25/2023, 2/26/2023, 2/27/2023 and 2/28/2023.
c. On 4/17/2023 at 3:41 PM, it was observed in the month of March there was no cleaning of the glucometer: 3/1/2023 to 3/31/2023.
d. The facility policy and procedure was observed: Applicable regulations and standards: Law 101 Health Department Regulation 9184, CMS F880 Infection Prevention & Control: Responsibilities; 5.3. Nurse Epidemiologist/Infection Control Coordinator, 5.3.1. Performs and monitors glucometer cleaning and disinfection, 5.3.2. Goes around monitoring compliance with infection control practices. Procedure; 6.13. Professional nurse puts on non-sterile gloves and proceeds to clean the glucometer with a sani-cloth disinfectant and germicide towel (approved by the EPA agency) EPA NO. 9480-4 State EPA NO. 9480-NY-1 72956-W-1, allow to dry for two minutes. 6.14. Once it is concluded and it is clean and disinfected with these procedures, the glucometer is left in optimal conditions to be used when required in the assigned area.10. On 04/17/2023 at 1:55 PM during the tour of the facility, it was observed that the food fridge designated for residents does not have a clock for temperature control.
11. On 04/17/2023 at 2:00 PM during the tour of the facility, the ice machine was observed with white spots, mold, dirty, dust spots all over the outside. No cleaning record was evidenced.
12. On 4/17/2023 at 10:10 AM three acoustics located on room [ROOM NUMBER] B were observed with yellow moisture stains.
In the bathroom, the area where the paper dispenser is, peeling paint and broken tiles was observed on the wall. Acoustic where it is located the air conditioning outlet with yellow stains, rusty metal. The sprinkler is missing [NAME] ring.
Based on a recertification survey, observations of the physical environment, review of policies procedures and facility staff interview performed on 04/16/2023 through 04/18/2023 to from 8:30 AM through 4:00 PM, it was determined that the facility failed to promote a safe, and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This deficient practice had the potential to affect 19 out of 19 residents receiving services at the facility. The facility failed to ensure promote the cleaning and disinfection of the glucometer, guaranteeing a safe and infection free environment.
Findings include:
1. A resident lifter located inside isolation room [ROOM NUMBER] with rust on metal mast area and sling bars, is observed on 04/16/2023 at 10:15 AM.
2. On 04/17/2023 at 9:37 AM the lifter that was previously located on room [ROOM NUMBER] was not observed inside this room or in the area were personnel storage resident lifters.
3. Infection control officer (employee #5) was interview on 04/17/2023 at 10:50 AM. She was informed by surveyor that the lifter that was observed on 04/16/2023 at room [ROOM NUMBER] is not found on room [ROOM NUMBER] or in the area were personnel storage resident lifters. Infection control officer (employee #5) on 04/17/2023 at 11:15 AM that she is going to investigate where the [NAME] is located.
4. On 04/17/2023 at 2:05 PM infection control officer (employee #5) and with physical therapy supervisor (employee #14) proceed to explain to the surveyor. This lifter accordingly with information provided during interview by the physical therapy supervisor (employee #14) and infection control officer (employee #5) is used with resident located on room [ROOM NUMBER]. When physical therapy finishes to use the lifter with this resident, they proceed to remove the lifter from the room, disinfect the metal parts with Caviwipes that is a towelette used to disinfect resident equipment, remove the sling, and sent it to the laundry to be washed and disinfected and maintain the lifter on physical therapy area in case they need for another resident.
Physical therapy supervisor (employee #14) stated on interview that facility had another 2 lifters to be used to move residents in addition to the lifter that was previously located on room [ROOM NUMBER].
It was requested to the infection control officer (employee #5) and with physical therapy supervisor (employee #14) on 04/17/2023 a log registry or documentation with the evidence that the lifter was cleaned and disinfected after being used with resident located on room [ROOM NUMBER] or any other resident.
No documentation or log registry was provided with documentation related with equipment cleaning disinfection after being used with residents.
5. Resident review #5 located on room [ROOM NUMBER], is [AGE] years old male admitted on [DATE] with a diagnosis of Status Post Right Transmetatarsal Second Toe Amputation. This resident is on transmission-based precautions and contact isolation since 03/15/2023 due to a positive culture of Klebsiella Pneumoniae on his wound.
6. Two other lifters were observed 04/17/2023 at 11:00 AM located on the room were personnel storage patient equipment. Those two lifters had rust on the metal mast area and sling bars.
