Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Centro De Cuidado Prolongado San Lucas during CMS and state inspections, most recent first.
Insufficient food and nutrition service staffing was identified when no dietary manager was available during survey, and the clinical dietician reported the manager only came for a few hours on some days. A kitchen employee left sick, delaying breakfast and lunch service, and the clinical dietician had to assist in the kitchen, affecting all residents.
The facility failed to properly transmit PBJ staffing data to CMS. The Clinical Manager stated that quarterly reports were submitted and confirmed by the system, but iQIES/CASPER showed missing quarterly data, a one-star staffing rating, excessively low weekend staffing, no RN hours, and no licensed nursing coverage 24 hours/day, even though working programs and task assignments showed RN coverage on every shift.
Broken Gauge on Steam Cleaning Machine: During a kitchen observation, the vapor pressure gauge on the serving tray steam cleaning machine was found broken. The report states that the broken gauge did not assure proper sanitization was performed and could affect all residents.
Unsafe and poorly maintained resident rooms were observed during a survey. One room had broken and damp ceiling panels, a dusty window, a broken light fixture cover, and mold on the shower door lock and frame. Another room had a loose bathroom grab bar, and a third room had mold on the lamp base plus dampness and dirt on the bathroom wall.
A facility failed to include key instructions, services, and treatments in baseline care plans for 2 residents. One resident with DM, HTN, fecal incontinence, and a Foley catheter had no documented diaper-change needs or catheter details in the care plan or nursing notes, and a caregiver reported delayed help with a diaper change. Another resident admitted for deconditioning and weakness had a baseline care plan that did not include ADL goals or meal assistance, despite stating he needed help during meals.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans: Multiple residents lacked comprehensive, person-centered care plans tied to assessed needs. Issues included psychotropic medication use without documented care plans, Foley catheter use without complete orders or care plans, bed rail use with consent and evaluation but no restraint-related plan, fecal incontinence without a plan, and a nutritional plan that lacked measurable goals, timeframes, and documentation of meal assistance or intake details.
Failure to Develop and Update Care Plans for Psychotropic Meds, Foley Catheters, and Restraint Use: Multiple residents had no documented care plans developed or updated for identified needs, including psychotropic meds, Foley catheter use, fecal incontinence, and bed rail restraint concerns. Findings included pharmacist-identified psychotropic meds, incomplete Foley catheter orders and documentation, a resident with 3 of 4 bed rails up, and a DON confirmation that a urinary catheter care plan was not in the record.
A resident with deconditioning and Medicare Advantage was discharged home without receiving the written Medicare Non-Coverage notice 48 hours before discharge. Staff stated that traditional Medicare residents receive the form two days before discharge, but Medicare Advantage residents do not, and no evidence was found that the plan representative provided the notice. The facility also failed to ensure the resident was informed of the right to appeal the discharge in advance.
A resident with Guillan Barre Syndrome, deconditioning, HTN, DM, and sleep apnea had a urinary catheter reinserted after she was unable to void following catheter removal. Nursing notes documented phone communication with the MD and the order to reinsert the catheter, but the written or electronic medical order was not found in the chart, and the DON confirmed it was not documented.
A resident with decondition, HTN, and DM had an initial pharmacist drug regimen review on admission, but no documented monthly review was found within the required 30-day timeframe. The pharmacist confirmed the review was not completed as required and was still pending.
A resident with deconditioning and weakness in both upper and lower extremities stated he needed meal assistance, but the charted hydration record only listed hourly intake in mL and did not identify the meal type, food type, or level of assistance needed. The DON and record review showed the resident’s food plan was not adjusted to his specific needs for mealtime support.
Lack of Formal Charge Nurse Designation on Each Shift: The facility failed to formally designate an RN as charge nurse on each shift. The DON stated the general supervisor served in that role, but the staff work assignment did not identify a charge nurse or list charge nurse duties such as staff supervision, emergency coordination, physician liaison duties, or direct resident care.
QAPI committee meetings did not show participation by the Medical Director or designee in several meetings, and one meeting did not show participation by the Infection Control Officer or designee. The facility director of institutional program confirmed that both roles are required active members and must participate in each monthly QAPI meeting.
The facility failed to establish a structure to comply with resident rights, posing Immediate Jeopardy to residents' health and safety. No personnel were assigned to monitor compliance, and the resident rights policy was hospital-based, not tailored to the facility. The policy lacked individualized mechanisms for CMS Medicare compliance.
The facility failed to appoint a full-time Director of Nursing, as required for proper nursing oversight. During a survey, it was revealed that the facility lacked an official Director of Nursing, with an Acting Manager temporarily handling some responsibilities. This deficiency was identified as posing an Immediate Jeopardy to the health and safety of all residents.
The facility was found to be inadequately managed, posing an Immediate Jeopardy to resident safety. An interview with HR personnel revealed ineffective resource use. The administrator's credential file lacked documentation of his responsibilities for care delivery and regulatory adherence. These issues were identified during the facility's Medicare provider survey request.
The facility lacked a governing body responsible for establishing and implementing policies for managing the SNF, posing Immediate Jeopardy to resident safety. Meetings treated the SNF as a hospital unit, with no accountability process for the administrator or identification of governing body members.
The facility did not establish a structure to comply with the resident's right to designate a representative as per state law. No personnel were assigned to monitor compliance, and the resident rights policy was hospital-based, not tailored to the facility's needs. The policy was a 13-page document that included all 483.10 resident rights statements without individualized mechanisms for CMS Medicare compliance.
The facility did not establish a structure to ensure residents are informed about their health status and treatments. No personnel were assigned to monitor compliance with resident rights, and the policy used was hospital-based, not tailored to the facility. The policy was a 13-page document that consolidated all resident rights statements, lacking individualized compliance mechanisms.
The facility did not obtain necessary consent signatures from two residents admitted for short-term rehabilitation after surgery. Both residents were alert and oriented, yet their records lacked signatures on informed consent forms for disclosure of information and treatment, violating their right to participate in their care planning.
