cms_PR
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| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid ▼ | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 439 | 439 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2013-08-16 | 281 | E | 0 | 1 | 02SG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the medical record and the facility's policies and procedures, it was determined that facility failed to transcribe the physician's orders [REDACTED].#9 and #10) and failed to clean the blood glucose monitoring device between use after each resident (Residents #2 and #3). Findings are: 1. At approximately 9:45 A.M., on August 13, 2013, Nurse #1 administered [MEDICATION NAME] 600 mg and [MEDICATION NAME] 5/325 mg (2), by mouth, to Resident #2. Both medications were signed as given on the resident's Medication Administration Record [REDACTED].M. to increase the dosage of [MEDICATION NAME] to 800 mg p.o. A.M. & hs and to discontinue the [MEDICATION NAME]. There was no evidence on the MAR for Resident #2 that indicated these changes. The orders written on 8/12/13 at 11:30 A.M. documented to give Tylenol with [MEDICATION NAME] #3 (2 tabs) p.o. q 4 hrs. X 48 hrs. and Magox 400 mg p.o. B.I.D. x 3 days and repeat test for Magnesium on 8/15/13. The Tylenol/[MEDICATION NAME] was written for pain management. The Magox was ordered in relation to the laboratory report dated 8/9/13 that documented that Resident #2 had a serum magnesium level of 1.70 MG/DL. The normal range recorded on the lab report is 1.80-2.40 MG/DL. At 11:30 A.M. an interview was conducted with the Nursing Supervisor. She stated that an order written [REDACTED]. She acknowledged that the medications were not given according to the physician's orders [REDACTED]. 2. During the medication pass on 8/13/13 from 9:10 A.M. to approximately 9:55 A.M., Nurse #1 was observed giving the medications poured to Residents #1, #2, #6, #9 and #10 without identifying each resident prior to administration in accordance with the standard of nursing practice and the facility's medication administration procedures. The nurse did not look at their identification bracelet and did not ask for or call their names prior to administering the medications. During an int… | 2016-04-01 |
| 440 | 440 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2013-08-16 | 332 | D | 0 | 1 | 02SG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, it was determined that the facility's medication error rate was 6% based on failure to administer medications according to the physician's written orders for one of five residents observed (Resident #2). Findings include: Observation of the medication pass was conducted on August 13, 2013. At approximately 9:45 A.M., the nurse administered [MEDICATION NAME] 600 mg and [MEDICATION NAME] 5/325 mg (2), by mouth, to Resident #2. Both medications were signed as given on the resident's Medication Administration Record [REDACTED].M. to increase the dosage of [MEDICATION NAME] to 800 mg p.o. A.M. & hs and to discontinue the [MEDICATION NAME]. There was no evidence on the MAR for Resident #2 that indicated these changes. At 11:30 A.M. an interview was conducted with the Nursing Supervisor. She stated that an order written [REDACTED]. She acknowledged that the medications were not given according to the physician's orders [REDACTED]. | 2016-04-01 |
| 441 | 441 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2013-08-16 | 371 | D | 0 | 1 | 02SG11 | Based on observation and interview, the facility did not ensure that food was held in a safe and sanitary manner. The findings are: During the initial tour of the kitchen and storage areas with the Director of Nutrition Services on August 12, 2013 at 10:30 A.M., the thermometer on the freezer in the kitchen read 15 degrees, not the zero degrees which is required. During the tour of the dry storage areas, both within the kitchen area and off an area adjacent to the kitchen in locked dry storage rooms, the cans of food, water and boxes of food were undated as to when they were delivered and/or when they were to expire. The Director of Nutrition Services confirmed that these food products were not dated so that they could be used before they were no longer safe for residents. | 2016-04-01 |
| 442 | 442 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2013-08-16 | 441 | E | 0 | 1 | 02SG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and a review of the facility policies and procedures, it was determined that the facility failed to ensure that the equipment used for blood glucose monitoring was cleaned between each resident's use and cleaned with a product to minimize the risk of transmitting blood-borne pathogens for two of six residents observed for glucose monitoring (Resident #2 and Resident #3). The facility failed to ensure that items stored in the sterile supply area were rotated and not outdated. Findings include: 1. On [DATE] at 4:00 P.M., Nurse #2 was observed removing the Precision Xceed Pro glucometer from a case that included test strips and unopened packs of lancets. After putting on gloves, she punctured Resident # 2's finger with a lancet and squeezed it to obtain blood that was placed on the test strip inserted into the glucometer. After reading the results, the nurse placed the glucometer back into the case with the unopened items without removing her gloves and without cleaning the glucometer. At 4:15 P.M., on [DATE], Nurse #2 proceeded to the next resident for testing. She removed the glucometer from the case, without cleaning it, and prepared Resident #3 for the finger stick. As she was about to stick the resident, she was stopped by the surveyor. An interview was conducted privately, with the nurse, at that time. When asked, in her language, about cleaning the glucometer, she stated: I never clean it. A review of the facility's procedure on cleaning the Precision Xceed Pro glucometer (Mantenimiento Del Sistema) documented that the exterior can be cleaned with an alcohol wipe. There was no documentation regarding the cleanliness of the glucometer when used between each resident and after the final use. The manufacturer's instruction on cleaning the Precision Xceed Pro glucometer documents the following: IMPORTANT: To avoid infection, it is recommended to clean the monitor every time it is used with a patient. It… | 2016-04-01 |
| 443 | 443 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2013-08-16 | 465 | D | 0 | 1 | 02SG11 | Based on observation, resident and staff interview, it was determined that the facility failed to provide Resident #5 and Resident #7 with a room free from an unpleasant odor and undesirable temperature control and failed to provide beds that were comfortable and functional. Findings include: During the initial tour on 8/12/13, at approximately 11 A.M., the surveyors entered room 108. An unpleasant odor prevailed throughout the room. Upon interview, Resident #7, in bed 108 A, stated that she requested to move from room 106 because of the same odor. She stated that at night between 2:00 and 3:00 A.M. the air conditioner changes to auto-mode and the room becomes very humid and filled with a bad odor. She further stated that the mattress was uncomfortable and that the bed shakes when raised up or down. Resident #5, in bed 108 B, was interviewed at that time and stated that she was also moved from room 106 due to problems with the air conditioner and the mattress. She stated that the current mattress was uncomfortable. She stated that she feels as if she ' s falling in a hole in the mattress. On 8/14/13 at 10:45 A.M., Nursing Supervisor was interviewed in room 108. She agreed that an unpleasant odor was prevalent. She stated that she is aware of the need for new mattress but has had a problem in obtaining them. The residents were transferred to another room. | 2016-04-01 |
| 444 | 444 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2013-08-16 | 517 | F | 0 | 1 | 02SG11 | Based on interviews, observation and record review, the facility did not have detailed written procedures to meet potential emergencies including severe weather. The findings are: On the tour of the kitchen and food storage areas on 8/12/2013 with the Director of Nutrition Services, the employee was asked for the emergency preparedness plan for water and food for the nursing home residents during emergency situations. She stated that emergency plans for both the nursing home and residents were combined. The copy of the plan reviewed by the surveyor on 8/13/2013 did not contain specifics as to type of emergencies, duration or procedures. It related only to food supplies and did not contain any specifics in relation to food and water supplies. The tour of the dry food storage areas showed nothing on the shelves allocated to emergency food supplies. The Director of the Nutrition Services said that she had not ordered food as she had been out on leave. When asked when the food would be delivered, she replied in a few days, but she could not relate what had been ordered. On a subsequent tour of the dry food storage areas on 8/13/2013 with the Clinical Dietician (the Director of Nutrition Services was ill and would be out until the following week), AT 10 A.M., the Dietician showed me the shelves in the area which were to contain emergency food supplies. The shelving did have a sign indicating emergency supplies. The only thing on the shelves was a bottle of vanilla flavoring. I asked her to show me the supplies listed on the emergency menu which I had been given, and she stated that there was not one item on the menu on the shelves. Another employee, a food service technician from the kitchen, joined us in the food storage area located within the kitchen area. In that room, which the Dietician stated was for general use and also for emergencies, there were 48 cans of beets, boxes of sugar and beans. There were also 456 bottles of potable water. The Dietician indicated that those could be used by both the hospital and n… | 2016-04-01 |
| 414 | 414 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2014-05-29 | 225 | C | 0 | 1 | 1FFV11 | Based on review of abuse and neglect protocol and interview with the social worker (employee #9), it was determinate that the facility failed to ensure that the results of abuse investigations must be reported to the administrator and to the State survey and certification agency within 5 working days of the incident. Finding included: 1. During the review of the Policy and procedure of abuse, neglect and sexual harassment prevention on5/29/14 at 11:00 am it was found that: a. The policy establish in the section VII, that the investigation of violation allegation and other incident is to be reported to all pertinent agencies in a time frame of 15 days. The social worker (employee #9) was interview related to the time frame to report the abuse and neglect investigation and stated the result of the investigation is notified to the patient and the pertinent agency within 15 days of the compliance is reported . b. The facility failed to ensure that all compliance of abuse and neglect investigation be notified to the state survey within 5 working days of the incident. | 2017-06-01 |
| 415 | 415 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2014-05-29 | 226 | E | 0 | 1 | 1FFV11 | Based on review of abuse and neglect protocol and interview with the Nurse supervisor (employee #2), it was determinate that the facility failed to ensure to develop and operational policy and procedure for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property on 2 out of 5 employee credential files reviewed. (CF#4 & #5) Finding included: 1. During the review of credential file on 5/29/14 at 11:00 am of new employee employees during 2013 and 2014 it was found that contractor maintenance employee credential file did not have evidence of abuse and neglect training during 2013 and 2014. 2. During interview with the nurse supervisor employee # 2 on 5/29/14 at 11:30 am related to the contracted maintenance employee as ask by the surveyor if the facility provided the abuse and neglect training and she state that she is not sure. 3. Review of the abuse and neglect training attendance from 2013 and 2014, no evidence was found that the two employee of the contracted maintenance employee assisted the training provided on 8/22/13, 8/26/13, 4/21/14 and 5/20/14. | 2017-06-01 |
| 416 | 416 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2014-05-29 | 281 | F | 0 | 1 | 1FFV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on eight record review, review of policies/procedures and interview with the nursing supervisor (employee #1) it was determined that facility failed to ensure that services are provided according to acceptable standards related to failure to take required precautions for residents with known allergies [REDACTED].#1 and #8). Findings include: 1. A mechanism to ensure that accurate identification of known drug allergy history were performed and reviewed prior to administer medications to residents was not promoted. The following findings were identified during the review of sample selection resident #1 with the nursing supervisor (employee #1) on 5/28/14 at 10:45 am: a. Resident #1 is a [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review was performed on 5/28/14 at 10:45 am and it was identified on the daily skilled nurse's note comments/concerns on the evening shift dated 5/27/14 that resident receive Tylenol with [MEDICATION NAME] # 3 to treat pain on left knee replacement area. On the daily skilled nurse's note comments/concerns on the night shift dated 5/27/14 it was documented that resident refers that she was allergic to [MEDICATION NAME] and that in the evening shift receive 1 tablet of Tylenol with [MEDICATION NAME] # 3. Nurse in charge of night shift call the physician who orders to discontinue this medication and to give to the resident [MEDICATION NAME] 25 mgs PO and maintain the resident under observation. Details of the reaction and its severity were not documented. b. Review of resident #1 Medication Administration Record, [REDACTED]. In the pre- admission screening and admission plan of care it was documented that resident had history of allergy to [MEDICATION NAME]. c. After the evening shift on 5/27/14 when resident receive Tylenol with [MEDICATION NAME] # 3 to treat pain on left knee replacement area and refers that she was allergic to [MEDICATION NAME] the allergy history … | 2017-06-01 |
| 417 | 417 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2014-05-29 | 315 | D | 0 | 1 | 1FFV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policies and procedures reviews and interviews with the Infection Control Coordinator (employee #2), Nursing Supervisor (employee #1) and the Physician (employee #7), it was determined that the facility failed to ensure that the catheterization of the resident was necessary and the treatment provided was adequate for 1 out of 8 records reviewed (RR#8). Findings include: 1. According to RR# 8 (closed record), performed on 5/28/14 at 9:30 a.m. with the Infection Control Coordinator (employee # 2), it was found that there is no treatment justification written by the physician. a. RR #8 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Secondary [DIAGNOSES REDACTED]. On 6/1/13, the resident began with a urinary complaint where she was having urine retention and discomfort on the lower side of the abdomen. At 6:00 a.m. of the same day, the Registered Nurse called by phone the physician and she ordered an insertion of Foley catheter #16, ordered toilet training and to discontinue the Foley tomorrow (next day) in a.m. a.i. The physician came to visit the resident on 6/1/13 at 7:00 p.m. but her progress note does not show evidence of a justification for the previous treatment. b. On 6/2/13, the Foley catheter was discontinued early in the morning but the resident had urine retention and discomfort at 9:00 p.m. on the same day. A telephone order is found were the physician ordered a Foley catheter #16 insertion. On 6/3/13 at 1:40 p.m. the physician ordered toilet training and discontinues Foley in a.m. on 6/4/13. However, the progress note does not show a justification for the treatment provided on these two consecutive days. There is no description of the used method for toilet training. b.i. According to policies and procedures for toilet training, which were reviewed on 5/28/14 at 11:00 a.m. with employee #2, those policies are specific to those residents that do not have Foley catheter insertion and have to resist to urin… | 2017-06-01 |
| 418 | 418 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2014-05-29 | 385 | D | 0 | 1 | 1FFV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policies and procedures reviews and interviews with the Infection Control Coordinator (employee #2), Nursing Supervisor (employee #1) and the Physician (employee #7), it was determined that the facility failed to ensure that the physician supervises the medical care in those residents that show signs and symptoms related to acute conditions, for 1 out of 8 records reviewed (RR#8). Findings include: 1. Residents with altered urinalysis results that are showing signs and symptoms such as: suprapubic discomfort and has lost the ability to keep the bladder continence, the physician fails to follow the Incontinence Protocol Guidelines. a. According to RR# 8 (closed record), performed on 5/28/14 at 9:30 a.m. with the Infection Control Coordinator (employee # 2), it was found that patient was admitted on [DATE] with a diagnose of Total Knee Replacement. Secondary [DIAGNOSES REDACTED]. On 6/1/13, the resident began with a urinary complaint where she was having urine retention and discomfort on the lower side of the abdomen. The physician ordered an insertion of Foley catheter #16, ordered toilet training and to discontinue the Foley the next day in a.m. On 6/2/13, the Foley catheter was discontinued but the resident had urine retention and discomfort at 9:00 p.m. on the same day. The physician ordered a Foley catheter #16 insertion. On 6/3/13 at 1:40 p.m. the physician ordered toilet training and to discontinue Foley in a.m. on 6/4/13 (cross references TAG F 315). a.i. No evidence was found of the physician's evaluation to determine the initial insertion of the Foley catheter based upon clinical indication for its use. a.ii. No evidence was found of explaining the resident a bladder training program. a.iii. No evidence of an assessment performed to determine history of previous urinary tract infection [MEDICAL CONDITION], current UTI, perineal skin problems, pattern of incontinent episodes, daily voiding patterns or prior rout… | 2017-06-01 |
| 419 | 419 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2014-05-29 | 431 | F | 0 | 1 | 1FFV11 | Based on observations made of the drug storage room in the back of the nursing station and staff interview, it was determined that the facility failed to ensure that drugs are reconciled accurately, expired medications were available for residents use which could affect 17 out of 17 admitted residents (Rs). (Rs #1 through 8 and random sample residents #1 through 9). Findings include: 1. During observations of the medication cabinet performed on 5/28/14 from 10:15 am till 10:30 am accompanied by a Registered Nurse (RN) (employee #6), it was identified that the drug cabinet is located in a room at the back of the nursing station. Review of the drugs storage revealed that some medications expired as follow; Senna S oral, 11 tablets expired on 4/30/14. The nurse removes the medication from the cabinet immediately after acknowledged by the surveyor. During interview on 5/28/14 at 10:00 am with the registered nurse employee # 6, she stated. we check the storage; I did not notice they were expired . During interview with the nurse supervisor (employee #1) on 5/28/14 at 11:00 am, she stated There should not be any expired medication, pointing to a memo on the door of the medication cabinet, see this tells them to remember they must check on a daily basis . 2. The facility failed to ensure that all medication on the cabinet is up to date, as per standards of practice and facility ' s policies and procedures. | 2017-06-01 |
| 420 | 420 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2014-05-29 | 441 | F | 0 | 1 | 1FFV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations made with the Infection Control Coordinator (employee #2), during the initial tour with a staff nurse (employee #6), drug pass, review of policies and procedures and review of drug cabinets it was determined that the facility failed to provide a safe environment through an organized infection control program to ensure that staff follows infection control practices, consistently and effectively that complies with professional standards of practice, recommendations of the CDC to promote sanitary and safe care so as to prevent in a manner or reduce the risk of spread of infections as evidenced by nursing staff improperly using 0.9 % Sodium Chloride for irrigation, expired medical supplies in the crash cart, provide housekeeping personnel with policies and procedures for guidance for cleaning and disinfecting the facility, have a organized infection control program, which could affect 17 out of 17 admitted residents (sample selection residents #1 through #8 and random sample residents #1 through # 9). Findings include: 1. During observations of the drug storage room on [DATE] from 10:15 am till 11:00 am accompanied by a Registered Nurse (RN) (employee #6), it was identified that the nursing staff has a tray which contain the supply for residents ' cannulation. In that tray, three bags of 0.9 % Sodium Chloride of 50 milliliter were observed which were not label and one appears to be punch by needle at the hub. The surveyors ask the nurse what were the Sodium Chloride bags use for and the nurse stated they are used for irrigation. 2. The 0.9 % Sodium Chloride that appears to be punch by needle was not label, dated, of when it was used, and as observed it had three needle punches at the hub. As recommended by the CDC, 0.9% Sodium Chloride should not be use for irrigation, and if used it should be for only one patient and discarded immediate. 3. The facility failed to follow proper infection control standards of practice and to … | 2017-06-01 |
