Centro De Cuidado Prolongado San Lucas
Inspection history, citations, penalties and survey trends for this long-term care facility in Rio Piedras, PR.
- Location
- Carr 844 Km 0 5 Cupey, Rio Piedras, PR 00928
- CMS Provider Number
- 405033
- Inspections on file
- 3
- Latest survey
- October 2, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Centro De Cuidado Prolongado San Lucas during CMS and state inspections, most recent first.
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.
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 ensure compliance with resident rights to be free from abuse, neglect, and exploitation. No personnel were assigned to monitor compliance, and the policies provided were hospital-based, not specific to the facility. The policies did not meet CMS Medicare requirements, as they were not individualized for the facility.
The facility failed to establish a structure to ensure compliance with resident rights, including freedom from abuse, neglect, and exploitation. No personnel were assigned to monitor compliance, and the policies provided were hospital-based, not specific to the facility. The facility also lacked individualized mechanisms to meet CMS Medicare requirements.
The facility failed to establish a structure to ensure compliance with resident rights, specifically the right to be free from abuse, neglect, exploitation, or involuntary seclusion. No personnel were assigned to monitor compliance, and the policies provided were hospital-based, not tailored to the facility's needs. These policies did not meet CMS Medicare guidelines for LTC facilities.
The facility failed to ensure residents were free from physical restraints unless medically necessary. No personnel were assigned to monitor compliance with resident rights, and the existing policy was hospital-based and not applicable to the facility. Additionally, there was no policy regarding the right to be free from chemical restraints.
The facility failed to ensure compliance with residents' rights to be free from chemical restraints not required for medical symptoms. No personnel were assigned to monitor compliance, and the existing policy was hospital-based and not applicable to the facility. Additionally, the facility did not develop or implement a policy to protect residents from chemical restraints used for discipline or convenience.
The facility did not assign personnel to monitor compliance with resident rights and used an inappropriate hospital-based policy for background checks. Additionally, the facility lacked a specific policy for Puerto Rico background checks and was not registered with the Puerto Rico Department of Health's background check program for skilled nursing facility personnel.
The facility failed to implement specific policies and procedures to prevent abuse, neglect, and exploitation of residents. No personnel were assigned to monitor compliance with resident rights, and the existing policy was hospital-based and not tailored to the facility. This lack of appropriate policies contributed to the deficiency.
The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment in a timely manner. No personnel were assigned to monitor compliance with resident rights, and the existing policy was hospital-based, not applicable to the skilled nursing facility. The policy lacked requirements for immediate reporting to the administrator and relevant authorities.
The facility did not ensure thorough investigation of alleged violations or prevent further potential abuse during investigations. No personnel were assigned to monitor compliance with resident rights, and the policy used was hospital-based, not suitable for the skilled nursing facility. It also failed to include the requirement to report investigation results to the administrator and State Survey Agency within 5 working days.
The facility failed to demonstrate its capability to transmit resident assessment data to the CMS System. The MDS Coordinator stated that the facility had not conducted an initial connectivity test and was still using a paper-based MDS-RAI assessment instrument. The facility planned to start electronic transmission after obtaining a Medicare provider number but did not provide a validation report or show efforts to upload the test file.
A facility failed to develop a baseline care plan within 48 hours for a newly admitted resident following a left total hip replacement. The absence of this plan meant that essential healthcare information, such as admission and physician orders, was not documented to guide the resident's care during the initial period post-admission.
The facility did not have a policy or procedure to ensure residents received appropriate treatment and assistive devices for maintaining their visual and hearing abilities. The absence of such documentation was confirmed during interviews with the Nursing Supervisor and Interim Manager, indicating non-compliance with maintenance targets for these devices.
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.
Failure to Establish Resident Rights Compliance Structure
Penalty
Summary
The facility failed to establish a structure to comply with the resident's right to contact external entities, as required by federal regulations. 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, bearing the logo of Episcopal Hospital San [NAME] Metro, rather than being tailored to the specific needs of the facility. The policy was a 13-page document that included all 483.10 resident rights statements in one policy, but lacked 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 free from abuse, neglect, and exploitation. During the survey, it was found that no personnel were assigned to monitor compliance with resident rights. The resident rights manual and policies provided were hospital-based and not tailored to the facility's needs. The policies reviewed included identifying and reporting victims of abuse, neglect, domestic violence, rape, and exploitation, as well as preventing abuse and neglect. However, these policies were not specific to the facility and bore the logo of Episcopal Hospital San [NAME] Metro. Additionally, the facility's resident rights policy and procedure for freedom from abuse, neglect, and exploitation did not meet the CMS Medicare requirements, as they were also hospital-based and not individualized for the facility.
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 free from abuse, neglect, misappropriation of property, and exploitation. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. The resident rights manual and policies provided were hospital-based and not tailored to the facility, as they contained the logo and references to Episcopal Hospital San [NAME] Metro. The policies reviewed included those on identifying and reporting abuse, neglect, and exploitation, but they were not specific to the facility's needs. Additionally, the facility lacked individualized mechanisms to ensure compliance with CMS Medicare requirements for resident rights, particularly concerning freedom from abuse, neglect, and exploitation.