The facility did not establish a structure to comply with residents' rights to self-administer medications when appropriate. No personnel were assigned to monitor compliance, and the resident rights policy was hospital-based, not tailored to the facility. The policy combined all resident rights statements into one document, lacking individualized mechanisms for CMS compliance.
The facility did not establish a structure to comply with the resident's right to choose their attending physician. No personnel were assigned to monitor compliance with resident rights, and the policy reviewed was hospital-based, not tailored to the facility. The policy was a 13-page document that included all 483.10 resident rights statements, lacking individualized mechanisms for CMS Medicare compliance.
The facility did not establish a structure to ensure compliance with resident rights, as no personnel were assigned to monitor this compliance. The resident rights policy was hospital-based and not tailored to the facility, lacking individualized mechanisms to meet CMS Medicare requirements.
The facility did not establish a structure to comply with resident rights, as no personnel were assigned to monitor compliance, and the policy was hospital-based rather than facility-specific. The policy included all 483.10 resident rights statements in one document, lacking individualized mechanisms for CMS Medicare compliance.
The facility did not comply with the resident's right to choose a roommate and failed to provide written notice before room changes. No personnel were assigned to monitor compliance, and the resident rights policy was hospital-based, not specific to the facility. The policy combined all resident rights into one document, lacking individualized compliance mechanisms.
The facility failed to establish a structure to comply with residents' rights to refuse transfers. No personnel were assigned to monitor compliance, and the resident rights policy was hospital-based, not tailored to the facility. The policy lacked individualized mechanisms for CMS compliance and consolidated all resident rights into one document.
The facility failed to establish a structure to comply with resident rights, as no personnel were assigned to monitor compliance. The resident rights policy was hospital-based and not tailored to the facility, lacking individualized mechanisms to ensure compliance with CMS Medicare requirements.
The facility did not establish a structure to ensure compliance with resident rights, as no personnel were assigned to monitor this, and the policy used was hospital-based and not tailored to the facility. The policy was a 13-page document that included all resident rights statements without individualized mechanisms for compliance.
The facility did not ensure residents' rights to receive visitors at their preferred times. No staff were assigned to monitor compliance, and the policy manual was hospital-based and not specific to the facility. The policy was a generic document lacking individualized compliance mechanisms.
The facility did not establish a structure to comply with resident visitation rights, as no personnel were assigned to monitor compliance. The resident rights policy was hospital-based and not tailored to the facility, lacking individualized mechanisms for CMS Medicare compliance.
The facility did not establish a structure to comply with resident rights, as no personnel were assigned to monitor compliance, and the policy was hospital-based and not tailored to the facility. The policy was a 13-page document that included all 483.10 resident rights statements without individualized mechanisms for CMS Medicare compliance.
The facility failed to establish a structure to comply with residents' rights to choose or refuse to perform services. No personnel were assigned to monitor compliance, and the resident rights policy was hospital-based, not tailored to the facility. The policy lacked individualized mechanisms for CMS Medicare compliance and was a 13-page document that included all 483.10 resident rights statements, lacking specificity for implementation.
The facility did not establish a structure to comply with residents' rights to manage their financial affairs. No personnel were assigned to monitor compliance, and the policy reviewed was hospital-based, not specific to the facility. The policy was a 13-page document that included all resident rights statements without individualized mechanisms for CMS Medicare compliance.
The facility failed to establish a proper structure for compliance with resident rights regarding personal funds. No personnel were assigned to monitor compliance, and the policy reviewed was hospital-based, not specific to the facility. The policy lacked individualized mechanisms for CMS Medicare compliance and was a 13-page document that included all resident rights statements without specificity.
The facility did not establish a structure to comply with resident rights regarding notice of certain balances. No personnel were assigned to monitor compliance, and the policy reviewed was hospital-based, not specific to the facility. The policy was a 13-page document that included all 483.10 resident rights statements without individualized mechanisms for CMS Medicare compliance.
The facility failed to ensure the security of residents' personal funds due to a lack of assigned personnel to monitor compliance with resident rights. The resident rights policy was hospital-based and not tailored to the facility, lacking individualized mechanisms for CMS Medicare compliance. The policy was a generic document, not addressing each area separately, indicating a lack of structure and oversight.
The facility failed to ensure compliance with resident rights by not assigning personnel to monitor these rights and using a hospital-based policy that did not address specific Medicare payment requirements. The policy lacked individualized mechanisms for compliance and included all resident rights statements in one document.
The facility did not establish a structure to ensure compliance with resident rights, as no personnel were assigned to monitor this compliance. The resident rights policy was hospital-based and not tailored to the facility, lacking individualized mechanisms for CMS Medicare compliance.
The facility failed to establish a structure to comply with resident rights, as no personnel were assigned to monitor compliance, and the policy manual was hospital-based and not tailored to the facility. The policy lacked individualized mechanisms for CMS Medicare compliance and included all resident rights in one document.
The facility failed to ensure compliance with resident rights, as no personnel were assigned to monitor this compliance. The resident rights policy was hospital-based and not tailored to the facility, lacking individualized mechanisms for CMS Medicare compliance.
The facility did not comply with the requirement to post a list of pertinent State agencies and advocacy groups in an accessible manner for residents. No personnel were assigned to monitor compliance with resident rights, and the policy was hospital-based, not tailored to the facility. The signpost with the required information had lettering too small for residents to read.
The facility failed to ensure residents had reasonable access to and privacy in their use of telephones, including TTY and TDD services. No personnel were assigned to monitor compliance with resident rights, and the policy was hospital-based, not tailored to the facility. The policy combined all 483.10 resident rights statements into one document, lacking individualized compliance mechanisms.
The facility did not assign personnel to monitor compliance with resident rights, and the policy used was hospital-based, not specific to the facility. The policy was a 13-page document that included all 483.10 resident right statements without individualized mechanisms for CMS Medicare compliance.