| 421 | 421 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2014-05-29 | 493 | F | 0 | 1 | 1FFV11 | Based on observational tour, review of policies and procedures, medical records and interviews performed on 5/28 and 5/29/14 with the Physician (employee #7), the Infection Control Coordinator (employee #2) and the Nursing Supervisor (employee #1), it was determine that the Governing Body fail to ensure that the facility have a organized Infection Control Program who is responsible of investigate, controls and prevents infections in the facility. | 2017-06-01 |
| 422 | 422 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2014-05-29 | 514 | F | 0 | 1 | 1FFV11 | 2. According to RR#2 performed on 5/29/14 at 9:30 a.m., the Medications Reconciliation Form does not have the allergy history of the resident. The Registered Nurse and the physician signed this form but they did not write the information on this section. 3. On RR #2, revealed that the progress notes of 5/26 and 5/27/14 performed by the Physical Therapist Assistant (PTA, employee #10) do not show the pain reevaluation when resident finished her therapy session. According to interview with employee #10 performed on 5/29 at 1:30 p.m., she stated: I thought that writing on the findings section my interventions with the resident were enough. a. On 5/23 and 5/27/14 the progress notes of the Occupational Therapist do not show pain evaluation before and after treatment. b. The Recreational Therapist progress notes performed on 5/23, 5/26 and 5/27/14 do not show pain evaluation before and after treatment. c. The facility's Rehabilitation Program failed to ensure the implementation of the Pain Management Program. 4. On RR #2, the registered nurse (RN) wrote on 5/23/14 at 5:00 p.m. that resident can not defecate. The RN put a cleansing enema as ordered by the physician. However, the constipation problem was not identified in the plan of care. 5. On the same medical record, three telephone orders made by the physician on 5/22/14 at 8:00 p.m., 5/24/14 at 1:00 p.m., and 5/26/14 at 12:30 p.m. were not dated and signed with the hour when he went 24 hours later to sign them. Based on interviews and records review it was determined that the facility failed to maintain clinical records in accordance with accepted professional standards of practice related to incomplete Medications Reconciliation Form (MAR) 17 out of 17 Mars reviewed, physician consults and progress notes not completed for 1 out of 5 medical records reviewed (RR). (RR#2). Findings include: 1. During the observation of medication administration and MARS review on 5/28/2014 from 8:55am to 9:42 am the staff nurse fail to complete the MARS in all its parts. 17 of 17 MAR… | 2017-06-01 |
| 423 | 423 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2014-05-29 | 520 | F | 0 | 1 | 1FFV11 | Based on the review of the Quality assessment and performance improvement program, (QAPI) accompanied by the facility's nursing supervisor (employee #1), and the physical therapy supervisor (employee #3) it was determined that the facility failed to include information with respect to which quality assessment and assurance activities are perform; in the discussion and presentation of quality assurance assessment committee meetings. Findings include: 1. The quality assurance and improvement committee are meeting every three months on an ongoing basis as reviewed on 5/29/14 at 1:55 pm. The facility is collecting and presenting information during committee meetings. Data related with resident outcomes, and other aggregate patient data used to evaluate resident outcomes. Nursing, physical therapy, Diet and kitchen services monitor the quality of services provided to residents, however evidence that all results obtained in the surveillance are presented, analyzed, discussed and areas which need improvement were prioritized was not evidence not found documented. 2. Based on data related with resident outcomes, and other aggregate data used to evaluate resident outcomes few information about quality deficiencies and the development and implementation of plans of action to correct these quality deficiencies, including monitoring the effect of implemented changes are presented, and discussed in the quality assurance committee meetings. 3. Information about infection control issues, hydration, immunization, complaints, adverse events and incidents, accidents, comprehensive assessment (using MDS instrument) pain assessment and management performed by physical, occupational and recreative therapy, appropriateness of housekeeping services (cleaning and disinfection accordingly with nationally recognized guidelines and applicable state and federal law), resident satisfaction with services provided, maintenance of physical environment and appropriateness of the implementation of resident care policies; and the coordination of m… | 2017-06-01 |
| 81 | 81 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2018-08-20 | 604 | D | 0 | 1 | 1LG411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to ensure residents (Resident (R) 84 and R88 were free from physical restraints not required to treat the resident's medical symptoms and failed to assess the Residents to ensure the least restrictive alternative for the least amount of time was used. This involved 2 of 10 residents reviewed for bed rails. Findings include: 1. On 08/19/18 at 10:20 AM and 10:50 AM R88 was observed in bed with all side rails up. At 10:50 AM RN3 verified all four side rails were up and stated R88 was not able to put the side rails down. She stated only the staff could put the side rails down. On 08/20/18 at 3:22 PM he was in bed with all four side rails up. During the observation on 08/20/18 at 3:22 PM R88 stated he did not like the side rails up and he wanted them down because they made him feel like he was in Jail. The Active problem list in his electronic medical record (EMR) for R88 indicated his [DIAGNOSES REDACTED]. SNF (skilled nursing facility) admission note for R88 written by the physician and dated 08/15/18 indicated he was admitted to the facility for Physical, Occupational and Recreational therapy after being hospitalized with a DX (diagnosis) of acute UTI (urinary tract infection) and General Weakness. The note indicated the upper bed rails would be elevated for a therapeutic way. R88 had physician's orders [REDACTED]. The plan of care for use of the side rails with a start date of 08/15/18 indicated use of top rails as a therapeutic mode. Review of his Admission MDS with an ARD of 08/19/18 revealed he had a BIMS (Brief Interview for Mental Status) score of 14 at Section C, Cognitive Patterns and required limited assistance with bed mobility and transfers at Section G, Functional Status. The resident's medical record was reviewed in its entirety and revealed no documentation of an assessment for the use of all side rails. On 08/19/18 at 4:20 PM the Director of Quality and … | 2020-09-01 |
| 82 | 82 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2018-08-20 | 636 | D | 0 | 1 | 1LG411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete Minimum Data Assessments MDS, an assessment tool used by the facility to identify problems and assist in care planning, after 12/06/17 for resident (Resident (R) 84 of 8 sampled residents. Findings include: Review of R84's electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of her MDS in the EMR revealed she had only a 5-day assessment dated [DATE], a 14-day assessment dated [DATE], a 30-day assessment dated [DATE], and a 90-day assessments dated 06/06/17, 09/06/17, and 12/06/17. She had no MDS assessment dated after 12/06/17. The assessments in the EMR were marked as complete in the facility's computer system however there was no indication they had been sent and were not present in the Centers for Medicare and Medicaid Services (CMS), system when reviewed in the surveyor's computer. On 08/20/18 at 12:40 PM the MDS Coordinator stated the MDS assessments in the computer system had never been transmitted to CMS and no MDS assessments were completed after 12/06/17 because the resident was not a Medicare resident. The resident was in a medicare bed. | 2020-09-01 |
| 83 | 83 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2018-08-20 | 640 | E | 0 | 1 | 1LG411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure the required Minimum Data Set (MDS), Discharge assessment was encoded and transmitted for 12 of 12 residents reviewed, 11 unsampled and one sampled, (Resident (R)1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, and R84 when they left the care of the facility. Findings include: 1. Review of R1's EMR Summary revealed she had been admitted post left knee replacement on 12/08/17. According to her Discharge Notes she was discharged home with family present on 12/18/17. The MDS tab of R1's EMR listed an Entry Tracking assessment, dated 12/11/17, and an Admission MDS assessment, completed 12/12/17. The Admission MDS assessment indicated R1 expected to be discharged back to the community and discharge planning had been started (Section Q). There was no Discharge Assessment available in the EMR. 2. Review of R5's EMR Summary revealed she had been admitted post right knee replacement on 02/23/18. According to her Discharge Notes she was discharged home with family present on 03/02/18. The MDS tab of R5's EMR listed an Entry Tracking assessment, dated 02/23/18, and an Admission MDS assessment, completed 02/28/18. The Admission MDS assessment indicated R5 expected to be discharged back to the community and discharge planning had been started (Section Q). There was no Discharge Assessment available in the EMR. 3. Review of R11's EMR Summary revealed she had been admitted post left knee replacement on 04/06/18. According to her Discharge Notes she was discharged home with family present on 04/15/18. The MDS tab of R11's EMR listed no Entry Tracking assessment. An Admission MDS assessment was completed 04/10/18. The Admission MDS assessment indicated R11 expected to be discharged back to the community and discharge planning had been started (Section Q). She had a Non-PPS assessment dated [DATE] that was coded under A0310., section F) as Discharge assessment-return not anticipate… | 2020-09-01 |
| 84 | 84 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2018-08-20 | 641 | D | 0 | 1 | 1LG411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure the Minimum Data Set Assessment (MDS), an assessment tool completed by the facility used for care planning, accurately reflected for one of eight sampled residents (Resident(R) 86's related to his urinary continence and his diagnosis. Findings include: Review Active Problems in R86's electronic medical record (EMR) revealed his [DIAGNOSES REDACTED]. During interview with R86 on 08/17/18 at 1:58 PM he stated he was a paraplegic; he had a Foley catheter (indwelling urinary catheter); and he was in the facility for IV antibiotics due to an infection in the pressure ulcers on his hips. He also stated c Foley catheter he is incontinent of bladder. When ask why he had a Foley catheter he stated he was not sure. Observation of the resident revealed he had an indwelling urinary catheter bag hanging one the side of the bed. The pressure ulcer plan of care with an initiation date of 08/08/18 indicated the resident was admitted for IV (intravenous) therapy due to an infection of the ulcers. A Consult Note Infectiology dated 08/16/18 indicated R86 was on [MEDICATION NAME] due to hip osteo[DIAGNOSES REDACTED] due to the stage 3 decubitus ulcers of the bilateral hips. Review of R86's Admission MDS Assessment with an Assessment Reference Date (ARD), end point of evaluation, of 08/12/18 revealed the assessment was inaccurately coded. The assessment was inaccurately coded to indicate he was continent of urine at section H, urinary continence. At Section I, Active Diagnosis, the assessment was inaccurately coded with a no response at wound infections, diabetes mellitus, and [MEDICAL CONDITION], indicating he did not have any infections, did not have diabetes mellitus and was not paraplegic. Each area of the Assessment and the last section of the MDS was coded at completed and signed by the MDS Coordinator. On 08/20/18 at 11:26 AM the MDS Coordinator was interviewed. During intervie… | 2020-09-01 |
| 85 | 85 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2018-08-20 | 700 | D | 0 | 1 | 1LG411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to assess the residents prior to the installation of bed rails; failed to review the risk and benefits of the bed rails with the residents or resident representatives and failed to obtain informed consent prior to installation of the bed rails. This deficient practice affected three residents (Residents(R)84, R86, and R88) of 10 residents sampled for the use of bed rails. Findings include: 1. On 08/17/18 at 11:57 AM and on 08/18/18 at 10:44 AM and at 12:37 PM R88 was observed in his bed with his upper/top side rails in the up position. On 08/19/18 at 10:20 AM and 10:50 AM the resident was observed in bed with all side rails up. The mattress fit tightly against the side rails. No gaps were observed between the side rails and the mattress. At 10:50 AM the RN3 verified all four side rails were up and stated R88 was not able to put the side rails down independently. She stated only the staff could put the side rails down. On 08/20/18 at 9:53 AM he was observed with the top side rails up. On 08/20/18 at 3:22 PM he was in bed with all four side rails up. On 08/20/18 at 3:22 PM R88 stated he did not like the side rails up and he wanted them down because they made him feel like he was in Jail. The Active problem list in his electronic health record stated his [DIAGNOSES REDACTED]. SNF admission note written by the physician and dated 8/15/18 stated he was admitted to the facility for Physical, Occupational and Recreational therapy after being hospitalized with a DX (diagnosis) of acute UTI (urinary tract infection) and General Weakness. The note indicated the upper bed rails would be elevated for a therapeutic way. The fall risk assessment in the dated 08/18/18 stated he was at high risk for falls. R88 had physician's orders [REDACTED]. Review of his Admission MDS with an assessment reference date of 08/19/18 revealed he had a Brief Interview for Mental Status (BIMS) (a cogn… | 2020-09-01 |
| 260 | 260 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2015-06-18 | 162 | F | 0 | 1 | 1RD011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation tour, interviews with resident and professional personnel performed from 6/16/15 thru 6/18/15 during the recertification survey, it was determined that the facility failed to supply brief and urinal disposable kit to the residents during the admission at the facility, for 1 out of 10 residents (R) in the sample selection (R #9 ). Findings include: 1.R #9, is a [AGE] years old male , admitted to SNF on 6/15/15 due to Intramedulary Nail Left Hip, oriented in time, place and person, he is bedridden, because of the [MEDICAL CONDITION] and the Below Knee Amputation on his left leg. Secondary Diagnoses: [REDACTED]. As observed, during the initial tour from 6/16/15 at 9:30 am, the resident room has a strong odor of humidity and urine. Resident bed was observed and reveals that the linen has old blood stains, gauze with blood on his bed and the resident has a dirty shirt on. The register nurse employee #1 indicates that the social worker call yesterday the relatives because the patient need clothes and brief. 2. On 6/17/15 at 9:00 am resident #9 was found in his bed and he asks if some can bring him the bottle because he wants to urine in the collector and not in the brief. During interview with the resident #9 on 6/17/15 at 9:00 am it was found that the resident before the accident he did not use brief. He started using brief at the hospital after surgery. The resident stated my wife came yesterday and brought some brief because someone from here called her and told her that I need brief. I prefer the urinal before the brief . 3. During RR on 6/17/15 at 11:00 am it was found that the social worker (employee #13) did not performed an interview to the resident the same day of the admission to assess and to identify resident's needs. She assesses the resident's needs on 6/16/15 at 2:00 pm and did not ask the patient if he needed something to feel comfortable. The social worker sated that on 6/16/15 at 9:00 am the nursing personnel … | 2018-10-01 |
| 261 | 261 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2015-06-18 | 167 | C | 0 | 1 | 1RD011 | Based on the observational tour of the facility, it was determined that the facility failed to ensure that the results of the most recent survey of the facility conducted by the State Agency with its plan of correction is available for residents to review. Findings include: During the initial observational tour of the facility on 6/16/15 at 8:30 am, it was found that in the main entrance of the resident ' s dining room there is a tray with a folder which identifies it as the survey results from the last Medicare survey. However, no evidence was found that this folder contained the K-tags deficiencies from the last survey performed on 2014 and the plan of correction for the deficiencies. The facility must make the results available with all the deficiencies and with its approved plan of correction for residentes examination . | 2018-10-01 |
| 262 | 262 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2015-06-18 | 172 | F | 0 | 1 | 1RD011 | Based on facility policies and procedures and residents group interviews, performed during recertification survey 6/16/15, from 1:30pm to 1:45pm, it was determine that the facility failed to ensure the access of family members and other relatives to visit the residents at the SNF which can affect all residents (R) admitted at the facility. (R #1 to R#21) Findings include: 1. During the group interview performed on 6/16/15, from 1:30pm to 1:45pm with 10 out of 21 residents. The surveyor discussed the facility rules on the group interview, and the 10 residents told the surveyor that the visiting hours were from 8:00 am to 8:00 pm. Review of the facility's policy on 6/16/15 at 3:00 pm on page 6 states that the facility has a general visiting hour from 8:30 am to 8:00 pm. a. The facility failed to develop a mechanism to ensure that residents can receive with their consent, visits from family members and other relatives any time at the facility, without visiting hour's restrictions. | 2018-10-01 |
| 263 | 263 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2015-06-18 | 176 | F | 0 | 1 | 1RD011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the initial observational tour and ten resident's medical records review with Nursing personnel (employee #1), Director of Nursing (employee #5), Pharmacist(employee # 7) and interview, it was determined that the facility failed to ensure that the right to 2 out of 21 admitted residents (R) the right to self administer drugs are promoted. (R #4 and #5). Findings include: 1. A mechanism to ensure that facility promote the right of each resident to be responsible for the self administration and storage of drugs that they may self-administer in a safe manner was not followed ,not performed accordingly with the following findings identified during survey procedures on 6/16/5 through 6/18/15: a. Sample selection R# 4 was observed during the initial tour requesting the nurse to provide a [MEDICATION NAME] inhaler device that the resident had in her purse. She stated that she use this device on an ongoing basis. However review of medical record documentation on 6/16/15 at 8:15 am did not evidence that this resident had available and self-administer the medication. Information of who will be responsible (the resident or the nursing staff) for storage and documentation of the administration of drugs, as well as the location of the drug administration (e.g., resident's room, nurses' station, or activities room) were not found documented. b. Resident #5 was admitted on [DATE] with a [DIAGNOSES REDACTED]. During the record review performed on 6/16/15 at 11:00 am it was found that the physician ordered by telephone on 6/8/15 at 7:00 pm [MEDICATION NAME] 160 microgram (mcg)/ 4.5 mcg 2 pump Bid with an abbreviate of (PS). Interview with the nurse (employee #1) on 6/18/15 at 1:00 pm related to the abbreviation (PS) she stated that PS mean Patient Suminister. During interview with resident #5 on 6/16/15 at 4:05 pm he state that he has the medication with him and he administered the [MEDICATION NAME] 2 puff at bed time. On 6/17/15 at 9:00 am during in… | 2018-10-01 |
| 264 | 264 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2015-06-18 | 226 | E | 0 | 1 | 1RD011 | Based on review of abuse and neglect protocol, review of new employee credential file and interview with the human resource manager (employee #8), interview with the Quality Coordinator (employee #2), it was determinate that the facility failed to comply with the Affordable Care Act, Title VI, subtitle B Part III, Subtitle C, Section 6201 regarding the establishment of screening process to all potential direct access employees by a back ground check program. Findings include: 1. A mechanism to ensure that a program to conduct background checks on all prospective direct resident access employees of facility was not performed accordingly with findings identified during survey procedures on 6/16/15 through 6/18/15: a. Quality Coordinator (employee #2), stated on interview on 6/18/15 at 10:55 am that facility had in place a mechanism to screen for criminal background to all potential direct access employees accordingly with Puerto Rico State requirements. They request to the potential employee Certificado de Buena Conducta and Law 300 of (MONTH) 2,1999 Verificacion De Historial Delictivo de Proveedores de Servicios de Cuidado a Ninos y Envejecientes de Puerto Rico However facility did not have in place a federal back ground check program to screen all potential direct access employees. b. Human resource manager (employee #8), stated on interview on 6/18/15 at 11:45 am that as part of pre-employment process facility only request to the potential direct access employees Certificado de Buena Conducta and Law 300 of (MONTH) 2,1999 Verificacion De Historial Delictivo de Proveedores de Servicios de Cuidado a Ninos y Envejecientes de Puerto Rico . | 2018-10-01 |