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 free from abuse, neglect, exploitation, or involuntary seclusion. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. The resident rights manual provided by the facility contained policies that were hospital-based and not specific to the facility, as they bore the logo of the Episcopal Hospital San [NAME] Metro. The policies included were related to identifying and reporting victims of abuse, neglect, domestic violence, rape, and exploitation, as well as preventing abuse and neglect. However, these policies were not tailored to meet the specific requirements of the CMS Medicare guidelines for long-term care facilities. Additionally, the facility's policy and procedure for freedom from abuse, neglect, and exploitation were also hospital-based and not adequately addressing the needs of the residents in the facility.
Failure to Ensure Residents' Right to be Free from Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless required for medical treatment. During the survey, it was discovered that the facility did not assign any personnel to monitor compliance with resident rights, which is a critical oversight. Additionally, the policy and procedure titled 'Patient Restriction Guide' was found to be hospital-based and not tailored to the specific needs of the facility, as it was addressed to a different institution, Episcopal Hospital San [NAME] Metro. Furthermore, the facility did not develop or implement a policy and procedure regarding the residents' right to be free from chemical restraints, indicating a significant gap in their compliance with resident rights.
Failure to Ensure Resident Rights to be Free from Chemical Restraints
Penalty
Summary
The facility failed to establish a structure to comply with the resident's right to be free from chemical restraints that are not required to treat medical symptoms. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. Additionally, the policy and procedure titled 'Patient Restriction Guide' was found to be hospital-based and not applicable to the facility, as it was addressed to the Episcopal Hospital San [NAME] Metro. Furthermore, the facility did not develop or implement a policy and procedure ensuring residents' rights to be free from chemical restraints, which are imposed for discipline or convenience rather than medical necessity.
Failure to Implement Background Check Policy
Penalty
Summary
The facility failed to comply with the resident right to not employ individuals with a history of abuse, neglect, exploitation, or theft. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. Additionally, the policy and procedure for criminal record verification or background checks was found to be hospital-based and not applicable to the facility. Furthermore, the facility did not develop or implement a policy for conducting background checks specific to Puerto Rico and was not registered with the Puerto Rico Department of Health's background check program for skilled nursing facility personnel.
Failure to Implement Abuse and Neglect Prevention Policies
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. During the survey process, it was discovered that no personnel were assigned to monitor compliance with resident rights. Additionally, the policy and procedure titled 'Abuse and Neglect Prevention, Identification and Reporting of Victims of Abuse/Neglect/Domestic Violence/Rape/Exploitation' was found to be hospital-based and addressed to a different institution, Episcopal Hospital San [NAME] Metro, rather than the facility in question. This indicates a lack of appropriate and specific policies tailored to the facility's needs, contributing to the deficiency.
Failure to Report Alleged Violations Timely
Penalty
Summary
The facility failed to ensure that alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported in a timely manner. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. Additionally, the policy and procedure titled 'Abuse and Neglect Prevention, Identification and Reporting of Victims of Abuse/Neglect/Domestic Violence/Rape/Exploitation' was found to be hospital-based and not directed to the skilled nursing facility. The policy did not include the requirement to report immediately, not later than 2 hours after the allegation is made if the events involve abuse or result in serious bodily injury, or not later than 24 hours if the events do not involve abuse and do not result in serious bodily injury, to the administrator and other officials, including the State Survey Agency and adult protective services, in accordance with State law.
Failure to Investigate and Report Alleged Violations
Penalty
Summary
The facility failed to ensure that all alleged violations were thoroughly investigated and to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress. Additionally, the facility did not report the results of all investigations to the administrator or designated representative and to other officials in accordance with State law, including the State Survey Agency, within the required 5 working days of the incident. During the survey, it was found that no personnel were assigned to monitor compliance with resident rights. Furthermore, the policy and procedure titled 'Abuse and Neglect Prevention, Identification and Reporting of Victims of Abuse/Neglect/Domestic Violence/Rape/Exploitation' was hospital-based and not directed to the skilled nursing facility, and it did not include the requirement to report investigation results as per State law.
Failure to Transmit MDS Data to CMS System
Penalty
Summary
The facility failed to demonstrate its capability to transmit resident assessment data to the CMS System in the required format. During an interview, the MDS Coordinator revealed that the facility had not conducted an initial connectivity test to ensure data transmission capability. The facility was still collecting data using a paper-based MDS-RAI assessment instrument and planned to begin electronic transmission only after obtaining a Medicare provider number. Despite being provided with contact information for the Puerto Rico state agency MDS-RAI automation coordinator, the facility did not provide a validation report for the initial test file, nor did it show any efforts to upload the test file or report any technical issues or questions related to the upload process.
Failure to Implement Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a newly admitted resident. This deficiency was identified during a record review, which revealed that the facility did not create a baseline care plan for a female resident who was admitted following a left total hip replacement. The absence of a baseline care plan meant that the resident's initial healthcare information, including admission orders, physician orders, dietary orders, therapy services, and social services, was not documented or utilized to guide her care during the critical initial period post-admission.
Lack of Policy for Vision and Hearing Services
Penalty
Summary
The facility failed to ensure that it had a policy and procedure in place to provide residents with appropriate treatment and assistive devices to maintain their visual and hearing abilities. During a review of the procedures manual, it was found that there was no policy or procedure related to maintaining hearing and vision devices. Interviews with the Nursing Supervisor and the Interim Manager confirmed that they were unable to locate such a policy in the manual. This indicates a lack of compliance with maintenance targets for hearing and visual devices, as the necessary documentation and guidelines were not available.
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