The facility did not establish a structure to ensure compliance with residents' rights, including the right to request, refuse, or discontinue treatment, and to formulate an advance directive. No personnel were assigned to monitor compliance, and the policy reviewed was hospital-based, not specific to the facility. The policy lacked individualized mechanisms to ensure compliance with CMS Medicare requirements.
The facility did not establish a structure to comply with resident rights regarding Medicare and Medicaid information. No personnel were assigned to monitor compliance, and the resident rights policy was hospital-based, not specific to the facility. The policy was a 13-page document that included all 483.10 resident rights statements without individualized mechanisms for CMS Medicare compliance.
The facility did not establish a structure to ensure compliance with resident rights, as no personnel were assigned to monitor this compliance. The resident rights policy was hospital-based and not tailored to the facility, lacking individualized mechanisms for CMS Medicare compliance.
The facility did not ensure that two residents were informed of their Medicaid/Medicare coverage rights at admission. Both residents, one with a left knee replacement and another with a right total hip replacement, did not sign the Important Message (IM) at admission, although it was signed at discharge.
The facility did not establish a structure to ensure compliance with resident privacy and confidentiality rights. No personnel were assigned to monitor compliance, and the resident rights policy was hospital-based, not tailored to the facility. The policy lacked individualized mechanisms to meet CMS Medicare requirements.
The facility failed to establish a structure to comply with resident rights, as no personnel were assigned to monitor compliance. The resident rights policy was hospital-based and not tailored to the facility, lacking individualized mechanisms to ensure compliance with CMS Medicare requirements.
The facility did not establish a proper structure for residents to voice grievances, as no personnel were assigned to monitor compliance with resident rights. The policy reviewed was hospital-based and not tailored to the facility, lacking separate mechanisms for CMS compliance. It was a 13-page document consolidating all resident rights statements.
Insufficient Food and Nutrition Service Staffing
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. No dietary manager was available at the time of survey, and the clinical dietician stated that the dietary manager only came sometimes for a couple of hours on some days. On the day of the survey, a kitchen employee came to work but had to leave because he was sick, which delayed breakfast and lunch service, and the clinical dietician had to help in the kitchen. This affected all residents.
PBJ Staffing Data Submission Failure
Penalty
Summary
The facility failed to ensure proper transmission of Payroll Based Journal (PBJ) staffing data to CMS based on payroll and other verifiable and auditable data. During interview, the Clinical Manager stated that all quarterly reports were submitted and that the system returned a confirmation showing the submission was completed, and she provided a Submission List indicating receipt of reports identified as the fourth quarterly report of 2025 and the first quarterly report of 2026. However, offsite review of the iQIES platform identified staffing concerns on the CASPER PBJ Staffing Data Report, including failure to submit data for quarter 1 2025 (October 1 through December 31), a one-star staffing rating, excessively low weekend staffing, no RN hours, and failure to have licensed nursing coverage 24 hours per day. Document review of working programs and task assignments showed that every working shift was covered with RNs.
Broken Gauge on Steam Cleaning Machine
Penalty
Summary
The facility failed to maintain mechanical equipment in safe and operational condition. During a kitchen observation on 03/25/2026, the vapor pressure gauge on the serving tray steam cleaning machine was observed broken. The report states that the broken gauge did not assure that proper sanitization was performed, and this issue could affect all residents.
Unsafe and Poorly Maintained Resident Rooms
Penalty
Summary
The facility failed to promote residents’ right to receive services in a safe, clean, comfortable, and homelike environment, including receiving treatment and supports for daily living safely. During observations of resident rooms with the Institutional Program Manager, one room had a broken ceiling panel, a damp ceiling panel, a dusty window, a broken ceiling panel in the toilet area, a broken light fixture cover in the toilet area, and mold on the shower door lock and frame. A second room had an unsafe and loose safety grab bar in the bathroom. A third room had mold on the lamp base and dampness and dirt on the bathroom wall. The deficient practice was identified in 3 of 8 rooms observed.
Baseline Care Plans Missing Key Resident Needs
Penalty
Summary
The facility failed to ensure that the baseline care plan for 2 of 14 residents included the instructions, services, and treatments needed to provide effective person-centered care. For one resident admitted with deconditioning, diabetes, and hypertension, the initial baseline care plan was completed but did not include the resident’s need for diaper changes or the use of a Foley catheter. The initial nursing assessment documented that the resident had a urine catheter inserted, but it did not identify the Foley catheter number, urine appearance, or urine color. The resident was observed using a diaper and Foley catheter, and a caregiver reported that a request for nursing help with a diaper change was not answered in a timely manner, requiring the caregiver to change the resident herself. The record also showed that the resident was classified as Level III and needed assistance due to fecal incontinence, but the nursing assignment and duty did not include diaper changes. A physician later ordered Foley catheter care, but the catheter number was not documented in the order or nursing notes. Another physician order directed removal of the urinary catheter, but there was no nursing progress note showing that the order was carried out, and the RN stated the Foley was removed without documentation. For a second resident admitted for deconditioning and weakness, the baseline care plan documented on admission did not include any initial goal related to activities of daily living, including nutrition or assistance during meals, even though the resident stated he had weakness in both upper and lower extremities and needed help during meals.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive person-centered care plans were developed and implemented for multiple residents based on their assessed needs. For Resident #1, who had diagnoses including hypertension, diabetes mellitus, right hip infection, and lumbar osteomyelitis, the pharmacist identified Desyrel 25 mg PO at bedtime as a psychotropic medication related to major depressive disease and monitoring mental status, but no evidence was found that nursing staff developed and implemented a care plan for psychotropic medication use from admission through the survey date. For Resident #3, who had deconditioning, an L4 fracture, diabetes mellitus type II, high blood pressure, major depressive disease, Parkinson disease, and chronic meningioma, the pharmacist identified Buspar 10 mg PO daily as a psychotropic medication, but no care plan for psychotropic medication use was found in the record. For Resident #33, admitted with infection of a stage IV sacral ulcer and deconditioning, the physician ordered a Foley catheter, but the order did not include catheter size, number of ways, or justification for placement. The record also lacked documentation that the catheter was placed, the time of placement, Foley size, urine amount, urine color, or appearance, and no care plan for the Foley catheter was found. For Resident #34, who had deconditioning, diabetes mellitus type II, and hypertension, the resident used diapers and had a Foley catheter, was observed with 3 of 4 bed rails up, and had consent and evaluation documents related to bed rail use; the physician also ordered Ativan 1 mg PO HS and Seroquel 50 mg PO HS for major depressive disorder. Despite fecal incontinence and the use of bed rails, Foley catheter, and psychotropic medications, no comprehensive care plan was found for the restraint-related bed rail use, psychotropic medication use, or fecal incontinence. For Resident #11, who had Guillain-Barre syndrome, deconditioning, hypertension, diabetes mellitus, and sleep apnea, a urinary catheter was ordered and catheter care was later discontinued, but the resident was still observed with a urinary catheter after removal and reinsertion, and no care plan for the Foley catheter was found. For Resident #10, who had deconditioning and weakness and reported needing assistance during meals, the nutritional care plan included assessment of functional capacity to achieve food intake but did not include measurable objectives or timeframes, and there was no evidence of documented meal assistance or final intake at each instance. The hydration record documented daily intake in milliliters, but did not specify meal type, food type, or level of assistance needed to meet food intake.