| 265 | 265 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2015-06-18 | 246 | E | 0 | 1 | 1RD011 | Based on observation and interviews with personnel and residents made during the physical environment survey, it was determined that the facility failed to ensure to receive services in the facility with reasonable accommodation of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered affecting 2 out of 12 ramdom sample residents (RS) (RS # 11 and #12). Findings include: 1. On 6/16/15 at 9:25 am during the initial tour survey was observed resident #11 without call system installed on her room. During interview with the nursing personnel (employee #1) on 6/16/15 at 9:26 am she stated this room does not have call system but the patient is stable, oriented by time, space and person that is why the facility installed a phone and if something happen she can call the nurse station . However the telephone was observed to far from the resident. In case of an emergency the resident can have difficult to reach it. This resident room it is located in the area that the SNF use when all residents rooms near to the nursing station are full. Employee #1 stated on interview on 6/16/15 at 9:26 am that this resident is going to be moved to the area near the nursing station after one of the rooms is available. 2. On 6/16/15 at 9:30 am ramdom sample residents #12 room was observed with two chairs without side handle and both chairs were observed with the vinyl scratch. During interview with the resident on 6/16/15 at 9:32 am she stated that friends and the family when visit her, took both chairs and sit down. She states I think the therapist or the nurses never are going to sit me there. They always transferred me from the bed to chair and when I ' m get available to walk their going to take me from the bed to the walker. Sometimes I ' m tired of been all the day resting in the bed but that chairs it is seen uncomfortable and that is why I preferred stay in bed. | 2018-10-01 |
| 266 | 266 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2015-06-18 | 252 | E | 0 | 1 | 1RD011 | Based on observations, review of documentation, policies/procedures and interviews with nursing personnel, housekeeping personnel and residents made during the physical environment survey, it was determined that the facility failed to ensure a safe, clean, comfortable and homelike environment related to humidity odors in residents ' room and the dining area affecting 21 out of 21 admitted residents. Findings include: 1. During the initial physical environmental tour performed on 6/16/15 at 8:30 am until 9:45 am it was observed resident #2 (R#2) in her room tucking with her quilt covering half of her face. This resident is located beside the air conditioner. The room temperature was taken with the laser thermometer and measured 69.8 degrees Fahrenheit. The humidity in that room was 79%, the room and the bathroom had a strong odor of humidity and urine. 2. During the initial tour performed on 6/16/15 at 8:30 am it was perceived in the facility entrance a strange odor (like urine). At 8:35 the dinner room was visit and nurse (employee #1) indicates that the strong smell is for the high humidity and the smell of urine maybe is because the resident from room #110 came yesterday and it was having problem with the urine. The odor stops at 11:30 am. The facility failed to ensure a safe, clean environment from been free of dangerous and toxic odors. 3. During the initial tour on 6/16/15 at 8:30 am thru 9:45 am in residents' rooms #103, #108, #111 and #123 a humidity odor was perceived. (Cross reference F-257) | 2018-10-01 |
| 267 | 267 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2015-06-18 | 254 | E | 0 | 1 | 1RD011 | Based on the initial observational tour of the physical environment with the nursing personnel, it was determined that the facility failed to ensure that bed sheets are appropriately maintained for 2 out of 10 resident's (R) sample selection ( R#1 and #9) Findings include: 1. During the initial tour of the facility on 6/16/15 from 8:30 am until 9:45 am, twenty one resident's rooms were visited and the facility had twenty-one admitted residents. The following was observed: a. The resident selection #1 in room was observed on 6/16/15 at 8:45 am and provided evidence that the resident's sheets had old stain of blood, old tape glue in it and ink stain on the backrest area. b. The resident sample selection #9 room was observed on 6/16/15 at 9:12 am and provided evidence that the resident ' s sheets had old stain of blood. | 2018-10-01 |
| 268 | 268 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2015-06-18 | 257 | E | 0 | 1 | 1RD011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observations, resident and staff interviews and environmental temperature measurements, it was determined that the facility failed to provide and maintain resident rooms and commonly used resident areas at comfortable and safe temperature levels affecting 11 out of 21 admitted residents. Findings include: 1. During the initial tour performed on 6/16/15 at 8:30 am until 9:45 am the residents in rooms 102B, 103 B, 108B, 109B and 123B were observed in their beds huddled beneath blankets and quilts. Each resident, when interviewed about their comfort level, indicated their room was cold or too cold. They indicated maybe it is because outside is cloudy or raining. Temperature was measured with a laser thermometer. The results are as follow: room [ROOM NUMBER]- 69.6 degrees Fahrenheit ( F ) room [ROOM NUMBER]- 69.6 F room [ROOM NUMBER]- 69.7 F room [ROOM NUMBER]- 69.3 F room [ROOM NUMBER]- 69.4 F 2. On 6/17/15 at 9:00 am until 12:00 pm during the physical environment tour the residents in rooms 101,102, 106, 108 and 109 were observed in their beds huddled beneath blankets and quilts. Each resident, when interviewed about their comfort level, indicated their room still cold or too cold stills. They do not say anything because they do not want to bother anyone. Temperature was measured. The results are as follow: room [ROOM NUMBER]- 68.9 F room [ROOM NUMBER]- 69.2 F room [ROOM NUMBER]- 69.6 F room [ROOM NUMBER]- 69.7 F room [ROOM NUMBER]- 69.8 F room [ROOM NUMBER]- 68.1 F (Cross Reference Tag: F-252) The (employee #1) stated during an interview on 6/17/15 at 11:45 am that they physical plant staff verify resident's room temperatures to ensure that the temperature range is between 71 F and 81 F. Periodic resident room temperatures were performed and documented by the facility, however residents shall be asked if the temperature is comfortable to ensure that residents can recuperate to their fullest potential and are reasonably accommodated. | 2018-10-01 |
| 269 | 269 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2015-06-18 | 279 | F | 0 | 1 | 1RD011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on ten resident's records reviewed (RR), performed during standard survey on 6/16/15 thru 6/18/15 from 8:30 a.m. to 5:00 p.m. , it was determined that the facility failed to develop, identified problem and goals, and individualized the intervention and reevaluate the comprehensive plans of care to resolve patients needs for 6 out of 10 residents (Rs) in the sample selection (Rs #1, #2, #7, #5, #9 and #10). Findings include: A mechanism to ensure that facility use the results of the assessment to develop, review and revise the resident's comprehensive plan of care was not performed accordingly with these findings identified during survey procedures on 6/16/15 through 6/18/15: 1. Resident #1 is an [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. During the initial tour on 6/16/15 from 8:48 am till 10:00 am the resident refer that several days on 6/12/15 during 7-3 shift she got up from bed to use the bathroom and she lost her balance when using her walker and fell to the ground. The record was reviewed on 6/16/15 at 1:00 pm and provided evidence that the resident was found on the floor at 12:30 am was send immediately to emergency room when X rays were taken on the left elbow, left hip and left knee, resident was also evaluated by a physician. After the fall incident plan of care was not review in order to establish preventive measures to avoid that resident falls down to the floor again. The record review on 6/16/15 2:00 pm provided evidence that when resident was admitted fall prevention protocol was activated and the resident was instructed to call for assistance when needing to use the bathroom and staff were to perform frequent round. During interview on 6/17/15 at 11:34 am quality assurance officer (employee #2) stated that facility policies and procedures for fall prevention and protocols establish that to every resident admitted to the facility risk assessment must be performed in order to identify fa… | 2018-10-01 |
| 270 | 270 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2015-06-18 | 281 | F | 0 | 1 | 1RD011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of ten clinical sample records, medication administration records (MAR) and interviews, it was determined that the facility failed to ensure the appropriateness of blood glucose monitoring and medication administration nursing standard of practice for 7out of 10 resident sample. (Resident #1 ,#2, #5,#6, #7, #8 and #9) Findings include: 1. A mechanism to ensure that healthcare professionals follows the best practices during continuous glucose monitor procedures with finger stick blood samples was not performed accordingly with these findings identified during survey procedures on 6/16/15 through 6/18/15: a. Resident #6 is an [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 6/16/15 at 10:48 am and provided evidence that physician order [REDACTED]. Accordingly with information provided by the director of nursing (employee #5) on 6/17/15 at 9:55 am continuous glucose monitor procedures with finger stick blood samples must be taken by licensed practical nurses and that results of the sample must be informed to the register nurse in charge of the resident. Continuous glucose monitor finger stick blood samples are taken by licensed practical nurses since physician order [REDACTED]. On 5/12/15 at 7 pm physician order [REDACTED]. On 6/16/15 at 4 pm blood glucose fingerstick blood sample results are 212 mgs/dl and accordingly with sliding scale 3 units of regular insulin subcutaneous must be administered however no insulin was administered when sugar reach a level for which physician establish in the insulin control/sliding scale. 2. A mechanism to ensure that healthcare professionals follows the best practices while administering medications and use Pyxis automated medication dispensing system was not performed accordingly with findings identified during survey procedures on 6/16/15 through 6/18/15: a. Resident #1 is an [AGE] years old female who was admitted… | 2018-10-01 |
| 271 | 271 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2015-06-18 | 323 | G | 0 | 1 | 1RD011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policies and procedures, review of medical records with the director of nursing (employee #5 ) and the quality assurance officer (employee #2 ) , it was determined that the facility failed to provide supervision and implement interventions to reduce the risk of falls for 1out of 10 residents (R) in the sample (R #1 ) Findings include: 1. A mechanism to ensure that facility perform assessment and implement interventions for residents who had a recent history of falls and/or who are at risk of falls was not performed accordingly with these findings identified during survey procedures on 6/16/15 through 6/18/15: a. Resident #1 is an [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. During the initial tour on 6/16/15 from 8:48 am till 10:00 am the resident refer that several days on 6/12/15 during 7-3 shift she got up from bed to use the bathroom and she lost her balance when using her walker and fell to the floor. The record was reviewed on 6/16/15 at 1:00 pm and provided evidence that the resident was found on the floor at 12:30 am was send immediately to emergency room when X rays were taken of the left elbow, left hip and left knee, resident was also evaluated by a physician. After the fall incident plan of care was not review in order to establish preventive measures to avoid that resident felt down to the floor again. The record review provided evidence that the fall protocol was activated for this resident when admitted to the facility and the resident was instructed to call for assistance when needing to use the bathroom and staff were to perform frequent round. However a complete assessment who include risk factors, to develop a fall incident, behavior, equipment and devices, environment medication side effects and medical status were not performed, not evidence on the medical record. During interview on 6/17/15 at 11:34 am quality assurance officer (employee #2) stated that facility polici… | 2018-10-01 |
| 272 | 272 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2015-06-18 | 353 | F | 0 | 1 | 1RD011 | Based on observations and review of assignments, categorization nursing schedule from (MONTH) 1, (YEAR) throught (MONTH) 17, (YEAR), staff interview, it was determine that the facility failed to implement procedures to ensure that adequate staffing to meet the needs of all residents (R) are assigned which could affect 21 out of 21 admitted residents. (R#1 to R #21) Findings include: 1. A mechanism to ensure that facility evidence that sufficient nursing staff are assigned and are available to meet resident's needs was not performed accordingly with findings identified during survey procedures on 6/18/15. 2. On 6/18/15 at 9:39 am the License Practical Nurse (LPN) and Register Nurse (RN) working schedule, nurse assignments and posted nurse staffing were review with Nursing Director (employee #5) and the following was found: The facility cannot provide evidence of how many LPN and RN were working on the different shift related to nurse working schedule, nurse assignments and posted nurse staffing did not reflect the same amount of nursing staff in the three documents for 15 out of 17 days review. On 6/18/15 at 10:30am on interview with employee #5, she state that the posted nurse staffing were filled by the facility clerk and the nurse assignments were filled by the nurse of the previous shift. 3. Facility fail to have a mechanism to ensure that all documents related to nursing staff reflect the exact amounts of staff available on the shifts. | 2018-10-01 |
| 273 | 273 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2015-06-18 | 356 | F | 0 | 1 | 1RD011 | Based on observation, record review, and interview with the Director of Nursing (employee #5 ) , it was determined that facility failed to post accurately nurse staffing records , and the actual hours worked by the Registered Nurses (RN) and the Licensed Practical Nurses (LPN) that were responsible for residents' care per shift. This had a potential to affect 21out of 21 admitted residents (R) (R #1 to R #21), family members and all visitors in the facility. Findings include: 1. A mechanism to ensure that facility post the accurately information related with the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift was not performed accordingly with findings identified during survey procedures on 6/18/15: a. Observation made during the initial tour on 6/18/15 at 8:25 am revealed the nurse staffing requirements document was posted on the wall across from the hallway and central nursing station. Review of the document revealed that at the bottom of the page of the nurse staffing requirements document it is indicated that the format must be maintained for 6 months. b. Posted staffing sheets for the last 18 months are requested to the Director of Nursing (employee #5). She stated during interview on 6/18/15 at 9:40 am that the nurse staffing requirements document are file (retained ) only for 6 months after being posted. Facility failed to maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by Tag F 356 requirement. c. Policy/procedure for the use of the nurse staffing requirements document were request to the Director of Nursing (employee #5) on 6/18/15 at 8:55 am. She stated during interview on 6/18/15 at 9:00 am that she knows that facility had a policy to operationalize the nurse staffing requirements and complete the document, however she does not know where is it located or filed. | 2018-10-01 |
| 274 | 274 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2015-06-18 | 371 | F | 0 | 1 | 1RD011 | Based on the kitchen observational tour, review of policies/procedures and interview with the (employee #3) Dietitian administrative, it was determined that the facility failed to ensure a safety place for the store, prepare and serve food under sanitary conditions which can affect 21 of 21 admitted residents. (R#1 to #21) Findings include: 1. The entrance floor of the refrigerator has a water puddle. Floor tiles was missing (the area has a rough finish) mold in the corners of the floor was observed. 2. Water leak behind the ice vending machine. 3. Stack of tray rusty. 4. Floor inside the freezer need to be clean and maintenance. 5. In the sink on front of the freezer the following was observed: a) There is 2 bucket full of water with cloth inside. b) Besides the sink and near of the jam cutter machine rack full of cleaning detergent. c) One packages of chicken were observed defrosting in this sink in the original package under cool running water. 6. Humidity odor in the disposable product storage was sensed. 7. Moldy ceiling tiles over the dry food storage air conditioner. 8. The employee bathroom (man and woman) are closed because there remodeling. 9.At the Dry Storage room the following was observed: a. A puddle was observed because the air conditioning has a leak. b. The wall was observed with old stain and pipe tube running through the wall cover with mold. c. Ceiling tiles out of place. | 2018-10-01 |
| 275 | 275 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2015-06-18 | 406 | F | 0 | 1 | 1RD011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policies and procedures, review of medical records with the director of nursing ( employee #5 ) and the quality assurance officer (employee #2 ) , it was determined that the facility failed to provide specialized rehabilitative services required by resident's and accordingly with comprehensive plan of care for 1out of 10 residents (R) of sample selection. (R #2 ) Findings include: 1. A mechanism to ensure that facility had an organized rehabilitative services program that provides personalized care and treatments. With the goal of helping you achieve the highest level of function and independence possible, who focus on physical, emotional, social, and spiritual needs was not performed accordingly with these findings identified during survey procedures on 6/16/15 through 6/18/15: a. Resident #2 is an [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. During the record review performed on 6/16/15 at 2:00 pm it was found that the physiatrist do not performed the initial evaluation and resident consult and it was found the Treatment plan for Physical Therapist form in blank. During interview with the resident on 6/16/15 at 12:45 pm until 1:45 pm it was reveals that the resident had not been evaluated by the physiatrist. Also the resident had not received a complete physical therapy. Resident stated I did not understand why I am still in bed since I got here. I was operated on Monday from last week and when the hospital transfers me to this facility the doctor told me that I will be available to start physical therapy and start walking with help. Since Saturday the only thing I was doing is transferring to the wheel chair and go to take a bath . Surveyor asked if somebody came to the room and asked if she wants to do something to be entertain and she refers Yesterday the big guy took me out to the dining area and brought some coffee and left me there watching television. I like that because it was som… | 2018-10-01 |
| 276 | 276 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2015-06-18 | 441 | F | 0 | 1 | 1RD011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A mechanism to ensure that facility nursing personnel comply with dress code policy was not performed accordingly with these findings identified during survey procedures on [DATE] through [DATE]: a. On [DATE] at 8:50 am it was observed a nurse (employee # 1) with a body piercing on right ear pinna area located on the cartilage rim along the top part of the ear and dark blue nail polish on her nails. Director of nursing (employee # 5) stated on interview on [DATE] at 1:20 pm that facility nursing personnel will exhibit professional attire all times and that employee dress code establish that nursing personnel cannot wear body piercings. Quality assurance officer (employee #2) stated on interview on [DATE] at 1:45 pm that facility policy requires fingernails to be kept clean, well cared for, and not longer than 1/4-inch from fingertip in length. Artificial and long natural fingernails are not permitted for those providing direct patient care and nail polish, if worn, must be well maintained and only clear nail polish may be worn. Infection control officer (employee #9) stated on interview on [DATE] at 10:00 am that accordingly with facility dress code policy for nurses revised on (MONTH) 3,2009 body piercing and dark color nail polish are not permitted for nurses. 4. On [DATE] at 10:00 am the weighting scale was observed at left side on the interior of the medication area. The license practical nurses moved the weighting scale outside of the medication area to weight the residents when finished she puts the scale on the medication room again. No evidence of cleaning and disinfection log of this weighting scale. The facility failed to ensure a designated area to locate the equipment used to weight the residents. 5. On [DATE] at 10:15 am a washstand, a trash can and emergency cart were observed. A sanitary roll paper was observed on the interior of the washstand. The trash can lacks of a lid. A physical therapist (employee #11) was observed en… | 2018-10-01 |