7. Facility failed to ensure that rusty equipment is being used with residents who are on contact and transmission-based precautions. Rusty irregular surfaces are more likely to harbor dangerous bacteria and could contribute to cross contamination or an outbreak if are not properly cleaned disinfected after use.
8. Policy and procedure for cleaning and disinfection of equipment used with residents was requested to the Infection control officer (employee #5) on 04/17/2023 at 3:33 PM. No policy and procedure for cleaning and disinfection of equipment used by residents was provided. A guide with disinfectants to be used to disinfect equipment used with residents was provided on 04/17/2023 at 4:00 PM. No policy with establish procedure to be follow when use disinfectants with equipment used by residents are provided.
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 Quality Assessment Performance Improvement (QAPI) Officer (employee #13), it was determined that t...
Read full inspector narrative →
Based on recertification survey review of policies and procedures, record review, and interview, with Quality Assessment Performance Improvement (QAPI) Officer (employee #13), 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 resident's 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 Quality Assessment Performance Improvement (QAPI) Officer.
During interview on 04/17/2023 at 3:20 PM QAPI Officer employee #13) stated that facility did not have an organized Behavioral health services program or policies and procedures of a Behavioral health services. She 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.
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 Quality Assessment Performance Improvement (QAPI) Officer (employee #13), it was determined that t...
Read full inspector narrative →
Based on recertification survey review of policies and procedures, record review, and interview, with Quality Assessment Performance Improvement (QAPI) Officer (employee #13), 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 Quality Assessment Performance Improvement (QAPI) Officer (employee #13). During interview on 04/17/2023 at 3:20 PM QAPI Officer (employee #13) stated that facility did not have an organized Behavioral health services program or policies and procedures of a Behavioral health services. She 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. QAPI Officer (employee #13) explain on 04/17/2023 at 3:30 PM that once facility develops policies and procedures to implement a Behavioral health services program, is going to be determine the quantity and competence's of staff needed to implement those services.
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.
- • 34% turnover. Below Puerto Rico's 48% average. Good staff retention means consistent care.
Concerns
- • 35 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • $29,997 in fines. Higher than 94% of Puerto Rico facilities, suggesting repeated compliance issues.
- • Grade F (35/100). Below average facility with significant concerns.
Bottom line: Trust Score of 35/100 indicates significant concerns. Thoroughly evaluate alternatives.
✓ Report will be sent to your email
About This Facility
What is Centro Medico Wilma N Vazquez Snf's CMS Rating?
CMS assigns CENTRO MEDICO WILMA N VAZQUEZ SNF an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Puerto Rico, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Centro Medico Wilma N Vazquez Snf Staffed?
CMS rates CENTRO MEDICO WILMA N VAZQUEZ SNF's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 34%, compared to the Puerto Rico average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Centro Medico Wilma N Vazquez Snf?
State health inspectors documented 35 deficiencies at CENTRO MEDICO WILMA N VAZQUEZ SNF during 2023 to 2024. These included: 30 with potential for harm and 5 minor or isolated issues.
Who Owns and Operates Centro Medico Wilma N Vazquez Snf?
CENTRO MEDICO WILMA N VAZQUEZ SNF 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 45 certified beds and approximately 25 residents (about 56% occupancy), it is a smaller facility located in VEGA BAJA, Puerto Rico.
How Does Centro Medico Wilma N Vazquez Snf Compare to Other Puerto Rico Nursing Homes?
Compared to the 100 nursing homes in Puerto Rico, CENTRO MEDICO WILMA N VAZQUEZ SNF's overall rating (1 stars) is below the state average of 3.5, staff turnover (34%) is significantly lower than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Centro Medico Wilma N Vazquez Snf?
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 Centro Medico Wilma N Vazquez Snf Safe?
Based on CMS inspection data, CENTRO MEDICO WILMA N VAZQUEZ SNF 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 1-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 Centro Medico Wilma N Vazquez Snf Stick Around?
CENTRO MEDICO WILMA N VAZQUEZ SNF has a staff turnover rate of 34%, 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 Centro Medico Wilma N Vazquez Snf Ever Fined?
CENTRO MEDICO WILMA N VAZQUEZ SNF has been fined $29,997 across 1 penalty action. This is below the Puerto Rico average of $33,379. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Centro Medico Wilma N Vazquez Snf on Any Federal Watch List?
CENTRO MEDICO WILMA N VAZQUEZ SNF 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.