Failure to Develop and Update Comprehensive Care Plans
Penalty
Summary
The facility failed to develop, review, and revise comprehensive care plans within 7 days of the comprehensive assessment for multiple residents, including residents with psychotropic medication use, Foley catheter use, physical restraint concerns, and fecal incontinence. The facility policy reviewed stated that the comprehensive care plan must be completed within seven days of the resident’s comprehensive assessment, or sooner if the condition requires it, and must include measurable goals, defined timeframes, specific interventions, assigned responsibilities, and services to maintain or achieve the resident’s physical, mental, and psychosocial well-being. For one resident with hypertension, diabetes mellitus, right hip infection, and lumbar osteomyelitis, the pharmacist identified Desyrel 25 mg PO HS as a psychotropic medication related to MDD and monitoring mental status, but there was no evidence that nursing developed or updated a psychotropic medication care plan from admission through the record review. For another resident with deconditioning, L4 fracture, diabetes mellitus type II, HBP, MDD, Parkinson disease, and chronic meningioma, the pharmacist identified Buspar 10 mg PO daily as a psychotropic medication related to MDD and monitoring mental status, but no nursing care plan for psychotropic medication use was found through the record review. Additional findings involved residents with urinary catheter and restraint-related needs. One resident with a stage IV sacral ulcer and deconditioning had a physician order for Foley catheter placement, but the order lacked catheter size, number of ways, and justification, and there was no documentation that the catheter was placed, including time, size, urine amount, color, or appearance; no Foley catheter care plan was found. Another resident with deconditioning, diabetes mellitus type II, and hypertension had 3 of 4 bed rails up, a Foley catheter, diaper use, psychotropic medications including Ativan and Seroquel, and fecal incontinence, yet no care plan was found for physical restraint use, psychotropic medication use, or fecal incontinence. A fifth resident with Guillan Barre Syndrome, deconditioning, hypertension, diabetes mellitus, and sleep apnea had a urinary catheter order that was later discontinued and then reinserted after the resident could not urinate, but no Foley catheter care plan was documented, and the DON confirmed the care plan had not been developed, reviewed, or updated.
Failure to Provide Medicare Non-Coverage Notice Before Discharge
Penalty
Summary
The facility failed to ensure that a Medicare-eligible resident received written notice of Medicare non-coverage 48 hours before discharge. Resident #38, a male admitted with a diagnosis of deconditioning, was oriented related to the important messages of Medicare on 10/24/2025 at 20:13, and was later discharged home. The Notice of Medicare Non-Coverage was not provided to the resident because the resident had Medicare Advantage. During interview on 03/26/2026, the Social Worker and Discharge Planning Supervisor stated that important Medicare messages were provided at admission to all residents. They stated that residents with traditional Medicare receive the Medicare Non-Coverage form two days before discharge, while residents with Medicare Advantage do not receive the form because the insurance plan determines the length of hospitalization. The facility policy stated that for Medicare Advantage residents, the medical plan is responsible for arranging delivery of the notice, but no evidence was found that a Medicare Advantage plan representative oriented or provided the document to the resident. The facility failed to ensure the resident was informed of the right to appeal the discharge 48 hours before discharge.
Missing Signed Medical Order for Urinary Catheter Reinsertion
Penalty
Summary
The facility failed to ensure that a medical order was signed and dated in the resident’s medical record for urinary catheter insertion for one resident reviewed. The resident was a female admitted with Guillan Barre Syndrome, deconditioning, hypertension, diabetes mellitus, and sleep apnea. During interview, she was observed with a urinary catheter and stated that after the catheter was removed in the morning, she was unable to urinate later that night, so the catheter was inserted again. Record review showed a nursing note documenting the resident’s report of inability to void after catheter removal and another note documenting phone communication with the resident’s doctor, who ordered the urinary catheter to be inserted again. However, the written or electronic medical order for the catheter insertion was not found in the medical record. The DON confirmed that the medical order was not documented in the electronic and/or written system.
Missed Monthly Pharmacist Drug Regimen Review
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed a monthly drug regimen review for 1 of 14 records reviewed, specifically Resident #2. The resident was a [AGE]-year-old female admitted with diagnoses of decondition, hypertension, and diabetes mellitus. The facility policy reviewed stated that the pharmacist performs and documents the Medication Regimen Review or Drug Regimen Review process at least once a month. Record review showed that the pharmacist completed a drug regimen review on the date of admission at 4:35 PM, but there was no evidence of a subsequent monthly review within 30 days of that initial review. Further review of the medical record did not identify documentation of a pharmacist review for February 2026. During interview, the pharmacist confirmed that a drug regimen review was not completed for the resident within the required 30-day timeframe and was pending to be carried out.