| 277 | 277 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2015-06-18 | 463 | D | 0 | 1 | 1RD011 | Based on observations made during the physical environment tour, it was determined that the facility failed to ensure that residents have a way to alert staff that they need help from bed in the room which could affect 1 out of 12 ramdom sample (RS) ( RS#11) . Findings include: 1. The emergency call system pull cords in random sample #11 room was observed without cord. The facility is using a telephone located three feet away from the resident like emergency call system. This was observed on 6/16/15 at 9:30 am (Cross reference F-246) | 2018-10-01 |
| 278 | 278 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2015-06-18 | 465 | F | 0 | 1 | 1RD011 | Based on tests, observations, review of documentation and policies/procedures and interviews with personnel and residents made during the physical environment survey, it was determined that the facility failed to ensure a safe and functional environment affecting 21 out of 21 admitted residents. Findings include: During the physical environmental survey performed on 6/17/15 at 8:30 am until 1:00 pm the following was observed: 1. Residents commodes cover of rust in rooms #101 and #110 2. Bed side rails in the resident rooms #102B, #104A,#104B,#108B and 111 with scratches and peeling off. 3. Bed side rails in the resident room with old tape stick on it and dirty #108A and 109B. 4. Resident beds side rails without covers or broken covers rooms #102A, #103B, #109A, #123A and 123B. 5. Resident room #102 was observed that the cover lamp in front the bathroom was broken and repaired with tape. 6. The soap holder in bathroom #103 and #104 it was observed with white mildew. 7. The fridge in room #105 has scratches and pink spots all over it. 8. Resident room #111 has an anteroom with all the Formica counter broken. The room did not have thermometer to track the resident room temperature and relative humidity. Floor tiles with rusty stains and the wheels frame of the beds was observed cover with rust. 9. Resident room #123 did not have thermometer to track the resident room temperature and relative humidity. It was observed two chairs without armrest, rusty and with the covers scratched. The entrance door lock does not have the cover. 10. Bathroom exhausted fan making a lot of noise in room #107 and #110. Cover of all bathroom exhaust fan are dusty. 11. Residents beds boards with broken Formica in rooms #101B,#102A,#104A, #104B,#109A,#109B,#111, #123A and #123B. 12. Missing tiles in the shower room #123. | 2018-10-01 |
| 279 | 279 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2015-06-18 | 492 | F | 0 | 1 | 1RD011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of personnel credential files (CF) performed on 6/17/15 from 2:00 p.m. thru 3:30 p.m., with employee #8 (Human Resources Director), it was determined that the facility failed to ensure accepted professional standards and compliance with state and federal laws for annual evaluation and competency for 4 out of 4 Physical Therapists, 1 out of 1 Occupational Therapist, 1 out of 1 Recreational Leader, 1 out of 1 Recreational Leader Assistance, 1 out of 1 Occupational Therapist, 1 out of 1 Occupational Therapist Assistant and 4 out of 4 Physical Therapist Assistant. Findings include: 1. During review of the Occupational Therapy policies and procedures manuals with employee #14 Occupational Therapist Supervisor, performed on 6/17/15 at 8:00 a.m. it was found that the last revision of the manual was on (MONTH) 2003. It has been not updated in a time frame of twelve years. 2. During review of CF it was found the following: a. Three (3) out of four (4) Physical Therapist CF did not have evidence of an updated annual evaluation. b. Four (4) out of four (4) Physical Therapist CF did not have evidence of an annual competency evaluation performed during 2014-[AGE] year. c. It was found that the Physical Therapist Interim Supervisor CF, the facility was perform a contract and employee #12 provide evidence of the contract sign by the intern supervisor but did not shows the function and duties of this position signed by the physical therapist. d. It was found that one (1) Occupational Therapist (OT), one (1) Occupational therapist assistant, four (4) Physical Therapist, four (4) Physical Therapist assistant and one (1) Recreational Therapist and one (1) Recreational Therapist assistant does have annual competency and competency evaluations. | 2018-10-01 |
| 280 | 280 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2015-06-18 | 501 | E | 0 | 1 | 1RD011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of records (RR), policies/procedures (P&P) and interviews, it was determined that the facility failed to provide the necessary care and monitoring and the medical director failed to show responsibility for the coordination of medical care in the facility to ensure that resident's (R) reach their highest practicable well-being for 4 out of 10 sample selection residents (R #1, #2, #4 , and #8). Findings include: During survey procedures throughout the five days of survey on 6/16/15 to 6/18/15 from 9:00 am to 5:00 pm the following was identified related with failure by the facility to coordinate medical care in the facility and provide clinical guidance and oversight regarding the implementation of resident care policies: 1. R #4 was observed during the initial tour requesting the nurse to provide a [MEDICATION NAME] inhaler device that she had in her purse. She stated that she use this device on an ongoing basis. However review of medical record documentation on 6/16/15 at 8:15 am did not evidence that this resident had available and self-administer the medication. Information of who will be responsible (the resident or the nursing staff) for storage and documentation of the administration of drugs, as well as the location of the drug administration (e.g., resident's room, nurses' station, or activities room) were not found documented. The facility failed to operationalize procedures to ensure the safe self administration and storage of drugs that resident's wish to self-administer. 2. Resident #1 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. During the initial tour on 6/16/15 from 8:48 am till 10:00 am the resident refer that several days on 6/12/15 during 7-3 shift she got up from bed to use the bathroom and she lost her balance when using her walker and fell to the floor. The record was reviewed on 6/16/15 at 1:00 pm and provided evidence that the resident was found on the f… | 2018-10-01 |
| 281 | 281 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2015-06-18 | 514 | F | 0 | 1 | 1RD011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A mechanism to ensure that each document in the facility is accurately identified with resident's name and personal information was not performed accordingly with these findings identified during survey procedures on 6/16/15 through 6/18/15: a. On 6/16/15 at 11:00 am it was found one wound culture requisition and laboratory results with the name and personal information identification of resident random sample selection # 6 located on room [ROOM NUMBER]-A in hand written. Another wound culture requisition and laboratory results of resident random sample selection #1 located on room [ROOM NUMBER]-A was found with personal identification information in handwritten and with addressograph with personal identification information of a resident who was discharged several days ago. Ward clerk ( employee # 6) stated on interview on 6/16/15 at 11:55 am that the addressograph was mistakenly taken for another resident identification addressograph card and use to label the wound culture requisition and laboratory results of resident random sample selection #8, located on room [ROOM NUMBER]-A. 3. Resident #7 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. During the record review performed on 6/17/15 at 1:00 pm and 6/18/15 at 9:30 am the following was found: a. The discharge planning form lacks information related to resident religion, age, sex, civil status and resident diagnosis. b. The item #3 related to nursing information did not provide evidence of what kind of education the nurse offer at the resident during the admission. c. No evidence of social worker intervention on the initial discharge planning form. d. The pre-admission and admission order sheet lacks information related to allergy history, type of surgery and date of surgery. e. The resident #7 was admitted on [DATE] and the Physician Assessment and Treatment Plan (Admitting Evaluation and Treatment Plan) were maintained in blank on 6/17/15 at 1:00 pm.… | 2018-10-01 |
| 282 | 282 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 151 | F | 0 | 1 | 1VLO11 | Based on observations and interview with Nurse Supervisor (employee #4) during the recertification survey, it was determined that the facility failed to ensure that residents who receive care at the facility have autonomy related to choices about their care, establish a specific rules for provisions they can bring to the facility during the resident stay which affects 14 out of 14 admitted residents (Sample selection residents #1 through #8 and Random sample residents #1 through #6). Findings include: 1.During observational tours performed on 5/11 at 8:30 am, the surveyor watched posted on every residents bulletin board a sign indicating Attention family and residents. It is not allowed to bring fruits, food, flowers or over the counter medicines (medicines you buy without a prescription) . Interview perform to (employee #4) on 5/11 at 9:35 am reveals that the facility puts this sign to prevent residents do not ate foods can affect her or his treatment and recovery and the flowers for infection control. 2. The facility failed to develop a mechanism to ensure that residents can receive with their consent, provisions or gives from family members and other relatives at the facility, without any restrictions. | 2018-09-01 |
| 283 | 283 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 155 | F | 0 | 1 | 1VLO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of eight medical records and interviews performed during recertification survey from 5/11 thru 5/14/15, it was determined that the facility failed to promote the right of residents to formulate advance directive for 4 out of 8 sample selection resident (Resident #1, #3, #4 and #5). Findings include: 1. Resident #4 is an [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The record review of resident #4 was performed on 5/11/15 at 2:53 pm and provided evidence that facility informs and provide written information to the resident concerning the right to accept or refuse medical or surgical treatment, however the area were resident or relative establish or formulate advance directives was left in blank. Facility failed to determine whether the resident wish to executed an advance directive or has given other instructions to indicate what care he or she desires in case of subsequent incapacity. 2. Resident #5 is a [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The record review of resident #5 was performed on 5/12/15 at 9:25 am and provided evidence that facility informs and provide written information to the resident concerning the right to accept or refuse medical or surgical treatment, however the area were resident or relative establish or formulate advance directives was left in blank. Facility failed to determine whether the resident wish to executed an advance directive or has given other instructions to indicate what care he or she desires in case of subsequent incapacity. 3. Resident #3 was admitted on [DATE] due to Left Total Knee Replacement. The resident was accompanied by her sister during the admission process. The Advanced Directives was signed by resident's sister. During interview with resident performed on 5/11/15 at 10:00 am she referred that she left her sister to sign the admission's papers because she was tired and in pain. When the surveyor asked ab… | 2018-09-01 |
| 284 | 284 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 164 | F | 0 | 1 | 1VLO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations made during physical environment tour and interview performed to Safety Offficer (employee #6), it was determined that the facility failed to promote residents' right for personal privacy from the outside of their rooms for 4 out of 14 (resident #3,#4,#5 and #7). 1. A mechanism to ensure that residents' have the right for personal privacy is promoted was not performed, nor followed according with the following findings: a. During the physical environment tour performed on 5/14/15 from 8:30 am until 1:00 pm, it was identified that curtains that cover the outside windows located in rooms #307, #308, #309, #310, #314, #315, #316 and #317 are wide open and the windows do not have dyes. These windows are located on the side of the facility's roof, subcontractors and personnel working in this area or who pass near the windows can see the residents in their room from the outside. b. It was observed at 9:30 am on 5/14/15 resident of room [ROOM NUMBER]A it was taking a bath in bed and the licensed practitical (employee #21) did not close the windows curtain completely. Interview performs to employee #6 reveals that anyone from the outside can see right through the windows because they do not have dyes. Surveyor asked to employee #6 if physical plant department has a list or daily register for the subcontractors who perform works around the facility and he indicates they do not have a daily register for subcontractors who perform daily jobs and repairs around the facility. c. The facility failed to ensure the staff promote resident ' s personal privacy and safety during stay in the facility. | 2018-09-01 |
| 285 | 285 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 172 | F | 0 | 1 | 1VLO11 | Based on individual and group interviews to residents, interviews with the nursing staff, Physician (employee #1), Physical Therapy Supervisor (employee #3), Director of Nursing (employee #2) Skilled Nursing Facility (SNF) Nursing Supervisor (Employee #4) and the review of administrative documents performed during recertification survey on 5/11 thru 5/14/15 from 8:00 am thru 5:00 pm, it was determine that the facility failed to ensure the access of family members and other relatives to visit the residents at the SNF, for 2 out of 8 residents (RR #1 and #3). Findings include: 1. During observational tours performed on 5/11 and 5/12/15 at 8:30 am, the surveyors watched posted on the bulletin boards located on each resident's room and treatment areas a letter for residents, family members and visitors establishing visiting hours from 3:30 p.m. until 8:30 pm. According to this letter and quote: the purpose for the resident's admission to this unit is to participate in a rehabilitation program that requires your participation in all senses, so visits during therapy activities interrupt your concentration, interventions and to perform the activities on the time frame that has been established by the professionals that work with you. The Hospital has established the visiting hours from 3:30 pm until 8:30 pm so you can receive your visitors and at the same time you can comply with your therapies. We appreciate your cooperation in a manner that you can take advantage on your therapies and complete the rehabilitation program established by each professional that works with you. a. During individual interview to resident #3, performed on 5/11/15 at 9:00 am she stated the following: During the admission process, a personnel member told me that visits has to be perform from 3:30 in the afternoon. Yesterday my sister came to visit me before 12:00 noon, but some of the staff did not allow her to enter the unit. She can not come in the morning hours because she takes care of our brother during the afternoon hours because he is b… | 2018-09-01 |
| 286 | 286 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 246 | E | 0 | 1 | 1VLO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on eight resident's records reviewed and interview, it was determined that the facility failed to ensure that 2 out of 8 residents receive services in the facility with reasonable accommodations of individual needs and preferences for resident (R) (R # 1 and # 4). Findings include: 1. Resident's records reviewed from 5/11/15 through 5/14/15 from 8:30 am until 5:30 pm provided evidence that disposable briefs were used with residents who are bowel and bladder continent against resident's preferences as evidenced by the following: a. Resident #4 is an [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 5/11/15 at 11:55 am and provided evidence that the resident's had history of Diabetes Mellitus type 2 and High Blood Pressure. Residents ' caregiver was interview on 5/11/15 at 3:30 pm and she was asking about resident's preferences and daily routines when he was more independent. Based on this interview it was identified that nursing personnel put briefs to the resident after they provide bath to him. Caregiver stated that he was bladder and bowel continent and with assistance he could use the urinal or bedpan. However licensed practical nurses put on disposable briefs without asking the resident first if he want to use underwear or any undergarment. The resident was asked on 5/11/15 at 4:00 pm if he would prefer to use underwear or any undergarment to be worn beneath outer clothing, in direct contact with the skin and he stated yes I would prefer to worn underwear or any undergarment beneath outer clothing or pajamas and call for assistance because I'm able to control my bladder and bowel. I think that personnel put me disposable briefs because I'm unable to access the toilet independently; however with assistance I'm able to use the urinal and bedpan. 2. The facility failed to promote that the nursing personnel behaviors should be directed toward assisting the resident in mainta… | 2018-09-01 |
| 287 | 287 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 248 | F | 0 | 1 | 1VLO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review the activity program activities and eight sample selection cases and interview with the recreational rehabilitation personnel employee (employee # 5 ) it was determined that the facility failed ensure that that 8 out of 8 residents (R) sample selection (R #1 through #8) and 7 out of 7 random sample(RS) residents (RS #1 through #7) received an ongoing activities program designed to meet the interests and the physical, mental and psychosocial well-being of the residents. Findings include: 1. A mechanism to ensure that facility involves residents in an ongoing program of activities designed to appeal to his or her interests and to enhance the resident's highest practicable level of physical, mental, and psychosocial well-being was not followed ,not performed accordingly with the following findings identified during survey procedures on 5/11/5 through 5/14/15: a. During interview on 5/14/15 at 2:55 pm recreational rehabilitation personnel (employee # 5) stated that during weekends no formal activities were provided to residents. She said that she prepare schedule and sometimes nursing personnel help to provide some activities, however no evidence was maintained documented of resident's response to the recreational activities and participation. b. Resident #4 is an [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 5/11/15 at 11:55 am and provide evidence that recreational therapist went on 5/8/15 to perform initial evaluation to the resident to identify resident preferences for recreational activities, however resident refuse to answer to her the questions and stated that he does not want to participate in any recreational activity. c. No evidence was found documented on the medical record of efforts performed in order to promote resident motivation to participate in recreational activities either individual or in group. No involvement of resident relatives was found to… | 2018-09-01 |
| 288 | 288 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 250 | H | 0 | 1 | 1VLO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A mechanism to ensure that facility failed to aggressively identify the need for medically-related social services, and pursue the provision of these services to meet the resident's needs was not followed, not performed accordingly with the following findings: 2. Resident #4 is an [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 5/11/15 at 11:55 am and provided evidence that resident received neurocognitive rehabilitation screening on 5/8/15 at 9:00 pm due to sadness and death wishes that he referred during admission to the facility on [DATE]. Based on neurocognitive rehabilitation screening performed on 5/8/15 at 9:00 pm resident was diagnosed with [REDACTED]. The recommendations for the management of this condition was neurocognitive rehabilitation follow-up to provide adaptive coping strategies to deal with the depressive mood and facilitate neurocognitive strategies to support adaptative emotional regulation and positive mood throughout hospitalization . Resident was also evaluated by the psychiatrist on 5/9/15 at 2:50 pm who ordered Cymbalta 50 mgs PO in am. Plan of care for Mood State was developed on 5/8/15 by the interdisciplinary team members. Accordingly with this plan of care emotional counseling were going to be provided and monitoring on mood state were going to be performed, however no documentation was found on the progress notes of nursing personnel ,physician, social work and rehabilitation personnel related with activities performed to emotional counseling were going to be provided and monitoring on mood state from 5/8/15 through 5/11/15. The clinical record was reviewed on 5/11/15 at 11:55 am and provide evidence that recreational therapist went on 5/8/15 to perform initial evaluation to the resident to identify resident preferences for recreational activities, however resident refuse to answer to her the questions and stated that he does not want to participat… | 2018-09-01 |
| 289 | 289 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 252 | F | 0 | 1 | 1VLO11 | Based on observation and interview, the facility failed to ensure that it provided a home-like environment related to signs indicating thinks that residents cannot receives from relatives and windows curtains and affecting 14 out of 14 admitted residents in the facility. Findings includes: 1. During observational tours performed on 5/11 and 5/12/15 at 8:30 am, the surveyors watched posted on the bulletin boards located on each resident's room and treatment areas a letter for residents, family members and visitors establishing visiting hours from 3:30 p.m. until 8:30 pm. According to this letter and quote: the purpose for the resident's admission to this unit is to participate in a rehabilitation program that requires your participation in all senses, so visits during therapy activities interrupt your concentration, interventions and to perform the activities on the time frame that has been established by the professionals that work with you. The Hospital has established the visiting hours from 3:30 pm until 8:30 pm so you can receive your visitors and at the same time you can comply with your therapies. We appreciate your cooperation in a manner that you can take advantage on your therapies and complete the rehabilitation program established by each professional that works with you. 2. During observational tours performed on 5/11 at 8:30 am, the surveyor watched posted on every residents bulletin board a sign indicating Attention family and residents. It is not allowed to bring fruits, food, flowers or over the counter medicines (medicines you buy without a prescription). 3. During the physical environment tour performed on 5/14/15 from 8:30 am until 1:00 pm, it was identified that curtains that cover the outside windows located in rooms #307, #308, #309, #310, #314, #315, #316 and #317 are wide open and the windows do not have dyes. These windows are located on the side of the facility's roof, subcontractors and personnel working in this area or who pass near the windows can see the residents in their room from … | 2018-09-01 |
| 290 | 290 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 253 | F | 0 | 1 | 1VLO11 | Based on observations, review of documentation and policies/procedures and interviews with personnel and residents made during the physical environment survey, it was determined that the facility failed to ensure housekeeping and maintenance service necessary to maintain a sanitary, orderly, and comfortable interior affecting 14 out of 14 admitted residents. Findings include: As observed tour through the facility on 5/11/15 at 9:00 am the following was found: 1. All cubicles curtain with stains and dirty. 2. Visitor bathroom was found with residues of toilet paper on the floor, garbage containers full of trash, strong odor of dirty sanitary pipes and floor in need of cleaning. 3. Accumulated dirt by the edges of the ceramic tile base and all the edges of the floors of the rooms of residents. 4. Resident ' s room window sills dusty and full of dirty around the frame and glass. 5. Room #317 tile located in front of the window have stains. 6. Room #314, #316 has dirt and stain on bathroom floor. | 2018-09-01 |
| 291 | 291 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 272 | D | 0 | 1 | 1VLO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on eight sample records review (RR) performed during recertification survey from 5/11 thru 5/14/15 it was determined that the facility failed to ensure that professional staff document the Minimum Data Set (MDS) accurately to identify the concerns that affect residents health conditions in a manner that can develop a plan of care, as seen on 1 out of 8 records review (RR#3). Findings include: 1. During RR #3 performed from 5/12/15 to 5/14/15 at different hours, the MDS coordinator failed to complete the requested information on the MDS. The sections with lack of information were: a. Section A- Identification Information b. Section B- hearing, Speech and Vision c. Section F- Preferences for Customary Routine and Activities d. Section G-Functional Status incomplete information on bed mobility transfer dressing, eating, toilet use and personal hygiene e. Section H- Bladder and Bowel f. Section I- Active Diagnoses g. Section J- Health Conditions h. Section M- Skin Conditions i. Section N-Medications j. section O- Special treatments, Procedures and Programs k. Section Q- Participation in Assessment and Goal Setting l. On Section V- Care Area Summary (CAA) it was not identified item # 17 related to [MEDICAL CONDITION] drug use considering that she was taking [MEDICATION NAME] ([MEDICATION NAME]) 3 mg by mouth in morning and 2 mg by mouth at hour sleep (HS). m. Section X- Correction request that could be filled out on 5/14/15 n. Section Z- Assessment Administration. 2. The MDS coordinator failed to document on an ongoing basis the MDS form according to her observations and verbal expressions that resident could say through an interview process. | 2018-09-01 |
| 292 | 292 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 279 | E | 0 | 1 | 1VLO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on eight sample selection residents records reviewed, interview with the registered Nurse (employee # 17) it was determined that the facility failed to develop and re- evaluate a comprehensive plan of care for 4 out of 8 residents (R) in the sample selection related to: depress mood and death wishes and positioning. (R #1, #3, #4 and #5). Findings include: 1. A mechanism to ensure that facility uses the results of the interdisciplinary member ' s assessments to develop, review and revise the resident's comprehensive plan of care was not followed, not performed accordingly with the following findings: a. Resident #4 is an [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 5/11/15 at 11:55 am and provided evidence that resident received neurocognitive rehabilitation screening on 5/8/15 at 9:00 pm due to sadness and death wishes that he referred during admission to the facility on [DATE]. Based on neuroneurocognitive rehabilitation screening performed on 5/8/15 at 9:00 pm resident was diagnosed with [REDACTED]. The recommendations for the management of this condition was neuroneurocognitive rehabilitation follow-up to provide adaptive coping strategies to deal with the depressive mood and facilitate neurocognitive strategies to support adaptative emotional regulation and positive mood throughout hospitalization . Resident was also evaluated by the psychiatrist on 5/9/15 at 2:50 pm who ordered [MEDICATION NAME] 50 mgs PO in am. Plan of care for Mood State was developed on 5/8/15 by the interdisciplinary team members. According with this plan of care emotional counseling were going to be provided and monitoring on mood state were going to be performed, however no documentation was found on the progress notes of nursing personnel, physician, social work and rehabilitation personnel related with activities performed to emotional counseling were going to be provided and monitoring on… | 2018-09-01 |
| 293 | 293 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 281 | F | 0 | 1 | 1VLO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of five clinical sample records and three random selection records, medication administration records (MAR) and interviews, it was determined that the facility failed to ensure that professional staff perform initial nutritional evaluations based on residents needs and conditions, to identify residents who can benefit from nutritional care interventions and the administration of residents medications on a timely manner for 5 out of 5 residents (R) sample and 2 out of 3 random selection (RS), (R #1, #2, #3, #4, #5 and RS #6 and #10). Findings include: A mechanism was not performed as evidenced by the following: 1. Resident #4 is an [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 5/11/15 at 11:55 am and provided evidence that the resident's had history of Diabetes Mellitus type 2 and High Blood Pressure. During admission 2000 kclas 3 gms of sodium 200 mgs cholesterol with 3 snacks diabetic diet was ordered to the resident. During interview on 5/11/15 at 1:00 pm resident stated that he had weight loss, chewing problems and also complaints of the taste of the food that was receiving. That nutritionist went to evaluate him during morning but before the evaluation and since his admission on 5/7/15 he was not eating great quantity of the food received because he does not like it. Resident caregiver report that resident was not eating well since admission to the facility on [DATE] due to complaint on taste of food, she also reported that relatives are available to bring home cook food in an effort to deal with resident poor appetite status. However due to the situation that resident are not being evaluated by dietitian they were waiting until this to suggest it. The clinical record was reviewed on 5/11/15 at 1:30 pm and provided evidence that dietitian evaluate the resident's nutritional status on 5/11/15 at 11:02 am. She document on the nutritional initial… | 2018-09-01 |
| 294 | 294 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 309 | H | 0 | 1 | 1VLO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of eight clinical records and policies/procedures (P&P) and interview, it was determined that the facility failed to provide the necessary care to assess and manage pain to ensure that residents (R) reach their highest practicable well-being for two out of eight sample selection residents (R #1 and R #3 ). Findings include: 1. RR# 3 was admitted on [DATE] after a Left Total Knee Replacement. On 5/12/15, the resident woke up early (8:30 am) as every day to receive physical therapy. At 10:00 am and 11:30 am she was not taken to the physical therapy because the RN that was administering medications failed to provide her early pain medication such as: [MEDICATION NAME] 5/325 mg 1 tab po every 3 hours. The resident has to wait 3 hours to receive her pain medication, (Cross Reference TAG 281). a. At 10:00 am the surveyor requested the RN to administer pain medication so the resident could go early to her physical therapy. At 11:30 am an observational tour was performed and the resident was lying on bed finishing her lunch meal. When asked on how she spent her therapy sessions she stated: Two times the escort came for me and because the RN did not give me the pain medication she (escort) told me I can not take you to the therapy because you have to take your pain medication, I'm still waiting for the medication. At 1:00 pm the MAR indicated [REDACTED]. The resident has to wait until 1:30 pm to attend her physical and occupational therapies. b. The surveyor requested the Nursing Supervisor (employee # 4) a copy of the rehabilitation scheduled program and stated: I have to request a copy to the Physical Therapy Supervisor because I don't have any. For more than 2 months I don't receive a copy of the residents scheduled Rehabilitation Program. When the scheduled program arrived to the facility, resident #3 had scheduled at 9:30 am occupational therapy and at 1:00 pm the physical therapy. However, the resident did not recei… | 2018-09-01 |
| 295 | 295 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 319 | E | 0 | 1 | 1VLO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of records (RR), policies/procedures (P&P) and interviews, it was determined that the facility failed to ensure that residents who displays mental or psychosocial adjustment difficulty receives appropriate treatment and services to correct the assessed problem, for 2 out of 8 sample selection residents ( R.R. #3 and #4). Findings include: 1. During survey procedures throughout the five days of survey on 5/11/15 to 5/18/15 from 8:00 am to 5:00 pm the following was identified related with failure by the facility to ensure that each resident receives care and services to assist him/her to reach and maintain the highest level of mental and psychosocial functioning: a.Resident #4 is an [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 5/11/15 at 11:55 am and provided evidence that resident received neurocognitive rehabilitation screening on 5/8/15 at 9:00 pm due to sadness and death wishes that he referred during admission to the facility on [DATE]. Based on neuroneurocognitive rehabilitation screening performed on 5/8/15 at 9:00 pm resident was diagnosed with [REDACTED]. The recommendations for the management of this condition was neurocognitive rehabilitation follow-up to provide adaptive coping strategies to deal with the depressive mood and facilitate neurocognitive strategies to support adaptative emotional regulation and positive mood throughout hospitalization . Resident was also evaluated by the psychiatrist on 5/9/15 at 2:50 pm who ordered [MEDICATION NAME] 50 mgs PO in am. Plan of care for Mood State was developed on 5/8/15 by the interdisciplinary team members. Accordingly with this plan of care emotional counseling were going to be provided and monitoring on mood state were going to be performed, however no documentation was found on the progress notes of nursing personnel, physician, social work and rehabilitation personnel related with activi… | 2018-09-01 |
| 296 | 296 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 325 | E | 0 | 1 | 1VLO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on eight resident's records reviewed and interview, it was determined that the facility failed to ensure that 2 out of 10 residents (R) is monitored to assure that maintains acceptable parameters of nutritional status, such as body weight and protein levels, and receives a therapeutic diet when there is a nutritional problem for R #4 and # 5. Findings include: 1. Resident's records reviewed from 5/11/15 through 5/14/15 from 8:30 am till 5:30 pm provided evidence that an initial nutritional assessment was not performed at the moment of admission related with a recommended diet, weight and fluids needed for the resident's condition and to identify residents who can benefit from nutritional care interventions as evidenced by the following: a. Resident #4 is an [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 5/11/15 at 11:55 am and provided evidence that the resident's had history of Diabetes Mellitus type 2 and High Blood Pressure. During admission 2000 kclas 3 gms of sodium 200 mgs cholesterol with 3 snacks diabetic diet was ordered to the resident. During interview on 5/11/15 at 1:00 pm resident stated that he had weight loss, chewing problems and also complaints of the taste of the food that was receiving. That nutritionist went to evaluate him during morning but before the evaluation and since his admission on 5/7/15 he was not eating great quantity of the food receiving because he does not liked. Resident caregiver report on 5/11/15 at 11:58 am that resident was not eating well since admission to the facility on [DATE] due to complaint on taste of food, she also reported that relatives are available to bring home cook food in an effort to deal with resident poor appetite status. However due to the situation that resident are not being evaluated by dietitian there were waiting until this to suggest it. The clinical record was reviewed on 5/11/15 at 1:30 pm and provided ev… | 2018-09-01 |
| 297 | 297 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 327 | E | 0 | 1 | 1VLO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on eight resident's records reviewed and interview, it was determined that the facility failed to ensure that 4 out of 10 residents (R) is monitored to assure that that their fluid intake are appropriate to maintain proper hydration and health for (R#1, #3, #4 and #5). Findings include: 1. Resident's records reviewed from 5/11/15 through 5/14/15 from 8:30 am till 5:30 pm provided evidence that an initial nutritional assessment was not performed at the moment of admission related with a recommended diet, and fluids needed for the resident's condition as evidenced by the following: a. Resident #4 is an [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 5/11/15 at 11:55 am and provided evidence that the resident's had history of Diabetes Mellitus type 2 and High Blood Pressure. During admission 2000 kclas 3 gms of sodium 200 mgs cholesterol with 3 snacks diabetic diet was ordered to the resident. No recommendations for the quantity of fluids or free water was included as part of diet ordered. Hidration intake documentation on 5/7/15,5/8/15,5/9/15 and 5/10/15 evidence that resident was receiving 64 ounces of liquids ( including water and food tray liquids) daily. The clinical record was reviewed on 5/11/15 at 1:30 pm and provided evidence that dietitian evaluate the resident's nutritional status on 5/11/15 at 11:02 am. She document on the nutritional initial evaluation format that resident had moderate nutritional risk due to Depression history, gastrointestinal distress (constipation history) and chewing difficulties. She also include in her initial evaluation that this resident had dehydration risk due to constipation history The recommendation for fluids for this resident accordingly with dietitian initial evaluation dated 5/11/15 at 10:00 am was 87 ounces daily. Facility failed to promote that resident's who had constipation history and are determined to be on dehydration ris… | 2018-09-01 |
| 298 | 298 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 333 | F | 0 | 1 | 1VLO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical records, medication administration records and interviews, it was determined that the facility failed to ensure that residents (R) are free of any significant medication errors for 2 out of 8 resident sample (R # 1 and #2) and 2 out of 2 random selection (RS) (RS # 9 and #10). Findings include: 1. Resident # 10 is a [AGE] years old male patient admitted on [DATE]. During a round on 5/13/2015 was observed that Register Nurse # 12 (RN #12) was administering his medications at 10:35 am (Losartan 25 mg tab po daily, [MEDICATION NAME] XR 75 mg po am, [MEDICATION NAME] 500 mg two tabs po daily, Xarelto 10 mg one tab po daily and Norvacs 10 mg one tab po daily). Facility morning medication administration time is 9:00 am 2. Resident # 2 is a [AGE] years old male patient admitted on [DATE]. During a round on 5/13/2015 was observed that RN #12 was administering his medications at 10:45 am (Losartan 25 mg tab po daily, [MEDICATION NAME] XR 75 mg po am, [MEDICATION NAME] 500 mg two tabs po daily, Xarelto 10 mg one tab po daily and Norvacs 10 mg one tab po daily). Facility morning medication administration time is 9:00 am. 3. Resident # 1 is a [AGE] years old female patient admitted on [DATE]. During a round on 5/13/2015 was observed that RN #12 was administering her medications at 10:57 am (Atelonol 25 mg one tab po daily, Juven one pack po daily, Pre-protein 30 ml po daily, [MEDICATION NAME] 20 mg 1 tab daily po, [MEDICATION NAME] 12.5 mg 1 tab po daily, [MEDICATION NAME] 30 mg SC daily,). Facility morning medication administration time is 9:00 am. 4. Resident #9 is a [AGE] years old female patient admitted on [DATE]. During a round on 5/13/2015 was observed that RN #12 was administering his medications at 11:04 am ( [MEDICATION NAME] 500 mg two tabs po daily, [MEDICATION NAME] 2.5 mg tab po daily, Norvacs 10 mg one tab po daily and [MEDICATION NAME] 40 mg SC daily). Facility morning medication administration ti… | 2018-09-01 |
| 299 | 299 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 356 | C | 0 | 1 | 1VLO11 | Based on observation, record review, and interview, it was determined that facility failed to post accurately nurse staffing records that included all required information, including the posting of the resident census, and the actual hours worked by the Registered Nurses (RN) and the Licensed Practical Nurses (LPN) that were responsible for residents' care per shift. This had a potential to affect 14 out of 14 admitted residents, family members and all visitors in the facility. Findings include: 1. Observation made during the initial tour on 5/11/15 at 9:15 am on the third floor revealed the nurse staffing requirements document was posted on the wall across from the central nursing station. Review of the document revealed that for 5/11/15 shift 11pm-7am no LPN (Licensed Practical Nurse ) personnel was posted and only 1 Register Nurse was posted for the 11pm-7am shift. 2. Review of the Register Nurse and Licensed Practical Nurse schedule for this week evidence that for 5/11/15 shift 11 pm-7 am 2 register nurses are assigned to cover the shift. 3. On 5/12/15 at 9:00 am, Nursing Supervisor (employee # 4 ) was asked if she was aware that only one Register Nurse was posted for 5/11/15 11 pm-17 am shift. During interview Nursing Supervisor (employee # 4) stated that for this shift was assigned 2 Register Nurses, and one of the register nurses was assigned to perform LPN duties. She also stated that for shift 11pm-7 am it always assigned 2 nurses no matter the census of residents receiving services at the facility. She explained that posting document was assigned to be completed by the MDS coordinator and this one was wrongly documented. | 2018-09-01 |
| 300 | 300 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 371 | F | 0 | 1 | 1VLO11 | Based on the kitchen observational tour, review of policies/procedures and interview with the kitchen's Production Supervisor (employee #23) and the dietitian supervisor (employee #24), it was determined that the facility failed to ensure a safety place for the store, prepare and serve food under sanitary conditions which can affect 14 of 14 admitted residents. Findings include: 1. During the kitchen initial observational tour performed with the kitchen's Production Supervisor (employee #23) on 5/11/15 from 8:00 am until 8:45 am the following was found: Milk and Freezer Area: a. Pipes from the ED panel go through the gypsum wall without fire stopping sealer in front of the milk fridge and freezer. b. Wooden wall it is dividing the area and it is uses for Housekeeping storage. This wooden wall division does not have a continuity to finish with the ceiling. c. Drainage grid with mold and rust. d. Broken wall tiles. Pre-processed room: a. Sink Faucet needs adjustment it is throwing water all the time. b. A leak from the ceiling was observed because the air conditioner condensation. c. Blender with peeling paint. Water Storage: a. Equipment in stock waiting tom be repair or to be seize. b. Straw baskets touching the roof. c. A metal rack full of dishes. Employee #23 indicates on 5/11/15 at 8:15 am these dishes are used for hospital activities. d. A wooden pallet in the floor full of 7up. e. The ceiling has mold stain. f. A stack of saucepans touching the ceiling. Production area: a. A puddle was observed because the air conditioning has a leak. b. An insect lamp full of flies above the trays car. The trays car was full of clean trays waiting to be used to serve the residents ' lunch. c. The rubbers around the doors of the refrigerators are detached. Employee #23 indicates the order for the new rubber door was submitted. We are waiting for the arrival. Line production area: a. Kitchen hood rusty. b. It was observed a hole in the wall tile behind the coffeemaker. Trays cleaning and disinfecting area: a. Seven large gar… | 2018-09-01 |