Meal Assistance Plan Not Individualized
Penalty
Summary
The facility failed to ensure reasonable efforts were made to review or adjust an individual resident’s food plan to meet the resident’s specific needs for assistance during meals. Resident #10, a [AGE]-year-old male admitted for deconditioning and weakness, stated during interview that he had weakness in both upper and lower extremities and needed assistance during meals. Record review showed a document titled Hidratacion [NAME] Residente (Resident Hydration) that was documented daily and included the resident’s intake per hour in milliliters, but it did not specify the type of meal, the type of food, or the level of assistance needed per meal to meet food intake.
Lack of Formal Charge Nurse Designation on Each Shift
Penalty
Summary
The facility failed to ensure that a charge nurse was designated on each shift to perform the responsibilities assigned by the facility. During an interview, the DON stated that the facility general supervisor acts as the charge nurse on each working shift. However, review of the staff work assignment for the three working shifts from 3/25/26 through 3/27/26 showed that the document did not formally designate the RN as Charge Nurse or identify specific charge nurse responsibilities such as staff supervision, emergency coordination, physician liaison duties, or direct resident care.
QAPI Committee Missing Required Members
Penalty
Summary
The facility failed to maintain a QAPI committee with the required participation of the Medical Director or his/her designee and the Infection Control Officer in each QAPI committee meeting. Review of monthly QAPI committee meetings for April, May, June, and July 2025, as well as January and February 2026, showed that the July 18, 2025, June 20, 2025, and April 28, 2025 meetings did not evidence participation by the Medical Director or his/her designee, and the May 20, 2025 meeting did not evidence participation by the Infection Control Officer or his/her designee. During review of the facility's QAPI rules and regulations updated in August 2025, the facility director of institutional program confirmed that the Medical Director or designee and the Infection Control Officer are required active members who must participate in each QAPI committee meeting. In interview, the facility director of institutional program also stated that these individuals must participate in each monthly QAPI committee meeting as established in the QAPI rules and regulation.
Failure to Establish Resident Rights Compliance Structure
Penalty
Summary
The facility failed to establish a structure to comply with resident rights, which posed an Immediate Jeopardy to the health and safety of all admitted residents. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. Additionally, the resident rights policy and procedure were found to be hospital-based, containing the logo of Episcopal Hospital San [NAME] Metro, rather than being tailored to the facility's needs. The policy was a 13-page document that included all 483.10 resident rights statements in one policy, without individualized mechanisms to ensure compliance with CMS Medicare requirements.
Failure to Appoint Full-Time Director of Nursing
Penalty
Summary
The facility failed to appoint a full-time Director of Nursing, which is a requirement for ensuring proper nursing oversight and management. During an interview with the Nursing Supervisor, it was revealed that the facility did not have a Director of Nursing in place. Instead, an Acting Manager was fulfilling some of the responsibilities, but this individual confirmed that there was no official Director of Nursing appointed. This deficiency was identified during a survey conducted on September 9, 2024, and was determined to pose an Immediate Jeopardy to the health and safety of all residents admitted to the facility.
Facility Management Deficiency Poses Immediate Jeopardy
Penalty
Summary
The facility was found to be inadequately managed, posing an Immediate Jeopardy to the health and safety of its residents. During an interview with the facility's human resources personnel, it was revealed that the facility failed to demonstrate effective and efficient use of its resources. A review of the administrator's credential file showed that he was appointed on June 21, 2024, but there was no documentation indicating his responsibility for planning, organizing, and supervising the delivery of care to residents. Additionally, there was no evidence that he was overseeing the facility's adherence to the latest healthcare regulations for a Skilled Nursing Facility (SNF). These deficiencies were identified during the facility's request for an initial survey to become a Medicare provider, as it is located within a hospital.
Lack of Governing Body for SNF Management
Penalty
Summary
The facility failed to establish a governing body or designate individuals functioning as a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility. This deficiency was identified as an Immediate Jeopardy to the health and safety of residents. The review of governing body rules, regulations, and committee meetings revealed that the facility's governing body meetings were conducted in a manner that treated the Skilled Nursing Facility (SNF) as merely another unit of the hospital, rather than as a separate entity with its own active governing body. Additionally, there was no evidence of a process to hold the administrator accountable or to report specific information about SNF services to the hospital. Furthermore, there was no identification of members assigned to the SNF governing body.
Failure to Establish Resident Rights Compliance Structure
Penalty
Summary
The facility failed to establish a structure to comply with the resident's right to designate a representative in accordance with state law. During the survey, it was found that no personnel were assigned to monitor compliance with resident rights. The resident rights policy and procedure, reviewed with the institutional program director, was hospital-based and included the logo of Episcopal Hospital San [NAME] Metro, indicating it was not tailored to the facility's specific needs. Additionally, the policy was a 13-page document that included all 483.10 resident rights statements in one policy, lacking individualized mechanisms to ensure compliance with CMS Medicare requirements.
Failure to Ensure Resident Rights Compliance
Penalty
Summary
The facility failed to establish a structure to ensure that residents are fully informed and understand their health status, care, and treatments, as required by CMS Medicare regulations. During the survey, it was found that no personnel were assigned to monitor compliance with resident rights. Additionally, the resident rights policy and procedure, reviewed with the institutional program director, was hospital-based and not tailored to the facility's needs, as it included the logo of Episcopal Hospital San [NAME] Metro. The policy was a 13-page document that consolidated all 483.10 resident rights statements into one policy, lacking individualized mechanisms to ensure compliance with each area of resident rights.
Failure to Obtain Resident Consent Signatures
Penalty
Summary
The facility failed to uphold the right of residents to participate in the development and implementation of their person-centered plan of care by not obtaining their signatures on necessary consent forms. This deficiency was identified in the records of two residents who were admitted for short-term rehabilitation following surgery. One resident, a male who underwent a left knee replacement, was alert and oriented upon admission, yet his medical record lacked his signature on the informed consent for disclosure of information, HIPAA notification, and treatment consent forms. Similarly, another male resident who had a right total hip replacement was also alert and oriented at the time of admission, but his record did not include his signature on the informed consent for disclosure of information and treatment consent forms.
Failure to Establish Compliance with Resident Rights for Self-Administration of Medications
Penalty
Summary
The facility failed to establish a structure to comply with residents' rights to self-administer medications when deemed clinically appropriate by the interdisciplinary team. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. The resident rights policy and procedure, reviewed with the institutional program director, was found to be hospital-based and not tailored to the facility's needs, as it included the logo of Episcopal Hospital San [NAME] Metro. Additionally, the policy was a 13-page document that combined all 483.10 resident rights statements into one policy, lacking individualized mechanisms to ensure compliance with CMS Medicare requirements.
Failure to Establish Resident Rights Compliance Structure
Penalty
Summary
The facility failed to establish a structure to comply with the resident's right to choose their attending physician. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. The resident rights policy and procedure, reviewed with the institutional program director, was found to be hospital-based and included the logo of Episcopal Hospital San [NAME] Metro, indicating it was not tailored to the facility's specific needs. Additionally, the policy was a 13-page document that included all 483.10 resident rights statements in one policy, lacking individualized mechanisms to ensure compliance with CMS Medicare requirements.
Failure to Establish Resident Rights Compliance Structure
Penalty
Summary
The facility failed to establish a structure to comply with the resident's right to be treated with respect and dignity. During the survey, it was found that no personnel were assigned to monitor compliance with resident rights. The resident rights policy and procedure, reviewed with the institutional program director, was hospital-based and included the logo of Episcopal Hospital San [NAME] Metro, indicating it was not tailored to the facility's specific needs. Additionally, the policy was a 13-page document that included all 483.10 resident rights statements in one policy, lacking individualized mechanisms to ensure compliance with CMS Medicare requirements.
Failure to Establish Resident Rights Compliance Structure
Penalty
Summary
The facility failed to establish a structure to comply with the resident's right to receive services with reasonable accommodation of their needs and preferences. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. Additionally, the resident rights policy and procedure were found to be hospital-based, containing the logo of Episcopal Hospital San [NAME] Metro, rather than being tailored to the facility's specific needs. The policy was a 13-page document that included all 483.10 resident rights statements in one policy, lacking individualized mechanisms to ensure compliance with CMS Medicare requirements.
Failure to Ensure Resident Roommate Rights and Notification
Penalty
Summary
The facility failed to comply with the resident's right to share a room with their spouse or roommate of choice and to provide written notice before any changes are made. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. The resident rights policy and procedure, reviewed with the institutional program director, was found to be hospital-based and not tailored to the facility's needs, as it included the logo of Episcopal Hospital San [NAME] Metro. Additionally, the policy was a 13-page document that combined all 483.10 resident rights statements into one policy, lacking individualized mechanisms to ensure compliance with CMS Medicare requirements.
Failure to Establish Resident Rights Compliance Structure
Penalty
Summary
The facility failed to establish a structure to comply with the residents' right to refuse transfers within the nursing home. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. The resident rights policy and procedure, reviewed with the institutional program director, was found to be hospital-based and included the logo of Episcopal Hospital San [NAME] Metro, indicating it was not tailored to the facility's specific needs. Additionally, the policy did not include individualized mechanisms to ensure compliance with CMS Medicare requirements, and it was a 13-page document that consolidated all 483.10 resident rights statements into one policy.
Failure to Establish Resident Rights Compliance Structure
Penalty
Summary
The facility failed to establish a structure to comply with the resident's right to self-determination and support of resident choice. During the survey, it was found that no personnel were assigned to monitor compliance with resident rights. The resident rights policy and procedure, reviewed with the institutional program director, was hospital-based and included the logo of Episcopal Hospital San [NAME] Metro, indicating it was not tailored to the facility's specific needs. Additionally, the policy was a 13-page document that included all 483.10 resident rights statements in one policy, lacking individualized mechanisms to ensure compliance with CMS Medicare requirements.
Failure to Ensure Resident Rights Compliance
Penalty
Summary
The facility failed to establish a structure to comply with the resident's right to provide immediate access to any representative of the State, the resident's individual physician, or any representative of the protection and advocacy systems. During the survey, it was found that no personnel were assigned to monitor compliance with resident rights. The resident rights policy and procedure, reviewed with the institutional program director, was hospital-based and included the logo of Episcopal Hospital San [NAME] Metro, indicating it was not tailored to the facility's specific needs. Additionally, the policy was a 13-page document that included all 483.10 resident rights statements in one policy, lacking individualized mechanisms to ensure compliance with CMS Medicare requirements.
Failure to Ensure Resident Visitation Rights
Penalty
Summary
The facility failed to uphold the resident's right to receive visitors of their choosing at their preferred times. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. The policy and procedure manual for resident rights, reviewed with the institutional program director, was found to be hospital-based and not tailored to the facility's specific needs. Additionally, the policy was a generic 13-page document that included all 483.10 resident rights statements in one policy, lacking individualized mechanisms to ensure compliance with CMS Medicare requirements.
Failure to Establish Resident Visitation Rights Compliance
Penalty
Summary
The facility failed to establish a structure to comply with resident visitation rights and ensure equal visitation privileges. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. The resident rights policy and procedure, reviewed with the institutional program director, was found to be hospital-based and included the logo of Episcopal Hospital San [NAME] Metro, indicating it was not tailored to the facility's specific needs. Additionally, the policy was a 13-page document that included all 483.10 resident rights statements in one policy, lacking individualized mechanisms to ensure compliance with CMS Medicare requirements.