| 301 | 301 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 455 | F | 0 | 1 | 1VLO11 | Based on the review of the maintenance documents of the electrical generators during the recertification survey with the facility's Safety Officer (employee #6), it was determined that the facility failed to ensure that personnel document the monthly transfer switch tests as required by the NFPA 99, section 3.4.4.1. and keep record of all works performed by the electrical company in charge of both generators. Findings include: 1. The facility lacks written evidence of the monthly maintenance as reviewed on 5/13/15 at 3:20 pm. The facility does not have a monthly check list or a maintenance monthly log which includes the services performed for both generators. However a weekly check list was provide and reveals weekly inspection was performed. Evidence also reveals the physical plant department does not have evidence of services and maintenances performed to the generators. 2. During the review of maintenance documentation of the Kohler electrical generator on 5/13/15 at 3:20 pm with the facility's Safety Officer it was determined that this generator have problems with transfer switch working under capacity, rubber fuel line need to be replaced. Also documented by the preventive maintenance personnel are findings such as no spare batteries, belts or starter and parts that need to be changed, however no evidence was found that these findings were addressed. 3. No evidence was found on 5/13/15 at 3:20 pm related to transfer switch problem resolved. 4. The facility does not have Policies and procedures for the weekly inspection performed by the physical environment employees. Interview with Safety Officer (employee 6) on 5/13/15 at 10:45 am indicates that the facility does not have policies and procedures for the weekly inspection of equipments that have monthly maintenance contract and were inspected weekly by his employees. 5. During the review of maintenance documentation on 5/13/15 at 3:20 pm until 4:45 pm it was found that the facility bought on 2013 and installed on (MONTH) (YEAR) a new electrical generator a C… | 2018-09-01 |
| 302 | 302 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 456 | F | 0 | 1 | 1VLO11 | Based on observations, record review and interview to safety officer (employee #6) and register nurse (employee #22), it was determined that the facility failed to ensure that resident's essential equipment are maintained in safe operating condition related to defibrillator test and the evidence (Strip) which could affect 14 out of 14 admitted residents. Findings include: 1. The SNF has one defibrillator that is located near the nursing station during the observational tour determined on 5/11/15 at 9:00 am until 11:45 am and a test was performed with and without electrical power only battery power. The battery allows the tests. Evidence was found of the biomedical technician's seal as checked since (MONTH) (YEAR) for both defibrillators. Evidence was found that the biomedical technician verified the battery during his last inspection. However no evidence was found about tests performed by nursing staff with electrical power and without electrical power. Interviewing employee #22 on 5110/15 at 11:25 am surveyor asked the nurse to do the test without electrical power and the employee do not know how to do it. Surveyor asks to employee 22 evidence of the test performs to the defibrillator and the employee #22 shows a file with a table and the table shows yes or no for questions about the test perform to the defibrillator with and without electrical power. Surveyor asked to the employee #22 for the (Strip) and she indicates the instructions for the defibrillator test the bio medics gave is that after the test is perform we have to throw away the strip. The surveyor asked if they perform without electrical power and she says yes. Surveyor asked how she performs the test and she indicates that she unplugged the defibrillator and immediately she performed the test. 4 if he received instruction to performed tests without electrical power and he refers a. The facility failed to ensure staff kept evidence of the tests performed daily to the defibrillator. | 2018-09-01 |
| 303 | 303 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 465 | F | 0 | 1 | 1VLO11 | Based on tests, observations, interviews and record review made during the physical environment survey with the facility's Safety Officer (employee #6), it was determined that the facility failed to ensure and maintain a clean and safe environment for the residents which has the potential to affect 14 of 14 admitted residents. (R#1 through #14) Findings include: 1. During the observational tour of resident's rooms on 5/11/15 from 9:00 am until 11:15 am, the following was determined: a. The protective painted cover on the shower floor was peeling in patient's room #310, #314, #317 and #318. b. Room #314 and 318 with two (2) seats without arm rests. c. All bathrooms on residents room with a strong odor of humidity. d. It was observed in the following rooms that the air return vents and AC vents were dusty: -room 309 (return) -room 310 (return) -room 311 (return) -room 312 (return) -room 315 (return) -room 316 (return) -room 317 (return) e. The facility failed to maintain the air returns and AC vents by allowing them to become dusty. f. Resident's sleeping rooms #508 B was observed on 5/11/15 at 9:10 am and provided evidence that a radio set owned by resident was being used without evidence of being inspected and approved by the safety officer before their use in care areas. g. Resident room #311 A an enteral pump was observed without bio medic ' s inspection label. h. All glass windows and frames on residents' rooms observed with mold stains, dirt and rust. i.All grab bars in residents bathrooms mildew and rusty; a. Exhaust fan on bathroom from residents room #317 do not function. b. Ceiling tile in entrance of room #318 with mold. 2. During the physical environment tour performed on 5/13/15 from 8:30 am until 1:00 pm, it was identified that curtains that cover the outside windows located in rooms #307, #308, #309, #310, #314, #315, #316 and #317 are wide open and the windows do not have dyes. These windows are located on the side of the facility's roof, subcontractors and personnel working in this area or who pass… | 2018-09-01 |
| 304 | 304 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 490 | F | 0 | 1 | 1VLO11 | Based on observation, interviews, and record review, it was determined that the facility was not administered in a manner that enabled each resident to attain or maintain their highest practicable well-being. Deficiencies in Quality of Life, and Quality of Care identified on survey procedures 5/11/15 through 5/14/15 has the scope and severity to be defined as substandard quality of care. Extended survey procedures were perform on 5/18/15 to review compliance all the tags within this section ( 483.75). Findings include: 1. During review of Administration requirements ( 483.75) on 5/18/15 extended survey procedures deficiencies in the following requirement were found: F 490-Administration F 492-Compliance with federal, state and local laws and professional standards. F 499-Staff qualifications. F 501-Medical Director. F 514-Clinical records F 517-Written plans and procedures to meet all potential emergencies and disasters. F 518-Train all employees in emergency procedures. F 520-Quality Assessment and Assurance 2. Deficiencies were also identified in Resident Rights requirements 483.10 (Refer to tag F 151,F 155,F 164 and F 172 ), 483.15 Quality of Life (Refer to tag F 246,F 248,F 252,F 253),483.20 Resident assessment (Refer to tag F 272,F 279 and F 281),Quality of Care 483.25 (Refer to tag F 309,F 319,F 325,F 327 and F 333), 483.30 Nursing Services (Refer to tag F 356), 483.35 Dietary services (F 371) 483.70 Physical Environment (Refer to tag F 455,F 456 and F 465) and 483.75 Administration( Refer to F 490, F 492, F 493,F 501,F 514 and F 520) in this document. 3.Administrator (employee # 16) was informed on 5/14/15 at 5:00 pm the deficiencies in Quality of Life, and Quality of Care identified on survey procedures 5/11/15 through 5/14/15. He was explained that those deficiencies have the scope and severity to be defined as substandard quality of care and that those requirements need to be met for each resident receiving service at the facility. It was also explained to him that they need to review the requirements n… | 2018-09-01 |
| 305 | 305 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 492 | F | 0 | 1 | 1VLO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of personnel credential files (CF) at the extended survey performed on [DATE] from 8:00 a.m. thru 5:30 p.m., it was determined that the facility failed to ensure that 1 out of 3 Licensed Practical Nurses, 1 out of 8 Registered Nurses, 3 out of 3 Physical Therapists, 2 out of 2 Biomedical contracted services, 3 out of 3 Nutritional Department employees and 2 out of 2 volunteers comply with facility, state and federal laws. Findings include: 1. It was found that 2 out of 24 CF do not have an actualized Professional License Registry. CF #9 has a provisional Professional License but no evidence was found from the State Board of Nurses that this employee complies with all the requirements established by the Licensed Practical Nurse Association. CF # 13, its professional license has expired on (MONTH) 19, 2013. 2. It was found that 3 of 24 CF failed to show a Health Certificate, (CF # 18, #19 (contracted personnel) and CF # 22). 3. It was found that 3 out of 24 CF failed to show an actualized Cardio Respiratory Certification (CPR), (CF # 13, #16, #18). 4. It was found that 6 out of 24 CF failed to have evidence of [MEDICAL CONDITION] vaccines, (CF #14, #18, #19, #20, #21, #22). 5. It was found that 8 out of 24 CF do not have evidence on the Influenza vaccine or refusal, (CF # 4, # 9, #11, #14, #18, #19, #21 and #22). 6. It was found that 5 out of 24 CF do not have evidence of annual evaluations and competency evaluations, (CF # #12, #13, #14, #17, #22). 7. It was found that 5 out of 24 CF do not have evidence of been contracted by the facility, (CF #12, #13, #14, #16, #22). 8. It was found that 5 out of 24 CF do not have evidence of their duties that perform at the facility, (CF # 12, #13, #14, #17, #22). 9. It was found that 6 out of 24 CF do not have evidence of complying with Local Law Number 300 (back ground check), (CF # 18,# 19, # 21, #22, #23, #24). 10. The professional staff participates on educational mandatory courses … | 2018-09-01 |
| 306 | 306 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 493 | F | 0 | 1 | 1VLO11 | Based on observation, interviews, and record review, it was determined that governing body failed to establish and implement policies regarding the management and operation of the facility; to promote that each resident to attain or maintain their highest practicable well-being. Findings include: 1. Deficiencies in Quality of Life, and Quality of Care were identified on survey procedures 5/11/15 through 5/14/15 has the scope and severity to be defined as substandard quality of care. Extended survey procedures were perform on 5/18/15 to review Compliance all the tags within this section ( 483.75). 2. During review of Administration requirements ( 483.75) on 5/18/15 extended survey procedures deficiencies in the following requirement were found: F 490-Administration F 492-Compliance with federal, state and local laws and professional standards. F 499-Staff qualifications. F 501-Medical Director. F 514-Clinical records F 517-Written plans and procedures to meet all potential emergencies and disasters. F 518-Train all employees in emergency procedures. F 520-Quality Assessment and Assurance 3. Evidence that facility governing body ensures that facility complies with all Administration requirements established in State Operations Manual Appendix PP for Long Term Care Facilities was not provided. | 2018-09-01 |
| 307 | 307 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 501 | F | 0 | 1 | 1VLO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of records (RR), policies/procedures (P&P) and interviews, it was determined that the facility failed to provide the necessary care and monitoring and the medical director failed to show responsibility for the coordination of medical care in the facility to ensure that resident's (R) reach their highest practicable well-being for 3 out of 8 sample selection residents (R #3, #4 and #5). Findings include: 1. During survey procedures throughout the five days of survey on 5/11/15 to 5/18/15 from 8:00 am to 5:00 pm the following was identified related with failure by the facility to coordinate medical care in the facility and provide clinical guidance and oversight regarding the implementation of resident care policies: Resident #4 is an [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 5/11/15 at 11:55 am and provided evidence that resident received neurocognitive rehabilitation screening on 5/8/15 at 9:00 pm due to sadness and death wishes that he referred during admission to the facility on [DATE]. Based on neurocognitive rehabilitation screening performed on 5/8/15 at 9:00 pm resident was diagnosed with [REDACTED]. The recommendations for the management of this condition was neurocognitive rehabilitation follow-up to provide adaptive coping strategies to deal with the depressive mood and facilitate neurocognitive strategies to support adaptative emotional regulation and positive mood throughout hospitalization . Resident was also evaluated by the psychiatrist on 5/9/15 at 2:50 pm who ordered [MEDICATION NAME] 50 mgs PO in am. Plan of care for Mood State was developed on 5/8/15 by the interdisciplinary team members. Accordingly with this plan of care emotional counseling were going to be provided and monitoring on mood state were going to be performed, however no documentation was found on the progress notes of nursing personnel, physician, social work … | 2018-09-01 |
| 308 | 308 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 514 | F | 0 | 1 | 1VLO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records review it was determined that the facility failed to ensure that facility maintain clinical records information documented in accordance with accepted professional standards of practice related to physician consults recommendations were not followed, not performed as evidenced on 2 out of 8 sample records review (RR) and 1 out of 2 radom sample (RS) as seen on RR #3, #4 and RS #9. Findings include: 1. Resident #4 is an [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 5/11/15 at 11:55 am and provided evidence that resident received neurocognitive rehabilitation screening on 5/8/15 at 9:00 pm due to sadness and death wishes that he referred during admission to the facility on [DATE]. Based on neuroneurocognitive rehabilitation screening performed on 5/8/15 at 9:00 pm resident was diagnosed with [REDACTED]. The recommendations for the management of this condition was neurocognitive rehabilitation follow-up to provide adaptive coping strategies to deal with the depressive mood and facilitate neurocognitive strategies to support adaptative emotional regulation and positive mood throughout hospitalization . Resident was also evaluated by the psychiatrist on 5/9/15 at 2:50 pm who ordered [MEDICATION NAME] 50 mgs PO in am. Since 5/9/15 after resident was evaluated by the psychiatrist [MEDICATION NAME] 50 mgs PO in am was administered to the resident without physician order [REDACTED]. 2. The facility failed to keep the clinical record and Medications Administration Record (MAR) with all necessary information related to resident's condition and care provided, as seen on RR# 3: a. RR# 3 was admitted on [DATE] after a Left Total Knee Replacement. During RR and Medications Administration Record (MAR) review performed on 5/ 12/15 at 9:00 am it was found that on the admission process the resident signed an Influenza and Pneumococcal Refuse Form where she establishes that she r… | 2018-09-01 |
| 309 | 309 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 516 | F | 0 | 1 | 1VLO11 | Based on observations during the tour on the inactive record department on 5/18/15 at 1:40 pm, it was determined that the facility failed to ensure that inactive medical records are filed under proper safety conditions. Findings include: 1.During the observational tour performed on 5/18/2015 at 1:40 pm for the extended survey with the Administration personnel (Employee #26) in the inactive record room it was observed a lot of boxes over wooden pallets. On the room it has an estimated over two hundred boxes of inactive medical records of the hospital and SNF. The storage was observed dirty, not organized, water stain in the wall because the air conditioning got problems and flood the storage, ceiling tiles with mold and boxes were observed broken. 2. Facility failed to ensure that all inactive medical records are filed and maintain under proper safety conditions. 3. Interviewing employee #26 on 5/18/15 at 1:45 pm it was reveals that the facility hired two people by contract to destroy the inactive medical record for more than 7 years. Surveyor asked to Human Resources Director (employee #10) about the contract, qualifications and training of these two persons and no evidence was provided at the moment it was requested. 4. Interviewing employee # 25 (Clinical Record Supervisor) on 5/18/15 at 2:40 pm it was found that the facility at this moment is still working on written clinical record and he do not know when the electronic record is going to start officially be implement. | 2018-09-01 |
| 310 | 310 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 517 | F | 0 | 1 | 1VLO11 | Based on the review of the facility's Disaster and Emergency Preparedness Plans during the extend survey with the Safety officer, it was determined that the facility failed to ensure that some important procedures are included related to detailed written plans and procedures for all potential emergencies and disasters, such as fire, severe weather and missing residents which could affect 14out of 14 admitted residents. (R # 1through #14) Findings include: No evidence was found on 5/18/15 at 2:30 pm of upgraded written plans and procedures related to protocols for emergencies and disasters, severe weather and missing residents. Also no evidence was found of individual duties during fire or other emergencies related to assignments for each staff member for each shift. | 2018-09-01 |
| 311 | 311 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 518 | F | 0 | 1 | 1VLO11 | Based on the review of the facility's in-service training for Emergency Preparedness during the extend survey with the Safety officer, it was determined that the facility failed to ensure that newly hired employees are trained in emergency procedures when they begin to work at the facility which could affect 14 out of 14 admitted residents (R) (R #1 through #14). Findings include: 1. No evidence was found on 5/18/15 at 2:30 pm of written evidence of in-service training for Emergency Preparedness for the employees who works in the facility. | 2018-09-01 |
| 312 | 312 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 520 | F | 0 | 1 | 1VLO11 | Based on the review of the Quality assessment and performance improvement program, (QAPI) accompanied by the facility's quality assurance officer director (employee #13), it was determined that that the Quality Assurance (QA) Committee was not effective in addressing identified resident care issues and in resolving deficiencies pertaining to the Quality of Care and Quality of Life of the facility residents. This deficient practice had the potential to affect 14 out of 14 residents admitted at the facility (R#1 to #14). Findings include: 1. The quality assurance and improvement committee are meeting monthly on an ongoing basis as reviewed on 5/18/15 at 10:58 am. The facility is collecting and presenting information during committee meetings. Data related with resident outcomes, and other aggregate patient data used to evaluate resident outcomes. Nursing, physical therapy, infection control and diet services monitor the quality of services provided to residents, however evidence that all results obtained in the surveillance are analyzed, discussed and areas which need improvement were prioritized was not evidence not found documented. 2. Review of facility records revealed that during a survey conducted on 5/15/14 and a revisit conducted on 7/30/14, the facility was cited for regulatory violations in multiple areas, including: F 248-Activities meet interests/needs of each resident. F279-Develop comprehensive care plans. F281-Services provided meet professional standards. F356-Posted Nurse Staffing F 371-Food procure , store/prepare/serve-sanitary. F 465-Safe/functional/sanitary/comfortable environment. F514-Resident records-complete-accurate-accessible. In response, the facility submitted a Plan of Correction (P[NAME]), alleging that each deficiency had been corrected. However, the findings of the 5/11/15 - 5/18 /15 survey revealed that the Quality Assurance committee failed to assure that these actions were implemented and performed in a manner which corrected the deficiency on an ongoing basis, as each of the pre… | 2018-09-01 |