Failure to Establish Resident Rights Compliance Structure
Penalty
Summary
The facility failed to establish a structure to comply with the resident's right to organize and participate in resident groups. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. The resident rights policy and procedure, reviewed with the institutional program director, was found to be hospital-based and included the logo of Episcopal Hospital San [NAME] Metro, indicating it was not tailored to the facility's specific needs. Additionally, the policy was a 13-page document that included all 483.10 resident rights statements in one policy, lacking individualized mechanisms to ensure compliance with CMS Medicare requirements.
Failure to Establish Resident Rights Compliance Structure
Penalty
Summary
The facility failed to establish a structure to comply with the resident's right to choose or refuse to perform services for the facility. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. The resident rights policy and procedure, reviewed with the institutional program director, was found to be hospital-based and included the logo of the Episcopal Hospital San [NAME] Metro, indicating it was not tailored to the facility's specific needs. Additionally, the policy did not include individualized mechanisms to ensure compliance with CMS Medicare requirements. The policy was a 13-page document that included all 483.10 resident rights statements in one policy, lacking specificity and clarity for implementation in the facility.
Failure to Establish Resident Financial Rights Compliance
Penalty
Summary
The facility failed to establish a structure to comply with the resident's right to manage their financial affairs. During the survey, it was found that no personnel were assigned to monitor compliance with resident rights. The resident rights policy and procedure, reviewed with the institutional program director, was hospital-based and included the logo of Episcopal Hospital San [NAME] Metro, indicating it was not tailored to the facility's specific needs. Additionally, the policy was a 13-page document that included all 483.10 resident rights statements in one policy, lacking individualized mechanisms to ensure compliance with CMS Medicare requirements.
Failure to Establish Resident Rights Compliance Structure
Penalty
Summary
The facility failed to establish a proper structure to comply with the resident's right to accounting and records of personal funds. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. The resident rights policy and procedure, reviewed with the institutional program director, was found to be hospital-based and included the logo of Episcopal Hospital San [NAME] Metro, indicating it was not tailored to the facility's specific needs. Additionally, the policy did not provide individualized mechanisms to ensure compliance with CMS Medicare requirements. The resident rights policy was a 13-page document that included all 483.10 resident right statements in one policy, lacking specificity and clarity for implementation.
Failure to Establish Resident Rights Compliance Structure
Penalty
Summary
The facility failed to establish a structure to comply with the resident's right to notice of certain balances. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. The resident rights policy and procedure, reviewed with the institutional program director, was found to be hospital-based and included the logo of the Episcopal Hospital San [NAME] Metro, indicating it was not tailored to the facility's specific needs. Additionally, the policy was a 13-page document that included all 483.10 resident rights statements in one policy, lacking individualized mechanisms to ensure compliance with CMS Medicare requirements.
Deficiency in Resident Financial Security Compliance
Penalty
Summary
The facility failed to ensure the security of personal funds of residents deposited with them, as evidenced by several deficiencies in their policies and procedures. During the survey, it was found that no personnel were assigned to monitor compliance with resident rights, which is a critical oversight. The resident rights policy and procedure, reviewed with the institutional program director, was found to be hospital-based and not tailored to the specific needs of the facility, as it bore the logo of Episcopal Hospital San [NAME] Metro. Additionally, the policy did not include individualized mechanisms to ensure compliance with CMS Medicare requirements, and it was a generic 13-page document that included all 483.10 resident rights statements in one policy, rather than addressing each area separately. These findings indicate a lack of structure and oversight in ensuring the financial security of residents' personal funds.
Failure to Monitor Compliance with Resident Rights
Penalty
Summary
The facility failed to comply with the resident's right to not impose charges against their personal funds for items or services covered by Medicare. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. The resident rights policy and procedure, reviewed with the institutional program director, was found to be hospital-based and not tailored to the facility, as it included the logo of Episcopal Hospital San [NAME] Metro. Additionally, the policy did not have individualized mechanisms to ensure compliance with CMS Medicare requirements. The policy was a 13-page document that included all 483.10 resident rights statements in one policy, indicating a lack of specific structure to address the Medicare payment requirements.
Failure to Establish Resident Rights Compliance Structure
Penalty
Summary
The facility failed to establish a structure to comply with the resident's right to be informed of their rights and the rules governing their conduct and responsibilities during their stay. During the survey, it was found that no personnel were assigned to monitor compliance with resident rights. The resident rights policy and procedure, reviewed with the institutional program director, was hospital-based and included the logo of Episcopal Hospital San [NAME] Metro, indicating it was not tailored to the facility. Additionally, the policy was a 13-page document that included all 483.10 resident rights statements in one policy, lacking individualized mechanisms to ensure compliance with CMS Medicare requirements.
Failure to Establish Resident Rights Compliance Structure
Penalty
Summary
The facility failed to establish a proper structure to comply with the resident's right to access personal and medical records. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. The policy and procedure manual reviewed with the institutional program director was found to be hospital-based and not tailored to the facility, as it contained the logo of Episcopal Hospital San [NAME] Metro. Additionally, the policy did not include individualized mechanisms to ensure compliance with CMS Medicare requirements. The resident rights policy was a 13-page document that included all 483.10 resident right statements in one policy, indicating a lack of specific procedures for each area of resident rights.
Failure to Ensure Resident Rights Compliance
Penalty
Summary
The facility failed to comply with the resident's right to receive notices in a format and language they understand. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. The resident rights policy and procedure, reviewed with the institutional program director, was found to be hospital-based and included the logo of Episcopal Hospital San [NAME] Metro, indicating it was not tailored to the facility's specific needs. Additionally, the policy was a 13-page document that included all 483.10 resident rights statements in one policy, lacking individualized mechanisms to ensure compliance with CMS Medicare requirements.
Deficiency in Posting Resident Rights Information
Penalty
Summary
The facility failed to comply with the requirement to post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups in a manner accessible and understandable to residents. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. The resident rights policy and procedure, reviewed with the institutional program director, was found to be hospital-based and not tailored to the facility, as it included the logo of Episcopal Hospital San [NAME] Metro. The policy was a 13-page document that included all 483.10 resident rights statements in one policy, lacking individualized mechanisms to ensure compliance with CMS Medicare requirements. Additionally, the signpost with the required information had lettering too small for residents to read.