| 313 | 313 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 156 | F | 0 | 1 | 1WB711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with the Social Worker (employee #15), resident's family members, the Administrator (employee # 13), the Owner and President of the Governing Body (employee # 1), administrative documents, policies and procedures (P&P's) and record reviews performed on the recertification survey on 5/19 thru 5/22/15, it was determined that the facility failed to provide services according to residents needs for 2 out of 8 sample residents (RR #1 and #6). Findings include: 1. The facility is requiring prior to admission, that resident to be admitted and who are disoriented must be accompanied by a family member to observe and to prevent resident ' s falls. During the admission process, the residents must bring with them all maintenance medications that are taking at home, (Cross reference TAG 323). a. According to interview with the Social Worker (employee # 15) performed on 5/21/15 at 11:45 am, she stated: There are two coordinators that goes to the hospitals to interview residents that are going to be admitted to our facility. During the interview, the coordinators give them a form named What to bring? , where it mention the personal items, clothes that they have to bring to our facility during the admission process and includes to bring their maintenance medications that they take at home. Also, the coordinator give orientation to family members that residents who are disoriented needs company during his/her stay at the facility, to give assistance and to watch them to prevent falls. b. During the review of the admission packet performed on 5/21/15 at 1:30 pm, it was found the form named What to bring? On step #4 of this form, establishes that maintenance medications must be brought to the facility in their bottles, not on pill boxes. This form is given to family members during the pre screening process that the coordinator performs prior to admission. c. According to interview with the Administrator (employee # 13) performed on 5/22/15 … | 2018-09-01 |
| 314 | 314 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 164 | F | 0 | 1 | 1WB711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview it was identified that facility failed to promote the right of each resident to personal privacy and confidentiality of his or her personal and clinical records which could affect all residents admitted at the facility. Findings include: 1. A mechanism to ensure that the right of personal privacy and confidentiality of resident clinical conditions are maintained is not followed accordingly with the following findings: a. During the flash tour observation performed on 5/19/15 at 9:00 am thru 11:00 am it was observed a red sign indicating Resident con historial de alergias Resident with allergic history also it was observed a red band on residents wrists indicating the information of what kind of medication is allergic too. b. According with information provided by Physical Therapist supervisor (employee #12) on 5/19/15 at 9:45 am We use this sign and the wrist band to identify the residents with medication allergies [REDACTED]. c. The facility failed to promote resident ' s privacy and confidentiality of information. | 2018-09-01 |
| 315 | 315 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 165 | F | 0 | 1 | 1WB711 | Based on eight sample records review and residents group interview performed during recertification survey from 5/19 thru 5/22/15, it was determined that the facility failed to ensure that 5 out of 5 residents know the grievances process. Findings include: 1. The group interview was performed on 5/19/15 at 2:50 pm with a participation of 5 residents. It was found that 5 out of 5 residents did not show knowledge of the facility's policies and procedures related to the grievances processes. a. Only one resident could mention that in case of any situation that cause anger and discomfort, will talk with the nursing supervisor for advice. | 2018-09-01 |
| 316 | 316 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 172 | F | 0 | 1 | 1WB711 | 2. The group interview was performed on 5/19/15 at 2:50 pm with a participation of 5 residents. When facility's rules were discussed the concern of three residents were related to the visiting hours, that has to be finished at 8:00 p.m. and if a family member wants to stay additional time they can not. Some of the residents said that there are family members that can not go to the facility early in the morning hours due to work and that they can visit during evening or night hours. However, if they arrive after 6:00 pm they know that soon they have to leave the facility because at 8:00 pm the security guard passes thru the rooms and announces that visiting hour has finished. 3. The facility failed to develop a mechanism to ensure that residents can receive with their consent, visits from family members and other relatives any time at the facility, without visiting hour' s restrictions. Based on observations, eight sample records review and interviews to Owner (employee #1), Administrator (employee #13) and during residents group interviews, performed during recertification survey from 5/19 thru 5/22/15, from 9:00 am thru 6:00 pm, it was determine that the facility failed to ensure the access of family members and other relatives to visit the residents at the SNF which can affect all residents admitted at the facility. Findings include: 1. During observational tours performed on 5/19/15 at 9:00 am, the surveyor watched posted on the bulletin board located on the hallway a sign indicating visiting hours from 8:00 a.m. until 8:00 pm. a. During record review performed on 5/22/15 at 2:00 pm it was found a report performed by the security guard of the facility dated 3/27/15 at 8:01 pm indicating he was under threat by the resident daughter because when he went to announce that the visiting hours was finished; when he open the door the resident was behind it and receive a wallop with the door. The residents' daughter performed a complaint about this situation. Interview with the Administrator (employee #13) and Facility… | 2018-09-01 |
| 317 | 317 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 221 | G | 0 | 1 | 1WB711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, individual interview and group interview, and record review during the recertification survey on 5/19/15 to 5/22/15, it was determine that the facility failed to ensure that resident (R) is free from physical restraints, unless needed to treat a medical symptom for 1 out of 8 residents in the sample (R#6). Findings include: A resident indicates she was threatened to be restraint with four side rails up if she does not follow instructions. Fall Risk care plan has side rails for safety measures. 1. Resident #6 is [AGE] years old female who was admitted for care on 5/15/15 with a [DIAGNOSES REDACTED]. During the group interview performed on 5/19/15 patients indicates that a register nurse threatened her to raise all four side rails if she does not follows instruction. Interview the resident on 5/19/15 at 4:30 pm she indicates she feels worried because she lives alone and does not have anybody who can help her. She feels sad because two times during the nights the register nurse said if she does not follow instructions she is going to raise the four side rails. Resident indicates that she was sitting in the border of the bed because she feels uncomfortable and her neck hurts. She says the doctor gave her instruction to do that when she felt pain because is a method to relieve the pain. Reviewing the facility protocol for side rails and restrains the document reveals that the patient has to be evaluated and the resident and family has to give the consent to maintain the four side rails raises. (Cross Reference Tag F323). | 2018-09-01 |
| 318 | 318 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 248 | E | 0 | 1 | 1WB711 | Based on eight sample records review (RR), interviews with residents and with the Physical Therapist Supervisor (employee # 12), policies and procedures (P&P's) for recreational activities performed during the recertification survey on 5/19 thru 5/22/15, it was determined that the facility failed to provide individualized recreational activities to residents according to their interests and skills, as seen on 2 out of 8 sample records review (RR#1 and #4). Findings include: 1. During RR #1 performed on 5/20/15 at 9:00 am it was found an individualized recreational program for the resident. The weekly program from 5/13/15/ to 5/30/15 shows that recreational activities will be offer from Monday's thru Saturday's in two periods: 9:00 am to 12:00 pm and 1:00 pm to 4:00 pm. a. According to interview with resident's family member performed on 5/19/15 at 11:00 am, she stated: She came disoriented and had difficulties to follow instructions. The first days after admission she remained in bed. She only received physical and occupational therapies. b. The recreational activity program does not mention what kind of individualized activities the resident will perform. The progress notes of the recreational activities therapist do not mention the individualized activities offered to resident #1 while remained in bed the first days after admission. 2. During case discussion of resident #4 with employee #12 performed on 5/22/15 at 1:00 pm, it was found the following issues: a. The recreational activities therapist performed the initial assessment, and on the visual assessment checked that resident uses eyeglasses. Did not identified that resident did not learn to read. b. During group interview performed on 5/19/15 at 2:50 pm, resident #4 stated: On the group recreational activity, I did not like it because the game was that the therapist mentions a letter and everyone has to mention names of things, last names and I do not know how to read. c. During RR of resident #4 performed on 5/22/15 at 1:00 pm with the Physical Therapist… | 2018-09-01 |
| 319 | 319 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 271 | E | 0 | 1 | 1WB711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During RR #1 performed on 5/20/15 at 9:00 am it was found that the nursing staff was administering medications to resident without a physician's order. a. Resident #1 has a secondary diagnose of Diabetes Mellitus. During the admission process, she brought from home a bottle of [MEDICATION NAME] 2mg to be taken by mouth daily. This medication was registered on the medications reconciliation form as soon the resident was admitted . During drug pass performed by the surveyor on 5/20/15 at 8:14 am, [MEDICATION NAME] was administered. However, no physician's order was found on the clinical record for its administration. 4. Resident # 5 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. During record review performed on 5/20/15 at 9:00 am it was found that the nursing staff was administering medications to resident without a physician's order. She brought from home and Allergy Eye Drops to be apply 1 drop in both eyes daily. This medication was not registered on the medication reconciliation form at the moment she was admitted . This medication was found written on the resident ' s Medication Administration Record [REDACTED]. Based on the review of twelve resident ' s (R) sample selection records, two medication reconciliation during drug pass and interview with the pharmacist (employee #14) it was determined that the facility failed to ensure that all admission orders [REDACTED]# 6). Findings include: 1. According to Medication Administration Record [REDACTED] a. Resident #1 the physician order establishes [MEDICATION NAME] 100 mgs 2 tablets by mouth at hours of sleep (HS) but the registered nurse was administrating since 5/12/15 [MEDICATION NAME] 100 mgs cap twice a day, no physicians order was found in the clinical record establishing that this medication will be given twice a day. During record review performed on 5/20/15 at 9:00 am it was found that on nursing progress notes from 5/12/15 at 8:00 am, the resi… | 2018-09-01 |
| 320 | 320 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 279 | D | 0 | 1 | 1WB711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on eight sample records review (RR) performed on a recertification FOSS survey from 5/19 thru 5/22/15 from 8:30 am until 5:30 pm, it was found that the facility failed to ensure that professional staff develop comprehensive plan of care to each admitted resident, as observed in 1 out of 8 sample records, (RR#1) Findings include: 1. During RR #1 performed on 5/20/15 at 9:00 am it was found that resident was admitted on [DATE] due to weakness on lower extremities after a Cerebro Vascular Accident ([MEDICAL CONDITION]). This resident has secondary [DIAGNOSES REDACTED]. She is taking the following medications: [REDACTED]. However, the nursing staff failed to develop an individualized plan of care with interventions for continuing care for [MEDICAL CONDITION], hypertension, anxiety, lower extremities weakness and cognitive condition due to disorientation upon admission at the facility. | 2018-09-01 |
| 321 | 321 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 281 | F | 0 | 1 | 1WB711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on eight record review, review of policies/procedures and interview with the nursing personnel (employee #2) it was determined that facility failed to ensure that services are provided according to acceptable standards related to failure to follow manufacture's specifications and operationalize policies and procedures for the appropriate use of glucose monitoring devices and wound care. Findings include: 1. A mechanism to ensure that personnel follows manufacture's indication to calibrate glucose monitoring device was not followed, not performed accordingly with the following findings: a. Facility was using True balance glucometer device, for this device control tests should be performed on monthly basis, with each new vial of test strips and when batteries are changed. b. Facility policy and procedure for the use of blood glucose device indicate that is the [MEDICATION NAME] system what they were using. Policy and procedure establish that control and verification tests of the device are going to be performed according to manufacturer ' s specifications of [MEDICATION NAME] system instead of True balance system. c. Monitoring of control tests and calibration of glucometer log for the month of May/2015 was review on 5/20/15. Accordingly with the log control tests and calibration of glucometer was performed on daily basis instead of on monthly basis as required by manufacture's specifications. No information was found documented on the log regarding control tests and calibration of glucometer performed when a new vial of test strips was used and if batteries are changed. d. Facility policy and procedure for the use of True balance blood glucose device did not include provisions who establish that control tests must be performed on monthly basis, with each new vial of test strips used and when batteries are changed. 2. A mechanism to ensure that physician order's include complete prescription of medications to be administered to resident's… | 2018-09-01 |
| 322 | 322 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 323 | F | 0 | 1 | 1WB711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with the Social Worker (employee #15), resident's family members, the Administrator (employee # 13), the Owner and President of the Governing Body (employee #1), administrative documents, policies and procedures (P&P's) and record reviews (RR)performed on the recertification survey on 5/19 thru 5/22/15, it was determined that the facility failed to develop a mechanism where the nursing staff identify residents with falls risks, to establish a 24 hour surveillance performed by the professional staff assigned in every work shift and keep informed the physician in those cases that need medications to control anxiety, as observed in 2 out of 8 sample residents, (RR#1and #6). Findings include: 1. The facility is requiring prior to admission, that resident to be admitted and who are disoriented must be accompanied by a family member 24 hours, to observe and to prevent residents ' falls, (Cross reference TAG 156). a. According to interview with the Social Worker (employee #15) performed on 5/21/15 at 11:45 am, she stated: There are two coordinators that go to the hospitals to interview residents and family members that are going to be admitted to our facility. During the interview, the coordinators give orientation to family members that the resident needs company during his/her stay at the facility, to give assistance and to watch them to prevent falls. b. According to interview with the Administrator (employee #13) performed on 5/22/15 at 9:30 am, she stated: We recently reviewed the policy related to falls prevention. There is a form with a questionnaire that the coordinator fills out when performs the pre screening of residents before they are admitted to the facility. If the resident shows three or more negative answers is at high risk of falls. During the orientation given to resident or family members it is require that residents who are disoriented, must be accompanied by a family member to prevent falls. c. During the re… | 2018-09-01 |
| 323 | 323 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 325 | E | 0 | 1 | 1WB711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on eight resident's records reviewed and interview, it was determined that the facility failed to ensure that 2 out of 8 residents (R) is monitored to assure that maintains acceptable parameters of nutritional status, such as body weight and protein levels, and receives a therapeutic diet when there is a nutritional problem for resident (R#2 and #4). Findings include: 1. Resident's records reviewed from 5/19/15 through 5/22/15 from 9:00 am till 6:00 pm provided evidence that an initial nutritional assessment was not performed at the moment of admission related with a recommended diet, weight and fluids needed for the resident's condition as evidenced by the following: Resident #2 is an [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 5/19/15 at 1:30 pm and provided evidence that the resident's had history of Diabetes Mellitus and hypertension. During admission diabetic low salt, low fat diet was ordered to the resident, however it was not found documented on the medical record the Kcals of the diet, protein requirements, sodium meq and fat mgs because dietitian did not perform nutritional initial evaluation and plan of care until 5/20/15. Review of the diet card in the kitchen on 5/20/15 at 10:45 am revealed that in the diet card it was documented that resident is receiving diabetic diet 1,500 kcals low in sodium, low in fat high in iron with snack at 8:00 pm. Resident nutritional care plan and evaluation was performed on 5/20/15 at 10:00 am and the nutritional recommendations for this resident was Diabetic diet 1,500 kcals ,87 meq sodium,50 gms of fat,15 mgs iron, low residue. Facility failed to evidence that for this resident a comprehensive assessment is performed to determine and establish therapeutic diet and specifications of nutritional requirements accordingly with resident nutritional factors, special needs and facility established period of time which is 72 hour… | 2018-09-01 |
| 324 | 324 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 327 | E | 0 | 1 | 1WB711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on eight sample records reviewed (RR) and interviews, interview with the Dietitian (employee # 8), it was determined that the facility failed to ensure that 2 out of 8 residents are monitored to assure that their fluid intake are appropriate to maintain proper hydration and health for residents (R #1 and #2). Findings include: 1. Resident's records reviewed from 5/19/15 through 5/22/15 from 9:00 am till 6:00 pm provided evidence that an initial nutritional assessment was not performed at the moment of admission related with a recommended diet, weight and fluids needed for the resident's condition as evidenced by the following: a. Resident #2 is an [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 5/19/15 at 1:30 pm and provided evidence that the resident's had history of Diabetes Mellitus and Hypertension. During admission diabetic low salt, low fat diet was ordered to the resident, however recommendation for the fluid intake to maintain proper hydration and health was not established as part of admission orders [REDACTED]. b. Dietitian (employee # 8) stated on interview that accordingly with facility policy initial evaluation of residents must be performed between 72 hour of admission. However she did not comply with this requirement because she was part-time employee and she only works from Monday through Thursday. 2. During RR #1 review performed on 5/20/15 at 9:00 am it was found that the Dietitian (employee #8) performed on 5/13/125 at 9:00 am the initial nutritional assessment and recommended 1, 900 ml of fluid requirement and 1,000 ml of free water intake. a. The Hydration and Food intake registry shows that resident #1 has not comply with the 1, 900 ml of fluid requirement recommended by the dietitian, since 5/12 thru 5/20/15. Resident's fluid intake has fluctuated between 90 ml to 760 ml. The free water intake has been over the 1,000 ml recommended. However, no ev… | 2018-09-01 |
| 325 | 325 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 332 | K | 0 | 1 | 1WB711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews with the Medical Director (employee # 7), Visiting physician (employee #6), Registered Nurse,(employee # 2) and pharmacist (employee # 14) at the facility performed on 5/20/15 from 4:30 pm thru 5:30 pm, it was determined that the facility fails to prevent residents (R) from harm for 2 out of 4 residents (R#1 and #6). This constitutes an Immediate Jeopardy to the residents. Findings include: A lack of mechanism to ensure that the resident is free of medication errors of 5 % or greater and residents are free of any significant medication errors were observed as follows: 1. According to Medication Administration Record [REDACTED] a. Resident #1 the physician order [REDACTED]. b. Resident #6 the resident is receiving since 5/15/15 Montelukast 10 mgs tab by mouth daily, Laxapro 20 mgs tab by mouth daily, Folic Acid 1 mg tab by mouth daily and [MEDICATION NAME] 20 mgs tab by mouth daily but these medications were given without physicians orders. 2. After the drug pass procedure the facility obtained a 17.85 % on medication errors. 3. After interviewing the registered nurse who performed the drug pass, the pharmacist, the visiting physician and the medical director performed on 5/20/15 from 3:30 pm thru 5:30 pm it was found that the facility failed to have an ongoing surveillance to avoid near future adverse effects from medication administration. | 2018-09-01 |