Deficiency in Resident Communication Access and Privacy
Penalty
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of communication methods, specifically telephones, including TTY and TDD services. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. The resident rights policy and procedure, reviewed with the institutional program director, was found to be hospital-based and not tailored to the facility, as it included the logo of Episcopal Hospital San [NAME] Metro. Additionally, the policy was a 13-page document that combined all 483.10 resident rights statements into one policy, lacking individualized mechanisms to ensure compliance with CMS Medicare requirements.
Failure to Establish Resident Rights Compliance Structure
Penalty
Summary
The facility failed to establish a structure to comply with the resident's right to examine the results of the most recent survey conducted by Federal or State surveyors and any plan of correction in effect. During the survey process, it was found that no personnel were assigned to monitor compliance with resident rights. The resident right policy and procedure, reviewed with the institutional program director, was hospital-based and included the logo of the Episcopal Hospital San [NAME] Metro, indicating it was not tailored to the facility's specific needs. Additionally, the policy was a 13-page document that included all 483.10 resident right statements in one policy, lacking individualized mechanisms to ensure compliance with CMS Medicare requirements.
Failure to Establish Resident Rights Compliance Structure
Penalty
Summary
The facility failed to establish a proper structure to comply with residents' rights to request, refuse, and/or discontinue treatment, participate in or refuse experimental research, and formulate an advance directive. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. Additionally, the resident rights policy and procedure reviewed with the institutional program director was found to be hospital-based, bearing the logo of Episcopal Hospital San [NAME] Metro, rather than being tailored to the facility. The policy was a 13-page document that included all 483.10 resident rights statements in one policy, lacking individualized mechanisms to ensure compliance with CMS Medicare requirements.
Failure to Establish Compliance with Resident Rights for Medicare and Medicaid Information
Penalty
Summary
The facility failed to establish a structure to comply with the resident's right to receive information about Medicare and Medicaid benefits. During the survey, it was found that no personnel were assigned to monitor compliance with resident rights. The resident rights policy and procedure, reviewed with the institutional program director, was hospital-based and included the logo of Episcopal Hospital San [NAME] Metro, indicating it was not tailored to the facility's specific needs. Additionally, the policy was a 13-page document that included all 483.10 resident rights statements in one policy, lacking individualized mechanisms to ensure compliance with CMS Medicare requirements.
Failure to Establish Resident Rights Compliance Structure
Penalty
Summary
The facility failed to establish a structure to comply with the resident's right to notification of changes, as determined during a survey. It was found that no personnel were assigned to monitor compliance with resident rights. Additionally, the resident rights policy and procedure were hospital-based, bearing the logo of Episcopal Hospital San [NAME] Metro, rather than being tailored to the facility's specific needs. The policy was a 13-page document that included all 483.10 resident right statements in one policy, without individualized mechanisms to ensure compliance with CMS Medicare requirements.
Failure to Inform Residents of Coverage Rights at Admission
Penalty
Summary
The facility failed to ensure that residents were informed of their rights regarding Medicaid/Medicare coverage and potential liability for services not covered at the time of admission. This deficiency was identified during a review of records for two residents who were discharged home. The first resident, who had undergone a left knee replacement, was admitted on an unspecified date and discharged on March 16, 2024. It was found that the Important Message (IM) regarding coverage was not signed by the resident or their representative at the time of admission, although it was signed upon discharge. Similarly, the second resident, a 79-year-old who had a right total hip replacement, was admitted on an unspecified date and discharged on March 16, 2024. The IM was also not signed at admission but was signed at discharge. These findings indicate a failure to properly orient residents to their rights concerning coverage at the time of admission.
Failure to Ensure Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to establish a structure to comply with the resident's right to personal privacy and confidentiality of personal and medical records. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. Additionally, the resident rights policy and procedure, reviewed with the institutional program director, was found to be hospital-based and included the logo of Episcopal Hospital San [NAME] Metro, indicating it was not tailored to the facility's specific needs. The policy was a 13-page document that included all 483.10 resident rights statements in one policy, lacking individualized mechanisms to ensure compliance with CMS Medicare requirements.
Failure to Establish Resident Rights Compliance Structure
Penalty
Summary
The facility failed to establish a structure to comply with the resident's right to a safe environment. During the survey, it was found that no personnel were assigned to monitor compliance with resident rights. The resident rights policy and procedure, reviewed with the institutional program director, was hospital-based and included the logo of Episcopal Hospital San [NAME] Metro, indicating it was not tailored to the facility's specific needs. Additionally, the policy was a 13-page document that included all 483.10 resident rights statements in one policy, lacking individualized mechanisms to ensure compliance with CMS Medicare requirements.
Failure to Establish Resident Grievance Policy
Penalty
Summary
The facility failed to establish a proper structure to comply with the residents' right to voice grievances without discrimination or reprisal. During the survey, it was found that no personnel were assigned to monitor compliance with resident rights. The resident rights policy and procedure, reviewed with the institutional program director, was hospital-based and included the logo of Episcopal Hospital San [NAME] Metro, indicating it was not tailored to the facility's specific needs. Additionally, the policy did not include separate mechanisms to ensure compliance with CMS Medicare requirements, and it was a 13-page document that consolidated all 483.10 resident rights statements into one policy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 17 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rio Piedras
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Multy Medical Skilled Nursing Facility | 1.2 mi | ★★★★★ | 13 | 0 |
| Millennium Institute For Advance Nursing Care Inc | 1.3 mi | ★★★★★ | 4 | 0 |
| Alternative Healthcare Solutions Llc | 3.5 mi | ★★★★★ | 0 | 0 |
| Centro Medico Wilma N Vazquez Snf | 22.3 mi | ★★★★★ | 0 | 0 |
| Ryder Memorial Hospital Inc | 22.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.