| 326 | 326 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 333 | K | 0 | 1 | 1WB711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews with the Medical Director (employee # 7), Visiting physician ( employee #6), Registered Nurse, (employee # 2) and pharmacist (employee # 14) at the facility performed on 5/20/15 from 4:30 pm thru 5:30 pm, it was determined that the facility fails to prevent residents from harm on 2 out of 4 residents. This constitutes an Immediate Jeopardy to the Residents Findings include: A lack of mechanism to ensure that the resident is free of medication errors of 5 % or greater and residents are free of any significant medication errors were observed as follows: 1. According to Medication Administration Record [REDACTED] a. Resident #1 the physician order establishes [MEDICATION NAME] 100 mgs 2 tablets by mouth at hours of sleep (HS) but the registered nurse was administrating since 5/12/15 [MEDICATION NAME] 100 mgs cap twice a day, no physicians order was found in the clinical record establishing that this medication will be given twice a day. During record review (performed on 5/20/15 at 9:00 am it was found that on nursing progress notes from 5/12/15 at 8:00 am, the resident had blood glucose results on 325 mgs/dl and the physician was consulted. The registered nurse wrote that administered [MEDICATION NAME] R 5 units subcutaneous (sq) but no physician ' s orders were found on the clinical record. b. Resident #6 the resident is receiving since 5/15/15 Montelukast 10 mgs tab by mouth daily, Laxapro 20 mgs tab by mouth daily, Folic Acid 1 mg tab by mouth daily and [MEDICATION NAME] 20 mgs tab by mouth daily but these medications were given without physicians orders. During the medication reconciliation review performed on 5/20/15 at 1: 00 pm it was found the resident brought from home [MEDICATION NAME] 50 mg tab by mouth daily. This medication is given by the nursing staff since 5/16/15 but no physician order was found. 2. After the drug pass procedure the facility obtained a 17.85 % on medication errors. 3. After in… | 2018-09-01 |
| 327 | 327 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 353 | F | 0 | 1 | 1WB711 | Based on interviews, review of staffing patterns, ten records reviewed and observations, it was determined that the facility failed to ensure that resident categorization are performed in order to identify resident nursing care needs and assigned nursing staff duties, to evidence designed staffing ratio for nursing staff assignment, to designated nursing personnel to perform director of nursing duties until director of nursing came from sick leave and to comply with Nursing Board of Puerto Rico State Law #9 from (MONTH) 1987 and State Law #117 from (MONTH) 1, 2004, Section 4 all which could affect 14 out of 14 residents (R) (R #1 through #8 and random sample resident #1 through #6). Findings include: 1. A mechanism to ensure that resident categorization are performed in order to identify resident nursing care needs and assigned nursing staff duties was not followed ,not performed accordingly with the following findings identified on survey procedures on 5/19/15 through 5/22/15: a. Resident care needs categorization to be used to assign license practical nurses (LPN's) and Register nurses (RNs) duties accordingly with resident individual needs was not available for review on 5/19/15 through 5/22/15. b. RNs and LPN's assignment duties for each eight hour shift (7-3,3-11 and 11-7 ) was not available for review on 5/19/15 through 5/22/15. c. LPN (employee # 4) stated on interview on 5/20/15 at 1 pm that no duties assignment was provided to her to guide her during resident care needs. She also stated that when she came in the morning, she talk with the other LPN's on duty to develop their own plan of work and based on resident census and physical and occupational therapy schedule she begun to assist resident's with the bath on the shower, while the other nurses assist resident's with dental hygiene and breakfast. No register nurse oversight their plan of work. d. LPN (employee # 9) stated on interview on 5/20/15 at 1:45 pm that no duties assignment was provided to her to guide her during resident care needs. She state… | 2018-09-01 |
| 328 | 328 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 356 | C | 0 | 1 | 1WB711 | Based on observation, record review, and interview, it was determined that facility failed to post nurse staffing records that included all required information, including the posting of the resident census, and the actual hours worked by the Registered Nurses (RN) and the Licensed Practical Nurses (LPN) that were responsible for residents' care per shift. This had a potential to affect 14 out of 14 admitted residents, family members and all visitors in the facility. Findings include: 1. A mechanism to ensure that facility post the nurse staffing data on a daily basis at the beginning of each shift was not followed not performed accordingly with the following findings: a. Observation made during on observational tour on 5/20/15 at 9:00am revealed that the nurse staffing requirements document was not posted on the bulletin board located in front of central nursing station. Review of the document posted on the bulletin board revealed the date of 5/19/15, the previous day. b. During interview on 5/20/15 at 10:55 am Associate Degree Nurse (employee #2 ) stated that on 5/20/15 there is 1 register nurse assigned for the 7-3 shift 1 register nurse assigned for the 3-11 and 1 register nurse assigned for the 11-7 shift. He also stated that there are 2 Licensed practical nurses assigned for the 7-3 shift 1.5 Licensed practical nurses assigned for the 3-11 shifts and 1 Licensed practical nurse assigned for the 11-7 shift. | 2018-09-01 |
| 329 | 329 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 385 | F | 0 | 1 | 1WB711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with residents, Medical Director (employee #7), Visiting Physician (employee # 6), the Pharmacist (employee # 14), eight sample record reviews (RR) with four supplemental sample records review, policies and procedures review (P&P's), it was determined that the facility failed to ensure that physicians participate actively supervising the services that residents receive at the facility which can affect 14 out of 14 residents admitted at the facility. Findings include: 1. The facility has a Medical Director and two General Medicine Physicians responsible of supervising the care provided to the residents. The General Medicine Physicians has established a visiting schedule where they alternate their visits. During recertification survey performed from 5/19 thru 5/22/15 the physician in charge of residents care was employee #6. However, it was found the following issues that required physician's supervision: a. Physicians failed to reevaluate the maintenance medications that residents bring to the facility during the admission process. They countersign the reconciliation medications form performed by the nursing staff but are not aware of including on the admission's order the medications that residents need for treating their conditions. It was found that the nursing staff is administering medications without physician's orders [REDACTED]. b. No evidence was found of the coordination between the physician and pharmacy services to identify medications errors. The facility obtained 17. 85% on medications errors during drug pass performed on 5/20/15 at 8:00 am. The physicians failed to follow the recommendations given by phone on 5/20/15 at 3:30 pm until 5:30 pm, notifying them the issues related to the administration of medications without physician's orders [REDACTED]. (Cross reference TAG 332, 333). c. The Medical Director who is a Physiatrist, failed to ensure that the recreational therapies are offered accordin… | 2018-09-01 |
| 330 | 330 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 411 | F | 0 | 1 | 1WB711 | Based on documents review and interview performed during the recertification survey on 5/19/15 thru 5/22/15 from 9:00 am until 6:00 pm, it was determine that the facility failed to provide or obtain from an outside resource for routine or emergency dental services affecting 14 out of 14 residents. Finding includes: 1. During record reviews performed on 5/21/15 at 2:30 pm contract for dental services was not found. 2. Interviewing to the facility owner (employee# 1) on 5/21/15 at 4:00 pm she indicates that is not renewing the contract for dental services because in reality it has never been used. The facility failed to ensure, provide or obtain from an outside resource for dental services to meet the needs of each resident. | 2018-09-01 |
| 331 | 331 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 425 | F | 0 | 1 | 1WB711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. A mechanism to ensure that facility provides routine medications accordingly with this regulation in order to meet resident's needs was not followed, not performed as evidenced by the following findings: a. Resident #10 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 5/22/15 at 8:50 am and provided evidence that for the resident physician order Coumadin 2 mgs PO daily, Aspirin 81 mgs PO daily, Lipitor 40 mgs PO daily, Enalpril 10 mgs PO twice a day, Glimepiride 4 mgs PO daily, Amiodarone 200 mgs PO twice a day, Metroplolol 100 mgs PO twice a day and Lasix 20 mgs PO daily when admitted to the facility on [DATE] at 8:30 pm. During medication drug pass on 5/22/15 at 9:00 am no medications were provided to the resident because they do not have them available. On 5/21/15 after admission they send a prescription to a pharmacy to provide medications but they are still waiting for them. Facility failed to ensure the availability of physician ordered medications and to promote that routine medications are administered in a timely manner. b. Medication drug pass nurse (employee # 11) stated on interview on 5/22/15 that she did not provide medications to resident # 10 because facility did not have them and when relative came with the medications she is going to administer them to the resident. 5. A mechanism to ensure that a physician prescription if available before nursing personnel administer medications to residents receiving care at the facility were not followed, not performed as evidenced by the following findings: a. Resident #10 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of Medication Administration Record [REDACTED]. No physician order was found on the medical record for the use of Antiacid PO PRN. 6. During RR #1 performed on 5/20/15 at 9:00 am it was found that the facility failed to ensure the availability of medication… | 2018-09-01 |
| 332 | 332 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 441 | F | 0 | 1 | 1WB711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations made during the recertification survey , during the initial tour with a Physical therapist supervisor (employee #12), wound care, review of policies and procedures and the lack of the Infection Control Officer , it was determined that the facility failed to provide a safe environment through an organized infection control program to ensure that staff follows infection control practices, consistently and effectively that complies with professional standards of practice, recommendations of the CDC to promote sanitary and safe care so as to prevent in a manner or reduce the risk of spread of infections as evidenced by nursing staff improperly using of wound cleanser, provide housekeeping personnel with policies and procedures for guidance for cleaning and disinfecting the facility, have an organized infection control program, which could affect 14 out of 14 admitted residents (sample selection residents #1 through #8 and random sample residents #1 through #6). Findings include: 1. During the recertification survey performed on 5/19 until 5/22/15 it was found that the Infection Control Officer was resigned and the program does not has a coordinator assigned yet. The program lacks of Infection control officer since (MONTH) (YEAR). However, no evidence was found of the Medical Director working to keep improving and surveillance for the program. 2. The Infection Control Committee last meeting was performed on (MONTH) (YEAR). However, the Medical Director does not participate on the meeting. 3. Facility offer incidental education to staff that has infection control issues but there is no a scheduled formal training program. 4. No evidence was found of what employees were designed by the Board of Directors to substitute the Medical Director and the Infection Control Coordinator in case of absent due to sickness, vacations, etc. 5. No evidence was found of the involvement of the interdisciplinary group in the Infection Control Pro… | 2018-09-01 |
| 333 | 333 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 465 | F | 0 | 1 | 1WB711 | Based on observations it was determined that the facility failed to consistently maintain its physical environment in a clean, comfortable and home-like appearance, and in a manner that promoted resident health and safety which can affect all residents admitted . Findings include: During the initial tour of the facility on 05/19/2015 at 9:00 a.m. the following was observed: Recreational activities room: a. Paint from the walls of the recreational activities room is peeling off and dirty. b. Water cooler nozzle with green mold. c. Chairs with rust and ripped vinyl. d. Arm rest chair covered with tape. Visitors ' bathroom: a. Grab bars rusty. b. Strong urine odor. (Man Bathroom) Residents ' rooms: a. Room ' s #310, #311, #314, #315, #316, #317, #318, #319 and #320 paint was peeling off and dirty. b. Entrance doors rooms #101, #102, #103, #104, #105, #106, #107, #108, #109, #110 and #111 paint was peeling off. c. All rooms ' beds side rails with scratches. d. Room #102 B the mattress cover was broke, board cables exposed and bed board of side scratch and deteriorated. e. During the tour for life safety from fire, all doors were tested and it was found they did not latch properly. f. Biohazard waste container in room #102, #105 and #110 with a big white stain on the cover. g. Chairs on room # 101 and #104 with cloth cover. This type of material does not permit a properly disinfection and cleaning. h. Nursing call system box covered with rust in room #105. i. Nursing call lamp located over doors room # 106 and #111 attach with clear duct tape. j. Rooms number attaches with tape uses for wound care on room # 104 and #105. k. Room #110 bed board Formica was ripped. l. Chair in room #110 with ripped cover. m.The bathroom door in room # 110 needs to be sanded. This can cause some harm to resident, visitor or employee. n. Table dinner was with the Formica broken. o. Night lamp in rooms # 106 and #110 has old adhesive stain on it. p. On room #106 there was 1 wheels chair (#110) with tape around wheels. q. Nurse call cord in… | 2018-09-01 |
| 334 | 334 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 490 | F | 0 | 1 | 1WB711 | Based on documents reviewed and observations during the extended survey, it was determined that the facility is not administered in a manner that ensures that it uses its resources effectively to attain or maintain the highest practicable physical, mental and psychosocial well being affecting 14 out of 14 admitted residents (sample selection residents #1, #2, #3, #4,#5, #6, #7, #8 and random sample residents #1, #2, #3, #4, #5 and #6). Findings include: 1. The facility failed to ensure that residents admitted to the skilled nursing facility receive an ongoing activities program designed to meet residents interests and their physical, mental and psychosocial well-being; please cross reference to Tags F248. 2. The facility failed to ensure that residents admitted to the skilled nursing facility receive dental services designed to meet resident ' s physical, mental and psychosocial well-being; please cross reference Tags F411. 3. The facility failed to ensure it is free of substandard quality of care deficiencies. (Please cross reference to Tags F221, F226, F248, F323, F325, F332 and F333). | 2018-09-01 |
| 335 | 335 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 492 | F | 0 | 1 | 1WB711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of personnel credential files (CF) at the extended survey performed on ,[DATE] and [DATE] from 9:00 a.m. thru 6:30 p.m., it was determined that the facility failed to ensure that 3 out of 3 physicians, 1 out of 1 social worker, 1 out of 1 nutritionist, 1 out of 1 occupational therapist, 1 out of 1 physical therapist, 1 out of 1 recreational therapist, 2 out of 2 physical therapist assistance, 7 out of 7 nursing CF and 1 of the housekeeping personnel; comply with facility, state and federal laws. Findings include: 1. The Administrative Organizational Chart was not provided at the moment that was required. 2. During credentials files (CF) revision performed on [DATE] at 11:00 a.m. it was found that the facility has not develop competency evaluations for two employees of the housekeeping services that provide services at the SFN by a contract. The duties that they have to performed are: picking up the biohazard and regular waste, to change the sharp containers and to mix chemical solutions prior to clean surfaces and floors. The facility does not have knowledge if these personnel have the capability of performing the duties mentioned above. 3. During review of CF at the extended survey performed on [DATE] at 11:00 A.M. it was found the following issues: a. Seven (7) out of seven (7) nursing CF did not have evidence of an updated annual evaluation, (CF #1, #2, #3, #4, #5, #6 and #7). b. Seven (7) out of seven (7) nursing CF did not have evidence of an annual competency evaluation performed during ,[DATE] year, (CF # 1,#2, #3, #4, #5, #6 and #7) c. It was found that one (1) Occupational Therapist (OT), one (1) Recreational Therapists (RT) and one (1) Assistant Physical Therapist did not have evidence of an updated annual evaluation and annual competency ,[DATE] (CF #3, #4 and #5) d. It was found that the administrator and medical director never was evaluated by the governing body. (CF#1 and #3). e. It was found that the adminis… | 2018-09-01 |
| 336 | 336 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 493 | F | 0 | 1 | 1WB711 | Based on observational tour, review of policies and procedures, medical records and interviews performed on 5/19 thru 5/22/15, it was determine that the Governing Body failed to enforce rules and regulations relative to its own governance and to the health care and safety of resident, for the protection of the residents' personal and property rights and to the general operation of the facility. Findings include: 1. No evidence was provided of the facility organization chart. 2. No evidence was found of the Governing Body meeting of since 2014 as reviewed on 5/22/15 at 10:00 am. 3. During interview with the administrator (employee #13) on 5/22/14 at 9:00 am, she stated the governing board is composed by the owner and her two brothers. She does not participate of the meeting because they performed it out regular working hours . 4. No evidence was found that data presented and analyzed by quality improvement was being discussed by the Governing Body. 5. No evidence was found of complains and reports for the different committees was being discussed by the Governing Body. 6. No evidence was found that the facility have an infection control officer in charge to organize the infection control program. | 2018-09-01 |
| 337 | 337 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 501 | F | 0 | 1 | 1WB711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with residents, Medical Director (employee #7), Visiting Physician (employee # 6), the Pharmacist (employee # 14), 8 sample record reviews with four supplemental sample records review, policies and procedures review (P&P's), it was determined that the Medical Director failed to ensure the development and implementation of needed resident care policies, and provide for the coordination of medical care in the facility. The Medical Director failed to actively participate in the implementation of an ongoing surveillance activities as part of the Quality Assurance Program. The Medical Director did not ensure that all medications administered on the facility have a physician's orders [REDACTED]. The Medical Director's failure to ensure that facility practices met current clinical standards of practice related to medication administration, the facility have 17.85 percent of medication error on the medication pass, which could affect 14 out of 14 admitted residents (sample selection residents #1 through #8 and random sample residents #1 through #6). Findings includes: 1. Review of the findings of the standard and extended survey of 5/19/2015 to 5/22/105 revealed multiple deficiencies in areas of Resident Rights, Resident Behavior/Facility Practices, Quality of Life, Resident Assessment, Quality of Care, Nursing Services, Dietary Services, Dental Services, Pharmacy Services, Infection Control, Physical Environment and Administration . An Immediate Jeopardy was identified in the area of Quality of Care, with 2 residents with medications administrations without a physician's orders [REDACTED]. | 2018-09-01 |
| 338 | 338 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 517 | F | 0 | 1 | 1WB711 | Based on the review of the facility's Disaster and Emergency Preparedness Plans during the extended survey, it was determined that the facility failed to ensure that some important procedures are included related to detailed written plans and procedures for all potential emergencies and disasters, such as fire, severe weather and missing residents which could affect 14 out of 14 admitted residents (sample selection residents #1 through #8 and random sample residents #1 through #6). Findings include: No evidence was found on 5/22/15 at 2:30 pm of upgraded written plans and procedures related to protocols for emergencies and disasters, severe weather and missing residents. Also no evidence was found of individual duties during fire or other emergencies related to assignments for each staff member for each shift. | 2018-09-01 |
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CREATE TABLE [cms_PR] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );